Fields Jessica D, Assaf Ryan D, Nguyen Kim Hanh, Platamone Corbin C, Pottebaum J Margo, Giannola Jesica, Kushel Margot B
Benioff Homelessness and Housing Initiative, Division of Health Equity and Society, Department of Medicine, University of California, San Francisco.
University of California, Berkeley-University of California, San Francisco Joint Medical Program, University of California, Berkeley.
JAMA Health Forum. 2025 May 2;6(5):e250820. doi: 10.1001/jamahealthforum.2025.0820.
Demographic and policy changes have occurred since the last large, representative study of homeless adults in the 1990s, which may affect health care access and use.
To describe the prevalence of poor health care access and short-term health care and use the Gelberg-Andersen Behavioral Model for Vulnerable Populations to assess the association between changes in homelessness with health care access and short-term care use.
DESIGN, SETTING, AND PARTICIPANTS: This representative survey of adults experiencing homelessness in California from October 2021 to November 2022 used multistage, venue-based, and respondent-driven sampling. Data were analyzed from May 2023 to December 2024.
Shelter status (predisposing vulnerable), insurance (enabling), impairment with activities of daily living (ADL; need), and illicit substance use during the previous 6 months (need).
The study assessed self-reported no prior-year ambulatory care use and prior 6-month unmet health care need, unmet medication need, emergency department (ED) use, and hospitalization. Population prevalence estimates with Wald 95% CIs and multivariable Poisson regressions were calculated to compute prevalence ratios (PRs).
Thirty-two hundred adults completed the survey (mean age, 46.1 [95% CI, 45.3-46.9] years; 1965 cisgender men [67.2%], 1148 cisgender women [31.2%], and 57 transgender and gender queer individuals [1.6%]), of whom 2016 (77.6%) were unsheltered, 2609 (82.6%) were insured, 1056 (34.4%) had an ADL impairment, and 911 (37.1%) reported illicit substance use 3 or more times a week. A total of 1121 (39.1%) reported no ambulatory care use; 765 (24.3%) reported an unmet health care need and 714 (23.3%) an unmet medication need; 1252 (38.9%) used the ED; and 668 (22.0%) were hospitalized. Lack of ambulatory care use (PR, 1.71; 95% CI, 1.51-1.94) and unmet health care needs (PR, 1.19; 95% CI, 1.02-1.40) were more prevalent for those who were unsheltered. Lack of ambulatory care use (PR, 0.63; 95% CI, 0.57-0.70) and unmet health care needs (PR, 0.80; 95% CI, 0.67-0.95) were less prevalent for those with insurance. Unmet health care needs (PR, 2.13; 95% CI, 1.79-2.55), ED use (PR, 1.15; 95% CI, 1.02-1.30), and hospitalization (PR, 1.74; 95% CI, 1.40-2.17) were more prevalent for those with an ADL impairment. Lack of ambulatory care use (PR, 1.46; 95% CI, 1.19-1.79) and unmet health care needs (PR, 1.30; 95% CI, 1.08-1.55) were more prevalent for those who used illicit substances 3 or more times a week.
This cross-sectional study found that adults experiencing homelessness reported poor access to ambulatory care and a high prevalence of short-term care use, despite high rates of insurance. Changes in homelessness during the past 30 years were associated with worsened health care access and use.
自20世纪90年代上次对无家可归成年人进行的大型代表性研究以来，人口结构和政策发生了变化，这可能会影响医疗保健的可及性和使用情况。
描述医疗保健可及性差和短期医疗保健的患病率，并使用弱势群体的格尔伯格 - 安德森行为模型评估无家可归状况的变化与医疗保健可及性和短期医疗使用之间的关联。
设计、背景和参与者：这项于2021年10月至2022年11月对加利福尼亚州无家可归成年人进行的代表性调查采用了多阶段、基于场所和受访者驱动的抽样方法。数据于2023年5月至2024年12月进行分析。
庇护状况（易患脆弱性）、保险（促成因素）、日常生活活动能力受损（ADL；需求）以及前6个月内的非法药物使用情况（需求）。
该研究评估了自我报告的上一年未使用门诊医疗服务以及前6个月未满足的医疗保健需求、未满足的药物需求、急诊室（ED）就诊情况和住院情况。计算了带有Wald 95%置信区间的总体患病率估计值以及多变量泊松回归，以计算患病率比值（PRs）。
3200名成年人完成了调查（平均年龄46.1岁[95%置信区间，45.3 - 46.9岁]；1965名顺性别男性[67.2%]，1148名顺性别女性[31.2%]，57名跨性别和性别酷儿个体[1.6%]），其中2016人（77.6%）无庇护场所，2609人（82.6%）有保险，1056人（34.4%）日常生活活动能力受损，911人（37.1%）报告每周使用非法药物3次或更多次。共有1121人（39.1%）报告未使用门诊医疗服务；765人（24.3%）报告有未满足的医疗保健需求，714人（23.3%）报告有未满足的药物需求；1252人（38.9%）使用了急诊室；668人（22.0%）住院治疗。对于无庇护场所的人来说，未使用门诊医疗服务（PR，1.71；95%置信区间，1.51 - 1.94）和未满足的医疗保健需求（PR，1.19；95%置信区间，1.02 - 1.40）更为普遍。对于有保险的人来说，未使用门诊医疗服务（PR，0.63；95%置信区间，0.57 - 0.70）和未满足的医疗保健需求（PR，0.80；95%置信区间，0.67 - 0.95）不太普遍。对于日常生活活动能力受损的人来说，未满足的医疗保健需求（PR，2.13；95%置信区间，1.79 - 2.55）、急诊室就诊（PR，1.15；95%置信区间，1.02 - 1.30）和住院治疗（PR，1.74；95%置信区间，1.40 - 2.17）更为普遍。对于每周使用非法药物3次或更多次的人来说，未使用门诊医疗服务（PR，1.46；95%置信区间，1.19 - 1.79）和未满足的医疗保健需求（PR，1.30；95%置信区间，1.08 - 1.55）更为普遍。
这项横断面研究发现，尽管保险覆盖率较高，但经历无家可归的成年人报告称门诊医疗服务可及性差且短期医疗使用患病率高。过去30年中无家可归状况的变化与医疗保健可及性和使用情况的恶化有关。
