In March, when coronavirus swept through the United States, each state began to implement a “stay-at-home” order. But what about the unhoused population? Homelessness is not foreign to the US. In 2019, a White House executive summary reported that 0.2% of the US population (17 in 100,000 people) experience homelessness every night. 

The CDC states, “People who are homeless are a particularly vulnerable group” due to congregate living spaces and possibly other underlying medical conditions.

The “stay-at-home” order is a massive challenge for the homeless, especially since shelters have slowed their intake to meet social distancing requirements. Shelters and housing are at capacity, resulting in crowded facilities with increased viral transmission. Homeless shelters have turned into “outbreak hotspots” in Washington DC, Nashville, and San Francisco.

Sheltering facilities are only short-term solutions. Emergency homeless shelters often operate on a nightly basis, and temporary housing may accommodate homeless individuals for as little as two weeks. When business shut down, public bathrooms are also closed, making sanitary and hygiene products more inaccessible to the homeless population. Beyond these immediate concerns, life during the pandemic is mentally and emotionally challenging.

As our country explores different ways to address homelessness, we can turn to Seattle / King County, Washington, one of the first three communities in the United States that declared homelessness as a state of emergency in 2015. Seattle is also one of the 5 top cities (along with Los Angeles, San Jose, Oakland, and San Francisco) with the highest homelessness rates in the United States. The state of Washington has been working to fix the homelessness crisis since 2015, but has its efforts to protect the vulnerable population during this pandemic been active enough? Yes and no. 

Washington has been adamant about its “housing first” philosophy when responding to the homelessness crisis. Housing First is an approach to quickly place homeless individuals or families into permanent housing. The model is low-barrier, meaning that applicants do not need to meet any state-mandated requirements. Washington’s low-barrier model supports the state’s belief that housing should be a human right. It abandons the linear model in which homeless people have to meet certain criteria to become “ready” and “awarded” housing. Although Seattle City allocated $80 million to support its homeless population, it is important to examine whether the budget is used toward the homeless. 

The Human Service Department‘s (HSD) mission is to invest in community-based programs and “support the city’s most vulnerable.” A part of HSD is the City of Seattle’s Navigational Team, an outreach program, their primary service is to refer homeless individuals to shelters within the city. However,the referral program’s efficacy is unimpressive. According to HSD’s performance report, out of the total 664 referrals made, only 28% of the individuals enrolled into sheltering facilities. The Navigational team is also responsible for removing multiple campsites in March and May, despite CDC’s explicit advisory against the removal of encampments as “clearing encampments can cause people to disperse throughout the community.” As several campsites were allegedly removed for public safety, who exactly is the city trying to protect? 

Moving people from campsites to other housing options, Tiny Home is an initiative that Seattle has piloted since 2018 to shelter those experiencing homelessness. Tiny homes are temporary housing and are much safer than tents , and provide access to electricity, heat, and light. Tiny homes are often grouped together to form Tiny Villages, with communal kitchens, bathrooms and access to counseling and social services. The Low Income Housing Initiative (LIHI) also suggests that this initiative is a cost-effective and efficient method to bridge individuals, couples, and even families from temporary to permanent housing. This year, Seattle built 40 tiny homes in February, and due to the pandemic expanded to another 50 homes. This is an example of an effective and sustainable response to the city’s homelessness crisis.

Comparing Seattle’s pandemic response to another metropolitan hub: Los Angeles, yields interesting insights. LA’s priority was to get the homeless population into shelter spaces by mobilizing them into motels and hotels while Seattle was reluctant to do so. In April, King County only moved 400 (compared to LA’s 4200) sheltered and unsheltered homeless people into hotels and motels. Seattle wanted to ensure that they move unhoused people into shelters with accessible social services. 

In March, when the Coronavirus Aid, Relief, and Economic Security (CARES) Act passed in congress, Seattle city received $14.1 million to support and expand its emergency services for the homeless population. The city used the money to expand shelter operations for daytime housing, provide social services and to pay for rent and utility to reduce evictions. Despite these advantages, the CARES Act potentially poses a barrier for health clinics and services like the International Community Health Services (ICHS) to provide care to the homeless population in the long-term. ICHS reports that the CARES package funding is only short-term and would only support health centers until November 30, 2020. Health centers that provide health services for the underserved communities rely heavily on federal funding and operate on skim margins. The stimulus package also prevents health centers from billing at its standard Medicare rates. With high operating expenses and foreseeably lower reimbursement rates, lack of long-term federal funding means health clinics must be wary of their financial future.

These health clinics are not alone when they grow weary of the future. As society begins to reimagine the “new normal,” the challenges that the homeless population face continues to exacerbate. To protect the vulnerable population, it is important to advocate for and discuss the issues they are facing and will continue to face, especially within healthcare. 

Although the United States has quickly adapted technology like Zoom+Care and adjusted insurance policies to accommodate for virtual healthcare, the telehealth model is not entirely accessible for homeless patients. Some barriers to telehealth are smart-technology ownership and reliable internet. A USC study suggests that although homeless adults do not lack the devices, older adults with underlying health conditions may limit their ability to use and understand new technology. It may also be challenging for unsheltered homeless individuals to access a private space to call their healthcare provider. Due to COVID, most states have allowed a teleconsultation to replace the in-person evaluation in psychiatry. However, some states continue to require an in-person evaluation to prescribe certain medications (like opioids). Mental health and psychiatry are essential, especially for homeless populations. This barrier in telehealth needs to be removed so that medical services become accessible to those in need.

We must make specific changes looking into the future of healthcare for the homeless. 

For example, we can expand street medicine if teleconsultations are not readily accessible to homeless individuals. Street medicine involves social workers and healthcare providers going to campsites or wherever homeless patients are to provide care. Although this will not replace the primary care visit, it provides temporary care and encourages the patient to seek continued care. HSD currently receives ample funding from the city of Seattle to institute street medicine. Additionally, its Navigation Team could consider extending its partnership to the city’s social workers to build trust and its relationship with the homeless communities.

Seattle needs to make housing and healthcare affordable for the homeless. As the city explores various temporary housing and healthcare options during the pandemic, their long term goal remains constant: to move as much of the homeless population into permanent housing as possible. The city needs to continue to work with landlords, subsidize utility bills, and invest into affordable housing projects like Tiny Homes. Ensuring available, accessible, affordable housing is the primary solution to prevent homelessness. Furthermore, the city needs to share the cost burden with health clinics to ensure that healthcare services are accessible to the homeless. Seattle could also use its ample funding to pilot street medical teams to provide care at campsites. 

The pandemic is forcing many to live in uncertainty. However, it’s certain that Seattle needs to be much more assertive in protecting its susceptible homeless population.

Edited by: Julia Bulova, Akila Muthukumar