The Emerging Crisis of Aged Homelessness in New York City: Could Housing Solutions be Funded By Avoidance of Excess Shelter, Hospital, and Nursing Home Costs?

Background and Purpose: The second half of the baby boomer generation has constituted a disproportionate share of the homeless population since the 1980s, making up 1 in 3 homeless single adults in the U.S. in 2010. Policymakers are ill-prepared and social service providers are poorly equipped to address the growing health care needs of this cohort that comes from the combined effects of homelessness and aging. This study, part of a multi-site project in three U.S cities, reports results from New York City on this convergence of aging and growing health care needs, and the potential of a set of housing solutions to mitigate this problem while providing net cost savings.

Methods: Specifically, we project shelter, healthcare, and nursing home use among a cohort of 13,000 homeless adults 55 and older in New York City based on administrative records of shelter use (from New York City Department of Social Services); hospital stays (from an all-payer claims database of hospital visits in New York State); and nursing home use (from the Center for Medicare and Medicaid Services).  We use age-period cohort spline Poisson regression models to project rates of elderly homelessness through 2030 and cluster analysis to assess patterns of multi-system service use that guide a range of appropriate housing interventions. 

Results: Results indicate that we have entered early stages of a crisis of aged homelessness, with continued growth in service use and costs predicted through at least 2030.  Shelter use among adults aged over 55 is projected to grow by 60% between 2017 and 2030, with growth concentrated in the older members of this cohort.  Among those 65 and older, we project shelter use is likely to triple.  While per-person shelter use decreases slightly with age, healthcare and nursing home use goes up, producing increases in overall costs and leading to projections that annual costs for this group will grow by $177 million (from $284 million to $461 million) between 2017 and 2030.  Cluster analysis suggest that the 85% of this cohort who have moderate shelter and healthcare use would likely benefit from a progressive engagement strategy that includes short-term rapid rehousing or subsidies and housing vouchers with minimal ongoing social services, while the 15% with higher service use and costs would benefit from flexible and enhanced Permanent Supportive Housing models that allow for aging in place.  Based on these findings, a scaled intervention could save 13 cents for every dollar spent.

Conclusion and Implications: Based upon recent services use, we predict a coming wave of aged homelessness among the latter half of baby boomers and an increase in their aging-related health care costs. The excess costs associated with their homelessness—not to mention the avoidable illnesses, exacerbated morbidity, premature disability, and accelerated mortality—should compel us to reflect and act.  Large sums of public funding will go toward this crisis whether we act or not, and policymakers should feel compelled to find the most responsible and efficient use of those funds.