California’s unhoused population is locked out of healthcare. Medi-Cal is California’s Medicaid healthcare program that promises to “be a catalyst for equity and justice” [1]. Although almost all unhoused individuals logistically qualify for Medi-Cal benefits, a great number of them are unable to access them [2]. The life expectancy of unhoused people is 30 years less than that of typical citizens in California [3]. To better understand why this is the case, policymakers need to acknowledge the invisible access barriers to healthcare. Only then can California begin to bridge the gap between the 181,000 unhoused individuals and the broader American community [4].  

Weak public transportation is a major obstacle that contributes to low healthcare accessibility because homeless people are entirely dependent upon these services to travel and receive care. Public transit is inefficient and substandard in California, accounting for the decline in ridership by about 10 percent between 2014 and 2018 [5]. A study in the Journal of Community Health finds that transportation barriers postpone care and treatment, contributing to significantly worse clinical outcomes and more emergency department visits [6]. This disproportionately harms the unhoused population, who often have chronic illnesses that require consistent medical attention and treatment [7]. Evidently, unhoused individuals encounter substantial obstacles even before directly visiting healthcare centers. The ability to commute should be a prerequisite when tackling the healthcare crisis for the homeless population in California. 

Identification poses a significant problem for homeless people as well. Unhoused individuals must apply annually and be properly identified in order to qualify and receive Medi-Cal benefits. However, many unhoused people face challenges in obtaining or replacing identification documents due to factors such as loss, theft, or lack of resources to navigate bureaucratic processes [8]. The National Law Center on Homelessness and Poverty finds that 45% of homeless individuals without photo ID are denied access to Medicaid and other medical services [9]. This provides evidence that the homeless population is systematically stuck, lacking the necessary resources to receive healthcare. There needs to be a more streamlined process to ensure that unhoused individuals are not marginalized and excluded from the healthcare system. 

The underprovision of street medicine is arguably one of the greatest obstacles for the homeless population to access Medi-Cal. Street medicine refers to healthcare services offered on the streets, often in underrepresented communities, which primarily target unsheltered individuals [10]. Currently, it is underprovided because it is costly. Street medicine providers often complain about their lack of reimbursement, arguing that they need higher compensation for their “labor-intensive and time-consuming” street care [11]. With weak financial incentives for healthcare workers to offer street care, the unhoused are further shut out from the healthcare system. This helps explain why a significant percentage of homeless people with mental illness who need services do not receive them, and those who do get very few [12]. Street medicine is an overlooked industry within the healthcare system. The University of Southern California’s Keck School of Medicine found that street medicine could help California save 300,000 ER trips annually [13]. There needs to be better federal and state funding allocated towards street medicine to ensure that providers are adequately compensated and able to provide care to the homeless. 

There are a couple of ways policymakers can tackle the above barriers. The first is through more investment in public transportation. Public transit has generated dramatically low revenue since the pandemic, creating a cycle where the systems in place are not operating at a capacity in which they can finance themselves. California’s public transportation services need to be bolstered. This can only be accomplished through increased external financing. Transit funding often finds itself on the chopping block, as evident in Newsom’s proposal to slash $2 billion from public transportation construction earlier last year [14]. Allocating more funding will strengthen public transportation in California, allowing unhoused individuals to travel to the necessary locations to receive treatment in a timely manner. 

Another strategy to address these obstacles to accessing Medi-Cal is to improve ID facilitation. The renewal process for Medi-Cal eligibility is overwhelmed due to a large influx of individuals rushing to file paperwork post-pandemic [15]. In an already burdened system, it becomes increasingly difficult for the homeless to ensure they are qualified annually to receive Medi-Cal benefits. Comprehensive outreach programs should be established to simplify the ID application process for the homeless population. These initiatives can help expedite processing times, ensuring prompt access to care for the homeless who are disproportionately impacted by a burdened healthcare system. 

An additional approach to combat these barriers is to bolster street medicine. The California Department of Healthcare Services (DHCS) implemented policies in 2022 that supported reimbursement between Medi-Cal and street medicine programs [16]. However, as long as providers do not feel compensated enough, street medicine will continue to be unsustainable. More legislation needs to be passed to pay street medicine providers adequately. This can only occur with increased lobbying to the California State Assembly Members, who have the power to change policy at the local and state levels. 

By expanding access to Medi-Cal services for the homeless, California can ensure that emergency rooms are no longer the primary source of care for the homeless population. Addressing these barriers to healthcare accessibility underscores Medi-Cal’s promise to “be a catalyst for equity and justice” [1].