Appendix (I-VII)

The epidemic of premature death among people who experience homelessness in the United States is staggering and has continued to grow. The mean age at death in this population is 51 years — nearly 25 years younger than that in the general population and an age at which Americans commonly died in 1900.1 The statistics are particularly striking for certain subgroups, such as people who sleep on the street. Age-adjusted mortality in this group is nearly 10 times that in the general housed population and nearly 3 times that among people who sleep primarily in shelters.2

Various factors contribute to an increased risk of premature death among people experiencing homelessness. People who become homeless have often had exposure to health-harming factors from an early age, such as neighborhood disadvantage and discrimination, that are linked with premature death in other historically excluded populations (e.g., people with severe mental illness and marginalized racial and ethnic groups). People who experience homelessness have a substantially higher disease burden than the general population, including more advanced cardiovascular disease and higher rates of cancer. Limited access to health care, medications, and a safe place to rest contributes to this burden and complicates management of medical conditions.

Substance use, which is often associated with a history of trauma, also leads to a devastating number of overdose deaths among people experiencing homelessness.1 In addition, violence, accidents, and exposure to severe weather cause thousands of deaths every year among people in this population. The Los Angeles County Department of Public Health notably found that relative to the general population, people experiencing homelessness were 41 times as likely to die from a drug or alcohol overdose, 18 times as likely to die from traffic-related injuries or by homicide, 8 times as likely to die by suicide, and 4 times as likely to die from heart disease.

Although no federal agency collects nationwide data on deaths among people experiencing homelessness, a study of data from 10 states found that all-cause mortality in this population increased 238% between 2011 and 2020.1 The aging of this population, the increased availability of fentanyl, and disruptions in social services during the Covid-19 pandemic have contributed to steep increases in deaths. In some cities, numbers of deaths among people experiencing homelessness have recently doubled.3

 The indignities that people experiencing homelessness endure during life carry over after death. Our team has found that when a postmortem examination of a person who was homeless is conducted, it is often only a partial or limited examination. Housing status is rarely recorded on local and state death reports; one study found that only 2% of U.S. counties clearly documented deaths among people experiencing homelessness.4 Furthermore, many people who were homeless remain unidentified after death. These factors not only dehumanize members of an already marginalized population but also thwart data collection on the number and causes of deaths among people experiencing homelessness. This lack of information impairs research. It hinders prevention efforts. And for clinicians caring for these patients, it deepens grief and complicates closure. 

 Steps can be taken to recognize people who were homeless after they die — and to support people experiencing homelessness during life. Improving the visibility of these currently invisible deaths could help save lives. One policy change could involve requiring the recording of housing status on death certificates. Collecting standardized data related to mortality among people who experience homelessness, including sociodemographic information and place and cause of death, could enhance understanding of this pressing public health issue among clinicians and policymakers. Linking mortality data with data on the use of health care and social services could permit identification of potential points of intervention.3 Postmortem examinations conducted in this population could consistently test not only for the presence of drugs but also for other plausible causes of sudden death. Meanwhile, increased investments in Housing First, street-medicine, and harm-reduction programs are critical to reduce rates of disease and premature death. Clinicians should also be trained to help patients who are suffering on the street.5 Finally, society needs to make a sustainable commitment to increasing the availability and affordability of housing and to preventing early-life trauma. 

The United States is failing to fulfill one of the most basic responsibilities of any country: preventing needless suffering and death. The United States falls short when it comes to both protecting the health of individual people and promoting societal well-being. These shortfalls are glaringly apparent in Mirror, Mirror 2024, the Commonwealth Fund’s eighth report since 2004 comparing the health systems of 10 high-income countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States.1 This edition of the report, which we coauthored, is the first to account for the effects of the Covid-19 pandemic on the comparative performance of health systems. The study is based on 70 measures of health system performance, grouped into five domains: access to care, care process, administrative efficiency, equity of care, and population health outcomes. Data are from 2020 or later and are drawn from publicly available sources, including the Organization for Economic Cooperation and Development (OECD), Our World in Data, and the World Health Organization, and from Commonwealth Fund surveys of doctors and residents in participating countries. The United States ranks last overall on these measures of performance and last or nearly last in four of the five domains. This record is all the more distressing because of the country’s exorbitant expenditures on health care, which far exceed those in any other high-income country. As the graph shows, Americans get much less value for the money they invest in their health system than people in other high-income countries.

Relative Performance and Spending among Health Systems in 10 High-Income Countries.

No element of a health system’s performance is more important than the health outcomes it achieves for its population. The United States has the lowest life expectancy among the 10 countries we studied, 4 years less than the 10-country average. It also ranks last on measures of preventable mortality and “treatable mortality,” as defined by the OECD. These measures capture deaths that could have been averted by means of preventive services or timely and effective treatment, such as deaths from hypertension, diabetes, cerebrovascular disease, ischemic heart disease, or renal failure. The United States had the highest excess mortality attributable to Covid-19 among people younger than 75 years of age in 2021. It also has the highest rate among the 10 countries of death from self-harm, which includes deaths by suicide, and the highest rate — by orders of magnitude — of death from assault, which includes deaths caused by gun violence.In addition, the United States ranks last on measures of access to care and equity of care and next to last on measures of administrative efficiency. With respect to access, its poor performance largely reflects cost-related barriers to care resulting from persistently high proportions of residents who are uninsured. Although the percentage of uninsured U.S. residents has fallen to historically low levels, it still far exceeds percentages in other high-income countries, where universal coverage is the norm. Another contributor to access barriers is inadequate coverage among insured Americans because of high deductibles and copayments. In the equity domain, the United States has the largest gaps between people with below-average incomes and those with above-average incomes on various measures of access to care, care process, and outcomes.2 The complexity of the U.S. health system has led to high rates of patients and doctors reporting spending large amounts of time on administrative issues related to insurance claims and medical bills, which contribute to the country’s poor performance in the area of administrative efficiency.What could the United States do to move from health care laggard to leader? Possible solutions would involve actions well beyond the health care sector and would require significant reforms in a polarized society where making even incremental changes is extremely challenging.Many of the U.S. health system’s shortfalls result from persistent economic barriers to obtaining essential care. The Affordable Care Act and related policies reduced the proportion of uninsured people to its current level of 7 to 8%. But 26 million Americans still lack insurance. Providing everyone in the United States with high-quality coverage that includes reasonable limits on out-of-pocket expenditures would ensure that Americans at all income levels have access to services that could help reduce preventable suffering and death. Substantial progress toward this goal could be made by building on existing programs, such as the Affordable Care Act, Medicare, and Medicaid.Providing insurance, however, will not be sufficient. The U.S. health care delivery system has profound problems that result in huge inefficiencies and excessive costs that would limit the benefits of expanded coverage. One such problem is the country’s worsening shortage of primary care clinicians, who are essential to assuring timely access to services and to managing increasingly prevalent chronic illnesses in an aging population. Improved compensation and reductions in administrative burdens for primary care clinicians would help the health system recruit and retain such clinicians and build desperately needed capacity.A second delivery-system failure is the high prices charged by U.S. health care facilities and professionals, which far exceed prices in other health systems.3 These high prices largely account for the extraordinary costs of care in the United States, which would make expanded coverage less affordable and which drive employers, who purchase insurance for more than half of Americans younger than 65 years of age, to impose high deductibles and copayments. One of the reasons health care organizations are able to charge such high prices is that they have obtained increasing economic power in local markets as a result of consolidation — both horizontal consolidation among hospitals and vertical consolidation, which involves large organizations acquiring physician practices. The arrival of private equity investors who “roll up” physician practices in local markets and then raise prices has also contributed to the escalation of U.S. health care costs.4 Increased scrutiny by antitrust agencies at every level of government is essential to mitigate the effects of consolidation on the cost of care in the United States.Improvements in coverage and the delivery system will need to be complemented by policies targeting critical influences on health outside the health sector. The United States lags behind comparator countries when it comes to addressing the social determinants of health, such as poverty, homelessness, inequality, and hunger. As its poor performance during the Covid-19 pandemic made clear, the United States needs a far more robust public health system to address the threat of pandemic illness.5 The toll of gun violence in the United States also demands policy attention.One notable finding from the report is the strong performance of the United States on measures of care process. These measures draw heavily on responses to survey questions concerning, for example, whether people received counseling from physicians about smoking cessation, alcohol use, diet, and weight control; whether they received preventive care, such as vaccinations and mammograms; whether their clinicians were respectful and engaged in their care; and whether physicians reviewed their medications with them. The United States ranked second overall in this domain, but the reasons for its relatively strong performance are uncertain. Perhaps pay-for-performance programs, such as the Medicare Advantage star ratings system, are having a greater effect on care processes than is commonly believed. The Affordable Care Act’s requirement that evidence-based preventive services be fully covered by insurance may also be affecting outcomes in this domain. 

•  Tsai, J., & Rosenheck, R. A. (2015). Risk Factors for Homelessness Among US Veterans. Epidemiologic Reviews, 37(1), 177-195. https://doi.org/10.1093/epirev/mxu004 
• Pavao, J., Tull, T., & Lee, S. (2013). "Military Sexual Trauma Among Homeless Veterans." Journal of General Internal Medicine, 28(S2), S536-S541. Link: https://doi.org/10.1007/s11606-013-2341-4
• Martijn, C., & Sharpe, L. (2006). "Pathways to Youth Homelessness." Social Science & Medicine, 62(1), 1-12. Summary: This paper discusses how repeated exposure to uncontrollable negative events, including family conflict, abuse, and neglect, leads to a learned helplessness mindset in homeless youth. This mindset makes it challenging for young people to seek help or leave the streets, as they often feel powerless to change their circumstances. Link: https://doi.org/10.1016/j.socscimed.2005.05.007 
• Bonin, J. P., Fournier, L., & Blais, R. (2007). "Predictors of Mental Health Service Utilization by People Using Resources for Homeless People in Canada." Psychiatric Services, 58(7), 936-941. Summary: This study examines mental health service usage among homeless individuals, identifying learned helplessness as a major barrier to accessing services. Those with PTSD and other mental health issues are often discouraged from seeking help due to feelings of helplessness and a lack of perceived control over their situation. Link: https://doi.org/10.1176/ps.2007.58.7.936 
•  Goodman, L. A., Saxe, L., & Harvey, M. (1991). Homelessness as Psychological Trauma: Broadening Perspectives. American Psychologist, 46(11), 1219-1225. https://doi.org/10.1037/0003-066X.46.11.1219 
•  Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. The Open Health Services and Policy Journal, 3(1), 80-100. https://doi.org/10.2174/1874924001003020080 
• Burt, M. R., & Aron, L. Y. (2000). "America’s Homeless II: Population and Services." Urban Institute Press. Summary: This comprehensive report explores the psychological impact of trauma on homeless individuals, showing how exposure to violence, substance abuse, and instability fosters helplessness. The report discusses how homeless individuals, especially those with a history of trauma, may become trapped in a cycle of dependency and helplessness. Link: Urban Institute Report PDF  
• Padgett, D. K., & Tsemberis, S. (2012). "Housing First Services for People Who Are Homeless With Co-occurring Serious Mental Illness and Substance Abuse." Research on Social Work Practice, 22(1), 114-122. Summary: This article focuses on the experiences of homeless women with histories of trauma, showing how PTSD and learned helplessness contribute to long-term homelessness. The study discusses how Housing First models can mitigate some of these psychological impacts by providing stability and trauma-informed care. Link: https://doi.org/10.1177/1049731511435867