Infants Exposed To Homelessness: Health, healthcare Use, And Health Spending From Birth To Age Six

Clark RE, Weinreb L, Flahive JM, Seifert RW
Source: Health Affairs
Publication Year: 2019
Patient Need Addressed: Homelessness/housing, Maternal/perinatal
Population Focus: Low income, Medicaid beneficiaries, Vulnerable/disadvantaged
Demographic Group: Child
Study Design: Pre-post with Comparison Group
Type of Literature: White

Homeless infants are known to have poor birth outcomes, but the longitudinal impact of homelessness on health, healthcare use, and health spending during the early years of life has received little attention. Linking Massachusetts emergency shelter enrollment records for the period 2008–15 with Medicaid claims, we compared 5,762 infants who experienced a homeless episode with a group of 5,553 infants matched on sex, race/ethnicity, location, and birth month. Infants born during a period of unstable housing resulting in homelessness had higher rates of low birthweight, respiratory problems, fever, and other common conditions; longer neonatal intensive care unit stays; more emergency department visits; and higher annual spending. Differences in most health conditions persisted for two to three years. Asthma diagnoses, emergency department visits, and spending were significantly higher through age six. While screening and access to healthcare can be improved for homeless infants, long-term solutions require a broader focus on housing and income.

Insights Results

Overview of article

  • The study compared a group of homeless infants to a matched group of infants (by year of birth, sex, race/ethnicity, and region of last residence) who do not fit into the definition of homelessness
  • Using John Buckner’s framework on 3 types of stress that homeless children are exposed to (living in a shelter, problems associated with poverty, and typical biological and family risks that all children face), this study sought to assess longitudinal effects of homelessness on health, healthcare use, and healthcare spending during the early years of life
    Methods of the article
  • Authors used a retrospective case control design to compare infants who were exposed to homelessness and entered an emergency shelter in Massachusetts and similar infants who were born to low-income families but did not experience a homeless episode during the study period
  • All data were from Massachusetts, where qualified homeless families are legally entitled to publicly funded shelter
  • Homeless and comparison groups were matched on the month and year of birth, sex, race/ethnicity, and region of last residence
  • Authors analyzed individual diagnoses for short gestation (less than 37 weeks), fetal growth retardation, and low birth-weight in the year following birth


  • During the first year of life, infants born in the year leading up to or the year following emergency shelter entry were significantly more likely to visit the ED or to be hospitalized than infants in the comparison group. They were also hospitalized more often and had more ED visits and higher median spending. Compared to comparison infants, homeless infants were no more likely to be admitted to a neonatal intensive care unit but had longer median stays when they were admitted
  • Homeless children were more frequently diagnosed with health conditions like low birth-weight, injuries and developmental disorders
  • Differences in diagnosed health conditions, use, and spending were greatest in the first 3 years of life
  • Looking at service use over the entire 6 years, ED use declined in both groups but remained significantly greater in the homeless group than in the comparison group

Key takeaways/implications

  • Overall, children born during a period of family homelessness have significantly greater health risks from birth through early childhood. Our analyses suggest that unstable housing’s impact on infants and children goes beyond the more general effects of poverty and low income
  • Additional research is needed to confirm homelessness’ impact during the perinatal period in other locations and to explain the mechanisms by which homelessness contributes to asthma risk. Moreover, future research using longitudinal data to measure the long-term impact of housing instability is needed
  • Limitations to the study include potential underlying differences between matched comparisons, more comparison infants lost covered during the second study year, inability to follow subjects who switched coverages, inability to link mothers’ claims with those of their infant, inability to capture services rendered by providers who were not Medicaid reimbursable, and inability to measure impact of time spent in shelter because of unreliable data on exit dates for many families