Health and Health Care Among Adults with Previous Experiences of Homelessness: Findings from the KFF Survey on Racism, Discrimination, and Health

Homelessness in the U.S. is a serious problem that touches the lives of millions of individuals and families across urban, suburban, and rural areas. According to the U.S. Department of Housing and Urban Development, more than 650,000 people were experiencing homelessness on a single night in January 2023, a 12% increase from 2022. The links between homelessness and health are complex. Health problems can be a causal factor in homelessness, and being unhoused may worsen health problems or cause new ones, as well as making it difficult for individuals to access health care services and heal or recover from illness.

This report, based on analysis of KFF’s 2023 Racism, Discrimination, and Health Survey, examines the socioeconomic circumstances and health needs of adults who report experiencing homelessness at some point in their lives.¹  This survey, designed for a different purpose than surveys that attempt to capture the experiences of individuals who are currently unhoused, is most likely to be sampling those who have experienced shorter term and episodic homelessness rather than those who have experienced chronic homelessness. Still, while not a measure of the population that is currently experiencing homelessness (and while causality cannot be shown between experiences of homelessness and the measures reported here), these data provide insights that might help direct efforts to address the needs of this population.

Overall, people with prior experiences of homelessness have disproportionate physical and mental health needs and face greater socioeconomic challenges compared to those who have never experienced homelessness. Among those with prior homelessness experience, women and those with lower incomes report even greater challenges on several measures. People who have experienced homelessness are disproportionately lower income, and the experiences they report could be a result of financial distress, lack of housing, or a combination of both. Despite these challenges, however, most adults who have been homeless at some point in their lives say their health care providers rarely or never ask them about their work, housing, or access to food or transportation, highlighting an opportunity to help improve health by identifying social and economic needs and facilitating access to services during health care visits.

Who Reports Experiences with Homelessness?

One in eight adults say they have personally experienced homelessness at some point in their lives, rising to one in five among Black adults and American Indian or Alaska Native (AIAN) adults. One in ten Hispanic (10%) and White (11%) adults report past experiences of homelessness, as do one in twenty Asian adults (5%). Some adults also report having close family members who have experienced homelessness. In total, one in five adults overall (19%) say they or a close family member have experienced homelessness, rising to one-third (34%) of AIAN adults and three in ten Black adults (30%).

Adults ages 18-64 are about twice as likely as those ages 65 and over to say they have personally experienced homelessness (13% vs. 6%) as are LGBT adults compared to non-LGBT adults (22% vs. 11%). For more on the experiences of LGBT adults, see this report.

Income and Economic Circumstances

Adults who have experienced homelessness are disproportionately low-income and face substantial financial challenges. About a third (35%) of adults who have past experiences of homelessness have family incomes below $20,000, roughly equivalent to the U.S. federal poverty level for a family of two. Just one in ten (11%) people with past experiences of homelessness have household incomes of $75,000 or more, compared to four in ten (39%) of those without such experiences.

Reflecting their lower incomes, one-third (34%) of adults who have experienced homelessness say they have difficulty affording their bills each month, and four in ten (41%) say they are just able to afford their monthly bills. Just one quarter (24%) say they are able to pay all their bills and have some money left over, compared to about six in ten (58%) of those with no prior experience of homelessness.

Two-thirds (65%) of adults with prior experiences of homelessness say they have had problems paying for necessities in the past 12 months, and nearly four in ten (37%) say someone in their household has had problems getting or keeping a job. While these challenges reflect the lower incomes of people who have experienced homelessness, disparities exist even when controlling for income. For example, among those with incomes below $20,000 a year, people who have experienced homelessness are significantly more likely than those without such experiences to report problems affording necessities (75% vs. 45%) and getting or keeping a job (45% vs. 27%).

Across income levels, home ownership rates are lower among those with prior experiences of homelessness compared to those without. Four in ten adults who have experienced homelessness say they own their current home compared with seven in ten (71%) of those without such experience. Home ownership increases with income, but the share who report being homeowners is about 20 to 30 percentage points higher among those who have never experienced homelessness across income levels. In addition, three in ten (31%) adults who have experienced homelessness also say they have been evicted or denied housing at some point, rising to almost four in ten (37%) among those with incomes under $20,000.

Health, Well-Being, and Social Supports

In addition to financial challenges, individuals who have experienced homelessness report substantial needs related to their physical and mental health.

Over one-third (36%) of adults who have experienced homelessness report being in fair or poor physical health, and nearly half (46%) say they have a health condition or disability that keeps them from participating fully in work or other activities. These shares are even higher among adults with prior experience of homelessness who are ages 50 and older (48% and 60%, respectively) or have a household income under $20,000 (46% and 65%, respectively). By comparison, 17% of adults who have not experienced homelessness describe their physical health as fair or poor and the same share (17%) report having a debilitating condition.

Adults who have experienced homelessness are at least twice as likely as their counterparts to report their mental health and well-being as fair or poor (36% vs. 15%) and to say they always or often feel anxious (46% vs. 22%) or depressed (34% vs. 12%). These shares are even higher among women, with about half of women with past experiences of homelessness reporting fair or poor mental health (48%) and frequent feelings of depression (46%) and almost six in ten reporting frequent feelings of anxiety (57%). The share reporting fair or poor mental health is also higher among people with prior homelessness experience and low incomes (47% of those with incomes under $20,000), but there are no significant differences by income in the share reporting feelings of anxiety and depression.

One-third of adults who have experienced homelessness say they are always or often lonely, and two-thirds say they have just a few or no friends and family members living nearby who they can ask for help or support. By comparison, 13% of adults with no prior experience of homelessness say they always or often feel lonely, and fewer than half (45%) say they have just a few or no friends and family nearby for support. Adults who report mental health challenges may be most in need of nearby social supports. However, it’s notable that among those in worse mental health who also report past experiences with homelessness, half (51%) say they are frequently lonely, and the share lacking a robust support network rises to more than eight in ten (84%).

Health care coverage, access, and experiences

Medicaid is a key source of coverage for people who have experienced homelessness, although about one in six reports being uninsured, and a quarter (26%) indicate they have been uninsured at some point in the past year. Reflecting their lower incomes, one-third (33%) of adults with prior experiences of homelessness report being covered by Medicaid, more than twice the share among those who have never experienced homelessness (13%). Also consistent with their lower incomes, one-quarter (26%) of adults who have experienced homelessness say there was a time in the past year when they were uninsured, including 17% who say they currently lack health insurance.

Despite reporting substantial health needs, three in ten adults who have experienced homelessness say they rely on an emergency room or have no regular place to go when they are sick or need advice about their health. The share who lacks a usual source of care is similar among those who report being in fair or poor physical health (30%) and fair or poor mental health (36%), groups that may be most in need of regular access to health services. The share also rises to four in ten among Black adults (41%) and low-income adults (39% of those with incomes under $20,000) who have experienced homelessness.

More than half of adults who have experienced homelessness report skipping or postponing health care in the past year, including three in ten who say their health got worse as a result. Specifically, about four in ten (38%) say they skipped or postponed care they needed because of the cost, about a quarter (23%) tried to get care but couldn’t find a doctor with available appointments, and three in ten (31%) say they skipped or postponed care for some other reason. Reflecting their greater health needs and lower rates of insurance coverage, these shares are significantly higher among those who have experienced homelessness compared to those who have not. Among those who have experienced homelessness, the share who report skipping or postponing care for any reason is similar among those who report being in fair or poor physical health (55%) and is significantly higher among women than men (65% vs. 45%).

In addition to unmet needs for health care, about four in ten (38%) of those who have experienced homelessness say they or someone in their household had problems paying for health care in the past year, nearly twice the share among those with no prior experience of homelessness (22%).

Four in ten adults with prior experience of homelessness report going without needed mental health services in the past three years, including larger shares of younger adults, women, and those with worse mental health. Reflecting their greater mental health needs, adults who have experienced homelessness are about twice as likely as those who haven’t to say there was a time in the past three years when they thought they might need mental health services or medication but did not get them (40% vs. 19%). Among those with prior experience of homelessness, the share who report unmet needs for mental health care rises to more than half (56%) of those who describe their mental health as fair or poor and nearly half of those under age 50 (47%) and women (46%).

While there may be many barriers to receiving mental health services among this population, it’s notable that about half of adults with prior homelessness experience who either sought or received mental health services say it was difficult to find a mental health provider who could understand their background and experience (50%) or one who could see them in a timely manner (46%), and four in ten say it was difficult to find a provider they could afford (39%).

Despite substantial health needs and socioeconomic challenges, most adults who have experienced homelessness say their health care providers rarely or never ask them about their work, housing, or access to food or transportation during visits. Among adults with prior homelessness experience who had at least one health care visit in the past three years, just about a quarter (26%) say their providers asked them about these social and economic factors every time or most of the time, and more than half (54%) say their providers rarely or never asked about these things. Notably, even among low-income adults with prior experiences of homelessness, half say their providers rarely or never ask about these social and economic factors during visits.

The Survey on Racism, Discrimination, and Health was designed and analyzed by researchers at KFF. The survey was conducted June 6 – August 14, 2023, online and by telephone among a nationally representative sample of 6,292 U.S. adults in English (5,706), Spanish (520), Chinese (37), Korean (16), and Vietnamese (13).

The sample includes 5,073 adults who were reached through an address-based sample (ABS) and completed the survey online (4,529) or over the phone (544). An additional 1,219 adults were reached through a random digit dial telephone (RDD) sample of prepaid (pay-as-you-go) cell phone numbers. Marketing Systems Groups (MSG) provided both the ABS and RDD sample. All fieldwork was managed by SSRS of Glen Mills, PA; sampling design and weighting was done in collaboration with KFF.

Sampling strategy:

The project was designed to reach a large sample of Black adults, Hispanic adults, and Asian adults. To accomplish this, the sampling strategy included increased efforts to reach geographic areas with larger shares of the population having less than a college education and larger shares of households with a Hispanic, Black, and/or Asian resident within the ABS sample, and geographic areas with larger shares of Hispanic and non-Hispanic Black adults within the RDD sample.

The ABS was divided into areas (strata) based on the share of households with a Hispanic, Black, and/or Asian resident, as well as the share of the population with a college degree within each Census block group. To increase the likelihood of reaching the populations of interest, strata with higher incidence of Hispanic, Black, and Asian households, and with lower educational attainment, were oversampled in the ABS design. The RDD sample of prepaid (pay-as-you-go) cell phone numbers was disproportionately stratified to reach Hispanic and non-Hispanic Black respondents based on incidence of these populations at the county level.

Incentives:

Respondents received a $10 incentive for their participation, with interviews completed by phone receiving a mailed check and web respondents receiving a $10 electronic gift card incentive to their choice of six companies, a Visa gift card, or a CharityChoice donation.

Community and expert input:

Input from organizations and individuals that directly serve or have expertise in issues facing historically underserved or marginalized populations helped shape the questionnaire and reporting. These community representatives were offered a modest honorarium for their time and effort to provide input, attend meetings, and offer their expertise on dissemination of findings.

Translation:

After the content of the questionnaire was largely finalized, SSRS conducted a telephone pretest in English and adjustments were made to the questionnaire. Following the English pretest, Cetra Language Solutions translated the survey instrument from English into the four languages outlined above and checked the CATI and web programming to ensure translations were properly overlayed. Additionally, phone interviewing supervisors fluent in each language reviewed the final programmed survey to ensure all translations were accurate and reflected the same meaning as the English version of the survey.

Data quality check:

A series of data quality checks were run on the final data. The online questionnaire included two questions designed to establish that respondents were paying attention and cases were monitored for data quality including item non-response, mean length, and straight lining. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, 4 cases were removed.

Weighting:

The combined cell phone and ABS samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). The combined sample was divided into five groups based on race or ethnicity (White alone, non-Hispanic; Hispanic; Black alone, non-Hispanic; Asian alone, non-Hispanic; and other race or multi-racial, non-Hispanic) and each group was weighted separately. Within each group, the weighting parameters included sex, age, education, nativity, citizenship, census region, urbanicity, and household tenure. For the Hispanic and Asian groups, English language proficiency and country of origin were also included in the weighting adjustment. The general population weight combines the five groups and weights them proportionally to their population size.

A separate weight was created for the American Indian and Alaska Native (AIAN) sample using data from the Census Bureau’s 2022 American Community Survey (ACS). The weighting parameters for this group included sex, education, race and ethnicity, region, nativity, and citizenship. For more information on the AIAN sample including some limitations, adjustments made to make the sample more representative, and considerations for data interpretation, see Appendix 2.

All weights also take into account differences in the probability of selection for each sample type (ABS and prepaid cell phone). This includes adjustment for the sample design and geographic stratification of the samples, and within household probability of selection.

The margin of sampling error including the design effect for the full sample is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. Appendix 1 provides more detail on how race and ethnicity was measured in this survey and the coding of the analysis groups. For results based on other subgroups, the margin of sampling error may be higher. All tests of statistical significance account for the design effect due to weighting. Dependent t-tests were used to test for statistical significance across the overlapping groups.

Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

1. The survey question used to define this group is: u201cHave you or any of your close family members ever experienced homelessness?u201d Including those who answered u201cYes, myselfu201d or u201cYes, both myself and a close family member.u201d This definition may differ from other measures of homelessness since it is a self-reported measure is likely to include a mix of experiences in terms of duration and severity of experiences with being unhoused. ↩︎