Conducted by researchers affiliated with the VA’s National Center on Homelessness Among Veterans, the analysis evaluated two national cohorts to understand how the profound health risks of homelessness compound over decades.
The research paper examined a 2004 cohort comprising 85,533 veterans and a 2014 cohort encompassing 222,974 veterans, following both groups through administrative records up to 2024. According to lead author Jack Tsai, PhD, MS, the expansive reach of the VA—the largest integrated healthcare system in the United States, operating more than 140 medical centers nationwide—enabled researchers to track individuals even as they moved across different regions and utilized various medical facilities, benefits, and homelessness services over a multi-decade timeline.
“The VA is the largest integrated health care system in the United States, with more than 140 medical centers nationwide,” Dr. Tsai explained, noting how this infrastructure allowed his team to evaluate long-term outcomes, mortality rates, and program participation across many years. Despite access to comprehensive care, the investigation revealed severe public health burdens that underscore homelessness not merely as a housing crisis, but as a critical medical emergency.
The Compounding Mortality Burden Among Vulnerable Veterans
The study found that comprehensive healthcare access alone did not eliminate premature mortality among the study population. According to the data, half of the veterans in the 2004 cohort died within 20 years of tracking, while approximately one-quarter of the 2014 cohort passed away within 10 years. The mean age at death was recorded at 63.9 years for one group and 65.3 years for the other.
Dr. Tsai pointed out that many underlying health risks likely accumulated long before veterans were officially identified through homelessness programs. “I suspect much of the risk for premature mortality accumulated over many years,” Dr. Tsai stated, adding that finding solutions will require looking far upstream. “There is no single solution. These findings leave a great deal of room for earlier prevention, but an important question is when that prevention should begin.”
Researchers noted that effective prevention strategies may need to operate across multiple stages of the life course, potentially beginning with adverse childhood experiences, extending into early adulthood, and continuing through later life. Earlier VA research and related presentations have highlighted elevated death rates and significant years of potential life lost among younger veterans facing housing instability.
Understanding Long-Term Program Use and Healthcare Needs
To measure ongoing engagement with support systems, the study examined continued participation in VA homelessness programs and urgent medical services. In both cohorts, one-quarter of surviving veterans utilized VA homelessness programs in 2024, while roughly one-third relied on emergency or urgent care services during that same year.
Dr. Tsai emphasized that the tracking metrics were designed to capture long-term service connectivity rather than isolate every individual housing episode. “We did not focus on counting every episode of VA homeless program use. We wanted to understand who continued using these programs one or two decades later,” he said.
Administrative records indicate that these subsequent visits can reflect a range of life circumstances, including persistent housing instability, a return to homelessness after a period of stability, or successful reentry into supportive services. Distinguishing between these distinct trajectories remains an essential goal for future clinical research. “There are important clinical differences between veterans who experienced homelessness throughout the period and those who later returned to homelessness. Future research needs to evaluate those different trajectories,” Dr. Tsai noted.
Clinical Predictors and the Need for Sustained Support
Multifactorial analysis within the study identified specific demographic and clinical predictors associated with mortality and program retention. Older age, pre-existing medical illnesses, and alcohol use disorder predicted mortality risk. Meanwhile, distinct combinations of factors drove continued reliance on homelessness programs.
Racial differences also emerged within the data, showing that White veterans faced a higher mortality risk, whereas Black veterans exhibited higher rates of continued program use. Investigators stressed that while health systems provide essential interventions, medical treatment alone cannot replace stable housing and sustained social support.
Furthermore, the analysis highlighted gaps in treatment continuity. While most veterans diagnosed with substance use disorders received some form of treatment, care typically lasted only a short time. Researchers cautioned that short-term interventions often fail to match the reality of long-term or recurring disorders, reinforcing the clinical necessity of pairing medical care with stable, long-term housing solutions. While the VA has reduced veteran homelessness by 56% since 2010, the new findings emphasize that substantial work remains to protect aging and vulnerable veterans.