Health system responses to homelessness in the United States: prevalence and predictors.

Introduction: 2024 marked the greatest number of Americans experiencing homelessness ever recorded. Health systems play a pivotal role in caring for unhoused populations, and reducing homelessness decreases healthcare costs and improves health outcomes. As homelessness increases, health systems face mounting pressure to address the social determinants of health, yet little is known about their responses to homelessness. Methods: In 2024, we collected primary data from the 200 largest health systems websites to measure the prevalence of health system homeless mitigation programs and systems-level factors predicting program presence. Results: Over half (56%) of the 200 largest health systems had a homeless mitigation program. The most common program types included affordable and permanent supportive housing, homeless outreach, and shelter medicine. Health systems located in Medicaid expansion states had more than twice the adjusted odds of having a homelessness mitigation program compared with those in non-expansion states (adjusted odds ratio [aOR]: 2.31; 95% CI, 1.11-4.79). Health systems in states with greater shelter capacity were more likely to have a homeless mitigation program, with each additional shelter bed per 10 people experiencing homelessness associated with about 12% higher adjusted odds (aOR: 1.12; 95% CI, 1.01-1.24). Conclusion: As federal spending for safety net programs-including homelessness, housing, and Medicaid-precipitously declines, health systems' homeless mitigation programs may increasingly fill critical policy gaps.