“I lost a friend…he used to sleep in that park. And then one morning they found him… Someone had stolen his sleeping bag and he passed away. Frozen to death.”

–  Austin, Texas

In September 2024, our article “Review of Local Homeless Mortality Efforts: A Call for Standardized Data and Reporting” was published online ahead of print. In it, we called on federal and national partners to provide recommendations for better data collection and reporting for this population. However, the recent change in federal priorities requires a revised discussion that better adapts to the current moment.

Summary of Our Paper

Read Our Article in the May Issue of JPHMP

In our article, we note the lack of nationwide homeless mortality data, which limits understanding of the cumulative impact of homelessness on health and the interventions needed to prevent future deaths. To fill this gap, we reviewed 17 state and local homeless mortality reports in the hopes of estimating an answer to a key question: “How many unhoused people die each year in the United States?”

Unfortunately, we discovered answering this question was not as straightforward as we thought. Different data sources, definitions of homelessness, time frames, and demographic data made estimating this number infeasible. Hence our call for a national standard.

Manner and cause of death data was the only consistent information, likely due to existing standardized definitions. All 17 jurisdictions listed either “accident” or “natural causes” as the leading or secondary manner of death, with nearly all specifying overdose or drug intoxication as causing or contributing to the death. Notably, the heavy reliance on medical examiner data may skew existing findings towards accidental deaths and not reflect broader causes of deaths among people experiencing homelessness.

Adapting to the Current Moment

Since starting this review in 2023, homelessness has increased 18%. Over one-third of the 770,000 people counted as homeless on a single night live unsheltered. Meanwhile, state and local jurisdictions continue to publish new or updated reports—such as in Utah; Illinois; Austin/Travis County, TX; Los Angeles County, CA; New York City, NY; and Denver, CO, to name a few.

Data modernization efforts at the Centers for Disease Control and Prevention (CDC) seemed to open the door for improving homeless mortality reporting. However, swift and sweeping changes at the federal level create significant uncertainty in how core public health functions will be maintained, let alone expand to new areas. Further, planned budget reductions in Medicaid, housing and food assistance, and other public programs that help with economic and social stability will likely result in more deaths among unhoused people. This further illustrates the need for a data-driven public health response to prevent such fatalities in the future. The announcement of a new Administration for a Healthy America, which would bring together agencies focused on substance use, mental health, chronic disease, and primary care services, may facilitate data sharing across behavioral and primary clinical care systems and allow for more robust exploration of causes of homeless deaths. However, recent staff and program reductions likely limit the capacity and expertise needed for this work.

5 Action Steps for Moving Ahead

“It’s astonishing that the death of a whole community of people is literally because they fell through very large gaps, and even their death is a gap. Even their absence is a gap.” –  Austin, Texas

As more responsibility for public health shifts away from federal agencies to states and localities, we recommend five action steps state and local public health practitioners and researchers can consider to advance homeless mortality determination and reporting:

1. Establish data sharing processes and agreements between public health, clinical care, and homeless service systems and conduct homeless mortality reviews.
2. Develop trainings for medical examiners and death scene investigators to learn about homelessness and ways to document it.
3. Partner with community organizations and academic institutions to add volunteer (or lower-cost) capacity for mortality data collection and reporting.
4. Humanize the data by working with local media, service providers, and people with lived expertise of homelessness to tell peoples’ stories.
5. Testify at annual budget hearings in state legislative sessions in support of social services and for the Medical Examiner’s Office to help retain funding and staff like forensic epidemiologists.

We remain hopeful that the federal government will eventually develop the common standards we call for in our paper. However, it appears more likely that state and local public health agencies, as well as collaborative groups like National Health Care for the Homeless Council’s Homeless Mortality Working Group (HMWG), are best positioned to lead these efforts. Ultimately, improving homeless mortality data and prevention requires an integrated effort between governmental and non-governmental partners.

About the Author

Barbara DiPietro

Barbara DiPietro; Barbara is the Senior Policy Director at the National Health Care for the Homeless Council. She holds a PhD in Public Policy from the University of Maryland, Baltimore County. For 25 years, she has focused on healthcare policies affecting unhoused people and how public systems can better serve vulnerable populations.

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