Op-Ed Policy

Saving Lives, Saving Costs: Why Missouri Taxpayers Should Care About Homeless Interventions

Image of encampment under a bridge.

Image by KSDK News, October 25, 2023.

Imagine there is a man named Charles. He has no permanent home – no known family. He lives on the streets of St. Louis; his body bears the marks of neglect and daily hardship. One day, Charles finds himself in a hospital room, his legs swollen and inflamed from infection. Charles is no stranger to these sterile walls. He has earned the nickname “frequent flyer” from the healthcare team, a term often used to describe individuals who frequently return to healthcare settings due to challenges managing their care after discharge. His “transition plan,” as it’s called, is quickly disregarded after his release because it assumes a stable living situation—something he lacks. When his symptoms inevitably return, he will be back in the emergency room where the medical team will once again work tirelessly to stabilize his condition, just as they have done many times before. However, as his symptoms improve again, a familiar challenge emerges. What do we do now? Where does he go from here? Back to his old place or a homeless shelter? Neither is likely to be able to handle his medical needs, and both options would just lead to the same outcome. That doesn’t seem right, does it? Should we keep him in the hospital longer this time? Realistically, how long can this continue, and how much is it costing the hospital?

This story is one that plays out far too often in cities across America. People experiencing homelessness, like Charles, frequently cycle through emergency rooms and hospitals. They receive temporary care only to be discharged back into the same environment that caused their condition initially. Unable to afford wound care, follow-up, or lacking the ability to recover in a clean space, many people are readmitted to the hospital within months, possibly in worse condition than before.

Bar graph showing visits per 100 persons to emergency departments by region of the US.

Figure 1: Emergency Department Visit Rates per 100 Persons by Homeless Status and Geographic Region, United States, 2015–2018. Annual ED visit rates were significantly higher for homeless persons (203 visits) compared to nonhomeless persons (42 visits). Among homeless persons, the Midwest had notably high visit rates (234 visits), second only to the West (268 visits) and significantly higher than the Northeast (127 visits). Data from the National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2015–2018.

People experiencing homelessness are over four times more likely to end up in an emergency room (Fig. 1) and these visits cost the healthcare system 4.7 times more than that for the members of the general population. This humanitarian crisis affects hundreds of thousands of Americans and places significant financial strain on the American healthcare system. The true scale of the crisis is likely underestimated due to ongoing difficulties in accurately tracking the populations experiencing homelessness and their healthcare usage. If these healthcare costs are not addressed, taxpayers will continue to shoulder the burden of inefficient care, especially for unhoused patients who rely on Medicare or Medicaid.

What is the solution?

Investing in solutions that address the medical needs of people experiencing homelessness will not only alleviate the humanitarian crisis but will also save money in the long term. Promising interventions tackling this issue are already making strides nationwide, yet they need public backing to navigate the hurdles of sustained implementation.

One such approach is the “Housing First” initiative, which is a model that prioritizes providing permanent housing to individuals experiencing homelessness without preconditions like sobriety or participation in treatment programs. Housing First operates on the principle that stable housing is fundamental before addressing other issues, such as employment or substance use. A study of this program’s effectiveness has found that Housing First saves over $15,000 per year per individual in emergency service use alone and decreases interactions with the criminal justice system, all while costing an estimated $23,000 less per year than shelter programs.

Other approaches, like medical respite care, focus on providing short-term assistance. Medical respite care offers short-term residential care for homeless individuals recovering from acute illness or surgery. Unlike traditional hospital stays, medical respite provides a safe place to heal without the high costs associated with inpatient care. Recovering patients experiencing homelessness are given access to a bed, three meals a day, transportation to medical appointments, a secure place to store belongings, regular wellness checks, and assistance setting up long-term care coordination with a primary care physician. This service reduces the average length of hospital stays by up to two days and substantially lowers readmission rates. This ultimately reduces the burden on hospitals and frees up resources for other patients. Even with all the services they offer, medical respite care is still projected to save between $2,000 and $3,000 per hospitalization for individuals experiencing homelessness while improving their overall health outcomes.

Despite the demonstrable benefits, the Housing First program and medical respite programs continue to face significant challenges, particularly in securing adequate funding and support for broader implementation. Critics contend that providing housing without requiring concurrent treatment or behavior modification is risky and costly, and policymakers and communities often hesitate to expand medical respite due to the considerable financial outlay, particularly when budgets are strained. Nonetheless, a growing body of evidence demonstrates that these approaches are economically prudent over time. Research indicates that for every dollar allocated to Housing First, $1.44 is recouped in related public savings. Similarly, every dollar invested in medical respite yields a return of $1.81 in reduced hospital expenditures. The vast majority of evidence indicates that the long-term savings generated by these programs far exceed the initial spending and create sustainable models for addressing homelessness and reducing healthcare costs. So, while skepticism or hesitation regarding the initial investments required to establish these programs is understandable, it is clear that the cost of inaction is far greater. Our current situation is unsustainable. Without changing something fast, we risk escalating the financial burden on taxpayers, straining the public health infrastructure, and prolonging the suffering of those experiencing homelessness who are left without the stable support they desperately need.

What can you do?

Just two years ago, Missouri passed legislation that criminalized camping on state property and penalized cities that supported permanent supportive housing. This law, and others like it, were driven by political agendas that targeted Housing First policies, aiming to shift resources away from providing stable housing towards punitive measures and temporary encampments. The impact has been devastating; communities like Springfield have seen more individuals experiencing homelessness pushed onto the streets while essential services struggle to keep up with the rising demand. This kind of legislation illustrates how elections can profoundly affect the lives of thousands, demonstrating that the power to vote can either bolster or dismantle crucial programs for those in need.

So, if you want to see these programs exist in your community, the role of taxpayers is simple but powerful: vote. Make your voice heard. Remember our most vulnerable community members as the local, state, and national elections approach. Consider electing officers dedicated to supporting the health of those experiencing homelessness and holding them accountable as they take office. Show up to the polls and stand up for your dollar. People like Charles are not just statistics—they are our neighbors for whom we have a shared responsibility to support and uplift. Their struggles are not distant issues but part of the fabric of our everyday lives. With your vote, you can decide the future of programs that help to turn hospital discharges into fresh starts, giving neighbors like Charles the chance to recover, rebuild, and thrive.

About the Author

This article was written by Sydney Murray, a medical student at Washington University School of Medicine in St. Louis. Sydney is currently conducting research with the Center for Advancing Health Services, Policy & Economics Research. His research focuses on finding sustainable interventions for homelessness, with a particular emphasis on establishing the need for medical respite care within Missouri and nationally.

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