Thursday, June 20, 2024

The cost of homelessness: 10%, the chronically homeless, use 90% of resources

This part two of a five-part series taking a look at money invested to support people in housing crises

Novant typically sees around 30 individuals self-reporting as homeless each month in the ER. (Port City Daily/Amy Passaretti)

SOUTHEASTERN N.C. — While the community has a system and funding in place to track the homeless population, there are some numbers that are more difficult to account for. 

The costs for public resources — medical expenses, emergency room visits and overnights spent in jail  — aren’t broken down according to who is homeless. Unhoused individuals have to self-report their status to jails and hospitals. 

READ PART 1: The cost of homelessness: $1M for tracking data, assisting nonprofits in Cape Fear

New Hanover County Sheriff’s Office Lt. Jerry Brewer told Port City Daily there is no way to search a number of homeless individuals in their system. 

“We don’t track people as homeless or not,” he stated.

Port City Daily filed a records request for arrests on one confirmed homeless person who has been living on the streets of downtown for at least a decade. According to data provided by NHCSO, the person spent 111 days in jail over 13 years.

Brewer said it costs $120 per day to cover one inmate, which means the sheriff’s office has spent $13,320 to “house” at least one homeless person in the last decade.

Yes, “house.”

“HUD considers folks who are in jail to be housed,” Cape Fear Continuum of Care executive director Judy Herring said.

Cape Fear Continuum of Care tracks how many people are homeless in the tri-county area annually through its point-in-time count. It’s funded by the U.S. Department of Housing and Urban Development; however, HUD does not include incarcerated individuals or emergency room patients in the count. 

“We want to put someone in the ER to count for [point in time], but the hospital has legitimate concerns about privacy and HIPAA,” Herring said.

Part one of Port City Daily’s “The Cost of Homelessness” covered funding that the CoC receives to gauge the amount of homeless people in southeastern North Carolina. Its member agencies, local nonprofits, tracked 1,800 people accessed services through its HUD-compliant system in 2022. The CoC a doled out more than $1 million last year for its administrative and tracking needs, as well as acting as a passthrough for federal grants for local nonprofits.

According to experts in the field, a good rule of thumb when thinking about resources the overall homeless population consumes is a 10%-90% rule: A small portion (10%), considered chronically homeless, utilize the most (90%). 

Their needs often exceed that of others, as many have underlying conditions, such as substance use disorder, mental health conditions or disabilities, meaning additional social services are often needed to support the population. 

According to HUD, people living in homeless shelters are twice as likely to have a disability than the general population. Thus, it becomes more difficult for them to afford rent while living on a fixed income.

Port City Daily looked into Novant’s charity care, New Hanover County Detention Center, and The Healing Place to gather a snapshot of the financial impact. Upon asking a county spokesperson about a breakdown of funds in the human and health services department for services for the homeless, PCD was told it wasn’t categorized as such (more on that in part three of the series).

The New Hanover County Detention Center doesn’t track inmates as homeless, and HUD considers individuals in jail as “housed.” (Port City Daily/File)

‘They need a break’

“The most challenged, most fragile, tend to need so much,” Good Shepherd Center’s executive director Katrina Knight said. “Proportionately, what they’re consuming swamps what the average unhoused household might be in need of.”

Research obtained by Port City Daily showed a 20-something homeless person with diabetes, depression and sexual abuse was admitted to an area hospital almost 70 times in three years. The bill was more than $200,000. 

According to research conducted by Dr. Thomas Dalton, who founded Eden Village — a development to house the chronically homeless — one homeless individual was admitted to the hospital 246 times in a 36-month period in recent years. 

But what happens if that person doesn’t have the means to pay?

According to the National Alliance to End Homelessness, between 2011 and 2018, ​​53% of those living in homeless shelters and 40% of unsheltered people were employed, either full or part-time. NAEH points to a 2015 study by the University of Chicago that indicated in 2015 a homeless individual had a mean salary of $6,934 — just over 3% of the total cost of a $200,000 hospital bill.

Novant offers charity care to anyone uninsured, unable to access other programs that could cover medical expenses, those ineligible for government-sponsored coverage, and have an annual family income of under 300% of current federal poverty guidelines.

For 2023, the U.S. Department of Health and Human Services reports the federal poverty guideline as $14,580 annually for a single person and $30,000 for a family of four.

In 2022, Novant New Hanover Regional Medical Center doled out $71 million to 13,000 charity care patients — again, there is no distinguishing who is homeless. In 2021, the hospital served 16,552 clients with financial assistance. 

On average, Novant sees just under 30 patients per month self-reporting as experiencing homelessness.

“We know that the true number is most likely higher due to those who choose not to report their housing challenges or notate temporary housing or shelter stays,” Novant spokesperson Julian March said.

Patients self-report their address when registering at the hospital, he added, or provide a shelter location. 

Novant’s medical intake includes questions on housing stability in the past 12 months. It assists staff with linking the patient to necessary resources at the hospital’s disposal.

“We also consider any internal Novant Health referrals that may support the patient, including potential referrals to a community health worker or a community paramedic, and our Outpatient Pharmacy can provide prescription assistance upon leaving the ED,” March explained.

According to a report in the New England Journal of Medicine, homeless people spent an average of four days longer per hospital visit than non-homeless people. This extra cost equals approximately $2,414 per hospitalization.

Novant is in the process of constructing two clinics specifically to serve the uninsured and under-insured of the community — at least 24,000 people in New Hanover County. Basketball star and Wilmington native Michael Jordan donated $10 million in early 2021 to construct both facilities.

“These clinics will be transformative for the neighborhoods they serve and the broader community and will offer much-needed services to those who are uninsured or underinsured, regardless of housing status,” March said.

Cape Fear Continuum of Care vice chair Pastor Meg McBride said homeless individuals often turn to hospitals or jail out of “desperation” to have a place to go. 

“They need a break,” she said, especially since shelters in the region tend to fill up quickly.

The city’s community development and housing planner Suzanne Rogers, who supports nonprofits serving vulnerable populations, as well as affordable housing developers, said there was a 95% occupancy of all beds as of January this year. 

In 2022, 559 individuals were enrolled in nine emergency shelters and six transitional shelters in the tri-county region.

At the beginning of 2023, there were 118 emergency shelter beds in the Cape Fear, 23 beds for transitional housing, 21 beds allocated to domestic violence shelters, 187 rapid rehousing beds, and 81 units of permanent supportive housing and 60 beds for rapid-rehousing. 

Recently, New Hanover County invested $25 million to build The Healing Place, a 200-bed recovery, detox and emergency shelter. It should help add to the number of beds in the region. 

Within the first month of operation at The Healing Place — it opened in February — more than 255 people took advantage of the overnight emergency shelter, which includes beds, showers, and two hot meals. Both the men’s and women’s emergency shelters, a total of 14 beds, stay consistently full at 50 to 60% capacity, according to The Healing Place spokesperson Megan Youssefi. 

She said it’s a low-barrier, safe resource for individuals who need a place to shower, eat, and rest.

“We think the new restrictions that were put in place regarding the 3rd street bridge and the downtown library are likely contributing to our volume,” she said.

Youssefi was referring to the county ordinance that went into place in February that bans anyone from sleeping on county property between 10 p.m. and 7 a.m. daily. It was aimed to disperse homeless congregations from the Chestnut Street library and Meadowlark Lemon Bridge on Third Street.

ALSO: ‘No trespassing’: Officials lay down the law, pose further restrictions on frequented homeless encampments

“We do not see ourselves as being a resource that can completely alleviate the homelessness issue in the area — we just don’t have the space,” Youssefi said.

The Healing Place’s model provides services at no cost to an individual; however, it costs the facility $67 per night per client.

New Hanover County pays $45 per day for clients it sends to The Healing Place.

According to the National Prevention Science Coalition to Improve lives, the cost of an emergency shelter bed funded by HUD is approximately $8,067 more than the   average annual cost of a federal housing subsidy.

The Warming Shelter, a nonprofit that opens any two consecutive nights the temperature drops below 30 degrees, spent $1,200 to operate five nights during Christmas. However, it’s primarily run by volunteers, secures a space for free and has food and other items donated. 

During December 2022, it served between 70 and 90 people per night and provided cots and blankets, two hot meals (dinner and breakfast), and showers. The laundry bill alone following the pop-up shelter was $600.

Permanent shelters pay more, as they are typically staffed with employees and require maintenance and upkeep costs of facilities, not to mention ongoing rent, utility bills and day-to-day operational expenditures.

“It’s hard for us to calculate [our shelter costs alone] because it’s difficult to separate out the built-in case management, which tends to all be combined for homeless and others,” Knight said of the Good Shepherd.

But when shelters are full, what happens? 

Dalton said it’s not uncommon for the ER to fill up. The 1986 Emergency Medical Treatment and Active Labor Act requires medical employees and volunteers to assist any person asking for help. 

“On a cold night in Wilmington, there can be as many as 50 people in the ER without medical diseases,” he said.

Some of the homeless clients wind up accessing medical attention through Novant by way of the county detention center. 

“We also have people come in that are sick and we have to provide medical care to,” Brewer said. “They can be in our custody but at the hospital racking up costly bills.”

The sheriff’s office is the only department with a jail in town. So even if an inmate is being investigated or arrested by the Wilmington Police Department, it’s NHCSO’s responsibility to cover the costs of medical expenses.

Medicare and Medicaid helps if a person is eligible, but the sheriff’s office endures that cost as well. With Gov. Roy Cooper signing Medicaid expansion into law in March, it will aid in coverage for a greater portion of the population, including the homeless.

“Medicaid expansion will assist all sectors of the population who fall within the income guidelines, therefore undoubtedly it will allow the homeless to receive medical/mental health benefits that they otherwise may not have access to,” New Hanover County social services director Tonya Jackson said.

The sheriff’s department spends $2.9 million annually on a contract with its medical provider Wellpath to cover in-house treatment. 

Over the last year, inmates under the custody of the NHCSO spent a total of 340 days in the hospital, billed to the department. The majority is covered by the NHCSO’s medical contract.

On average, jailed individuals make 10 emergency visits per month, four hospital admissions monthly, 30 new patient visits and 41 follow-up patient visits. Nurses treating patients in the detention center made contact with nearly 45,000 last year and 35 emergency response visits.

Some inmates facing substance use disorders are also sent to detox when arrested. Last year, it amounted to 1,660 inmates.

“We have our own medical unit,” Brewer said. “They just detox there.”

According to the National Institute on Drug Abuse, 85% of the prison population nationwide has an active substance use disorder or were incarcerated for a crime involving drugs.

One in five homeless people in the U.S. have a substance use or mental health disorder, according to a study by the National Library of Medicine.

The city and county will receive more than $34 million in opioid settlement funds over the next two decades. Combined, the two have planned to invest $8 million over five years toward opioid treatment services, a fraction of the cost contributed to assist the homeless population.

The city and county’s opioid settlement committee has allocated $182,000 annually for five years to provide medication-assisted treatment, considered the “gold standard” for recovery, in the New Hanover County Detention Center. The jail’s healthcare consultant estimates 30 inmates are currently utilizing MAT. The additional funding could cover at least five more per week, or 300 per year.

During its last meeting, the committee also decided to allocate additional funds in 2025 to the Getting Home initiative — pairing county social workers with Wilmington Police Department officers for street outreach to the homeless population. The funding will allow the program, currently operating with American Rescue Plan Act money through December 2024, to continue.

Part three in the series will focus on more details about the investments made by local governments, namely New Hanover County and the City of Wilmington, to assist those experiencing homelessness.

Tips or comments? Email

Want to read more from PCD? Subscribe now and then sign up for our morning newsletter, Wilmington Wire, and get the headlines delivered to your inbox every morning.

Related Articles