The U.S. Healthcare System Assumes Stable Housing, Leaving Many Unhoused People Without End-of-Life Care
On San Pedro Street, the humid afternoon air holds exhaust and heat as buses rumble past and commuters move through downtown Los Angeles.
A few blocks away, a person wrapped in a blanket crosses a wide intersection at their own pace. Others drift along the sidewalks with a distant focus, their movements quiet but persistent.
These are the everyday scenes of a crisis that has become both familiar and unsettled—but for many living in these conditions, the most urgent question is not where they will sleep, but where they will die.
For people experiencing homelessness with serious or terminal illness, that question often has no clear answer.
A System Built for Housed People
Hospice care in the United States is built around a basic assumption: that patients have stable housing and someone to help care for them. For people living in encampments, shelters, vehicles, or moving between temporary spaces, those conditions rarely exist—effectively excluding many from end-of-life care altogether.
“The healthcare system doesn’t have a solution for these folks,” said Kimberlin Correa, founder of Homeless at the End and former executive director of The INN Between, a residential hospice and medical respite program in Salt Lake City. “They don’t qualify for hospice care, and they don’t stay in the hospital. So they’re discharged back to the street.”
Without consistent care, people with advanced illnesses often deteriorate quickly—managing pain, symptoms, and fear largely on their own.
The scale of the problem is difficult to measure. There is no standardized national system tracking how many people experiencing homelessness die each year or where those deaths occur. What is known, however, is stark: people without stable housing face significantly higher mortality rates and develop serious illnesses earlier than their housed peers.
By the time many receive a diagnosis, said Michael Light, a social worker with the University of Washington’s Homeless Palliative Care Team, the disease is often already advanced.
“They usually have more complex conditions, more comorbidities, and more barriers to care,” Light said. “And then on top of that, they’re trying to manage all of it without stable housing or consistent access to care.”
Even basic aspects of treatment become difficult. A person undergoing chemotherapy may have nowhere safe to recover. Someone with advanced liver disease may not have access to a bathroom or a place to rest. Medications can be lost, stolen, or impossible to store.
As illness progresses, people are often forced to move between the street, shelters, and hospitals with little continuity of care.
That instability is not incidental. It is built into the system itself.
“All of the systems are generally created to support people who are housed,” Light said. “Healthcare, housing, and social services don’t coordinate well—and often fail to meet the needs of people who are living unhoused.”
The result is what Light describes as an “intersection of suffering”—the combined toll of serious illness and life without stable housing.
In many cases, the emergency room becomes the only consistent point of care. Without access to coordinated services, patients cycle through hospitals as their conditions worsen.
“It is more expensive,” Light said. “People end up relying on emergency departments and inpatient care because there aren’t other systems in place to support them.”
Models That Bring Care and Dignity Together
Efforts to address the gap do exist, but they remain limited. In Colorado, for example, a faith-based initiative is working to build a continuum of care for terminally ill unhoused people, though challenges remain.
In Salt Lake City, Correa helped build The INN Between, a program that provides housing, care coordination, and hospice services for people experiencing homelessness at the end of life.
“We gave them a home so they could qualify for hospice care,” Correa said.
The model works because it is built for people who fall outside traditional systems, said Jillian Olmsted of The INN Between. Many residents are too medically fragile for shelters but do not meet criteria for inpatient care, or face barriers accessing it.
“We provide a place where housing, care coordination, hospice support, and dignity can exist together,” Olmsted said.
The results have been significant. The program has reported a 91% reduction in hospital utilization, with estimated savings ranging from $24,000 to $99,000 per person annually.
Still, models like this remain difficult to scale. Programs that combine housing, healthcare, and hospice often fall outside traditional funding structures, making them harder to sustain despite clear outcomes.
But when programs like this do work, their impact can extend beyond care, creating space for connection and dignity at the end of life.
Correa recalled one patient, a man named John, who had been estranged from his family for decades. As his condition worsened, staff were able to reach his mother, who had not heard from him in 25 years.
By then, John could no longer speak. Staff held the phone to his ear as his mother told him she loved him and forgave him.
“If he could speak, he would say the same thing,” a staff member told her.
Moments like that underscore what is often missing: the chance to die with dignity, not in isolation.
In most communities, no such option exists.
Bringing Care to the Streets—But Not Everywhere
Some cities are experimenting with medical respite programs and street-based palliative care teams that bring services directly to people where they are, similar to street medicine efforts that deliver healthcare outside traditional settings. But these models remain unevenly distributed.
Too often, people continue to navigate serious illness without a system designed to support them.
“We often see people and systems start to really care once someone is near death,” Light said. “But that same level of care isn’t there earlier—when it could actually change the outcome.”
On streets like San Pedro, where daily life unfolds in plain view, the final chapters often remain unseen—shaped not just by illness, but by the limits of a system that was never built for those living outside it.
And for many, the question of where they will die remains unanswered.