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Clinical Scenario
They’re discussing the treatment of a young homeless man who was assaulted in an alley. He sustained a broken nose, soft tissue trauma, and lacerations to the face and ears, along with several broken teeth. The gist of the conversation centers on what needs to be done in the emergency department.
The resident physician suggests calling an otolaryngologist to evaluate the patient and perform repairs on his face and ears. The attending, however, strongly believes that “no otolaryngologist will see and operate on this homeless guy with no insurance. It’s better to glue his lacerations, bandage his ears, and forget the broken nose. Let’s patch him up quickly and get him out; we can’t afford the expense of his care. If he isn’t an addict now, he will be in the future. Let him be someone else’s problem down the line.” The resident reluctantly agrees. You consider stepping toward them and saying, “I’m an otolaryngologist. Do you mind if I see the patient?”
Discussion
Caring for the homeless and uninsured in America can be a challenge. It has been estimated that nearly 600,000 people in the United States are homeless, a number that may well be underestimated. Because of the “fluidity” of homeless persons’ dwellings, it’s very difficult to capture the true prevalence of homelessness. Some persons may live in a shelter for a while, and then move back to the streets and parks for longer periods.
Most homeless people are also uninsured, although most uninsured are not necessarily homeless. Current statistics on the prevalence of the uninsured (or underinsured) indicate that over 27 million people (3 million of them children) are living in the United States with limited access to, and availability for, continuity of care.
Perhaps the most challenging groups of people to deal with when it comes to offering proper healthcare are the economically disadvantaged, the uninsured, low-income children, racial and ethnic minorities, the elderly, and those with chronic physical and mental conditions.
In particular, the homeless are vulnerable to physical assaults due to weakness, malnutrition, substance abuse, and lack of safe shelter. Lack of education and communication skills may prevent them from understanding the nuances involved in accessing the U.S. healthcare system and obtaining forms of personal identification to better receive treatment for injuries and illnesses.
Two other special groups that may be marginalized with respect to lack of care are veterans with mental health illnesses and undocumented migrants. Veterans who choose to be homeless often experience significant post-traumatic stress disorder, and, while eligible for healthcare from the Department of Veterans Affairs, choose not to seek that care. Undocumented migrants are rapidly becoming a substantial group in need of healthcare, with few or no options in a community where they fear being reported and deported. While they may not become homeless, many are uninsured and may turn to unlicensed practitioners for health issues.
Homeless and other uninsured people often have significant mental health disorders, which can limit their decision-making capacity and their attention to the daily skills of life. Limited access to safe shelter, food, clean water for drinking and bathing, and clean clothes all predispose the homeless to infections and gastrointestinal disorders. Substance use—alcohol, drugs, and tobacco—can further aggravate pre-existing medical conditions or lead to new ones. As homeless encampments arise in areas where they weren’t previously seen, societal support for healthcare for this population may deteriorate, and they may increasingly be seen as social pariahs, further reducing concern for their plight.
Limited Healthcare Delivery Options
Public or social healthcare in the United States is insufficient to provide the infrastructure for these groups. Our healthcare delivery system is primarily built on the foundation of federal, state, and third-party insurance coverage. While some care is available through community health plans, free clinics, and federally qualified health centers, they currently serve a small proportion of the homeless and uninsured populations.
Additionally, some homeless people don’t trust public health entities to have their best interests at heart in the limited care that’s provided. This isn’t an indictment of local health centers, which typically provide the best care they can under their constraints, but rather a recognition that, in general, the United States has failed to transition to a healthcare system that provides the greatest good for the greatest number.
The emergency and acute care departments at hospitals typically provide the bulk of the significant care for the homeless, particularly those with serious illnesses and untreated chronic conditions. Understandably, the attitude of providers at some emergency departments may tend toward a cynical approach when it comes to caring for the homeless, particularly in light of limited resources and budget constraints.
Many hospitals do provide “charitable care” for low-income persons, including the homeless and uninsured/underinsured, with federal government reimbursement in the form of Medicare Disproportionate Share Hospital payments. Medicaid and the Children’s Health Insurance Program can be helpful in supporting care for the homeless and uninsured, but the level of support varies among states.
It’s a difficult navigation for an individual otolaryngologist to locate and obtain the resources to care for a homeless person who requires medical help—in particular, surgical procedures. Often, the otolaryngologist will have to present the patient’s needs to hospital administration, secure a willing anesthesiologist to become a pro bono member of the surgical team, and provide their surgical services and postoperative care without compensation. The engagement of social workers in the otolaryngologist’s healthcare system is valuable in obtaining financial support where feasible. Depending on the hospital and the patient’s surgical recovery, it can be quite daunting.
There is also, unfortunately, the issue of the possibility of a lawsuit against all the providers if all doesn’t go well. In sum, the otolaryngologist takes on a good deal of risk. One may ask, “Is it worth it?” or “Why not let it be someone else’s problem?”
Everyone’s Problem
Fortunately, our profession is guided by a code of ethics, a code of moral conduct, ethical principles, and professional virtues, all of which give us the answer to the questions posed above. While we all believe in helping patients and not harming them, we also must understand our obligation to the principle of “social justice.”
This principle is evolving in its modern application to healthcare obligations, and we now understand that it applies to all patients, regardless of their socioeconomic status or where they live. We are obliged to care for those who need our skills and capabilities, without judgment or bias, and to the very best of our abilities and experience. Homeless and uninsured persons aren’t “invisible” to us, aren’t “subhuman,” and shouldn’t be objects of pity. They are human beings who, for their own reasons (or society’s reasons) choose to live outside the social environment with which we are most familiar. We must see them as real people, empathize with them, understand them, and help them however we can. Yes, caring for the homeless and uninsured may be a challenge, and they may take more of our valuable time than other patients, but if we deny them our care, we stand to lose a bit of our professional soul in the process.
So, in answer to the clinical scenario presented at the beginning of this article, you should go examine this young man, talk to him, and get to know him. Identify ways you can help him and ask for his consent. Then, go about making the effort to get all of the resources you’ll need for him rounded up and willing to help. It isn’t “charity,” but rather human compassion and a recognition of our professional duty to him as physicians and surgeons.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.