A recent policy change in Massachusetts increased pediatric emergency department visits associated with homelessness, resulting in substantially increased healthcare costs, according to research published in Pediatrics.

In 2012, the Massachusetts emergency shelter eligibility policy for homeless families presented new eligibility requirements dictating that families with children required documentation that they spent ≥1 night in conditions not suitable for human habitation to qualify for emergency shelter assistance. According to Amanda M. Stewart, MD, MPH, of the Division of Emergency Medicine at Boston Children’s Hospital, and colleagues, the emergency department is an environment where this condition can be met.

Study investigators retrospectively reviewed emergency department visits of children (ages 0-18 years) who were seen at a Massachusetts children’s medical center with a complaint of homelessness or a problem caused or made worse by homelessness. Demographic characteristics and homelessness circumstances were compared and an interrupted time series analysis was used to compare emergency department visits prior to and following the change in the Massachusetts emergency shelter eligibility policy. Specifically, comparisons were made between both time points in the change of the number of emergency department visits for homelessness to the number of homeless children residing in Massachusetts.

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A total of 297 visits to the emergency department by children for the complaint of homelessness were identified in Massachusetts after the policy change. During the study period, the number of homeless children in Massachusetts increased 1.4 times, yet the number of visits to the emergency department for homelessness increased 13-fold.

Following the change in the policy, emergency department visits rose by 4.5 times compared with prepolicy numbers (incidence risk ratio, 4.5; 95% CI, 1.33-15.23), a finding that could not be explained by an increase in total visit volume. Postpolicy, children’s visits were less likely to involve a medical complaint (rate ratio, 3.27; 95% CI, 1.18-9.01). Approximately 89% of the mean $557-per-visit cost payments, which were >4 times the cost of a night spent in a shelter, were made using state-based insurance plans.

The findings from the study are limited to children in Massachusetts, the only state where a “not meant for human habitation” shelter policy exists.

The study investigators noted the importance in understanding “the magnitude of the problem of child homelessness, the characteristics of children being seen for homelessness, the reasons for families’ homelessness, and the unintended health care costs to enable legislators and policy makers to create more effective policies for these families in Massachusetts.”


Stewart AM, Kanak MM, Gerald AM, et al. Pediatric emergency department visits for homelessness after shelter eligibility policy change [published online October 15, 2018]. Pediatrics. doi:10.1542/peds.2018-1224