In a time when more than half a million people in the United States nightly face homelessness, health care leaders across the country have an opportunity to make a difference on this growing issue. Sleeping under an overpass, in an alley, in the woods, in a car, or stretched out in a subway car—so many are just looking for any safe, quiet, warm place, including a public shelter. And nearly a million people a year are evicted, forced to move in with relatives or friends. For many, these temporary solutions are the last viable options before street homelessness.
As this recent series of Health Policy Briefs shows, addressing the housing crisis is key to solving the homeless crisis. Housing remains unaffordable and far out of reach for far too many people. Federal funds for affordable housing are fast dwindling and, as a direct consequence, failing to meet growing demand. Federal support for affordable housing, cut sharply in the 1980s, remains far below its previous levels—precisely when homelessness in the US has exploded. Only one-fourth of households that qualify for housing assistance receive it due to the de-funding of this vital resource.
A Dangerous Health Condition
But a certain reality in this equation is often misunderstood and underreported, that homelessness and inadequate housing are major health issues. And the sooner this connection is recognized, the better. In terms of health, falling into homelessness can be dangerous, costly, and deadly. Safe, stable housing is a key determinant of both physical and mental health.
People experiencing homelessness—exposed to cold, heat, rain, and snow, among other inhospitable elements—suffer from worse health than those who sleep under a roof every night. In fact, homelessness itself can accurately be characterized as a dangerous health condition. Average life expectancy for a person without stable housing is 27.3 years less than the average housed person. People between the ages of 25 and 44 experiencing homelessness face an all-cause mortality risk that is 8.9 times higher than the general population; it is 4.5 times higher for those 45 to 64.
Without a place to live, it is nearly impossible for a person to take care of basic health needs. Serious, chronic diseases such as hypertension, asthma, and diabetes are more difficult to manage outside a home, especially if medications are lost or stolen. Infections and injuries are harder to heal, and pneumonia and other acute problems are aggravated without a place to rest and recover. Risks of communicable diseases such as hepatitis and tuberculosis run higher. Necessary long-term treatment and counseling are nearly impossible to deliver, to the detriment of the estimated 26 percent of adults staying in shelters with serious mental health conditions and the 46 percent of temporarily sheltered individuals living with a mental illness or substance abuse disorder.
Patients without housing are also much more likely to be readmitted to hospitals (50.8 percent) than others (18.7 percent), and when admitted tend to stay 2.3 days longer. As a result, overall costs run higher. Hospitalization and emergency department (ED) costs among 6,500 homeless individuals in Boston turned out to be 3.8 times higher than those for the average Medicaid beneficiary.
Yet, even in the face of such overwhelming evidence, US society reflexively tends not to pay attention to homelessness as a health problem. Instead, public policy experts often perceive homelessness as a matter of public safety, urban economics, or aesthetics that affect tourism and gentrification.
If we are to help improve health among people experiencing homelessness, addressing housing is the first priority. Proper housing can prevent both medical conditions from developing in the first place and existing conditions from worsening. Housing can, in and of itself, be categorized as a form of health care.
Looking Outside The Hospital Walls
The question now confronting us, then, is this: How can providers best deliver this health care directly to a community? How can health care providers and systems venture beyond the institutional setting, outside the walls of a hospital or medical office, to the places where people live, learn, work, and play?
The first step is to join and support partners that are already shouldering some of the heavy lifting. There are 300 federally qualified health center programs (at least one in every state) that focus on providing health care to people experiencing homelessness. For more than 30 years, Health Care for the Homeless (HCH) programs have figured out how to make the health system responsive to the needs of our homeless neighbors through outreach; patient-centered, trauma-informed care; and holistic care. All of the federally qualified health center HCH programs conduct outreach and address mental health, substance use disorder, and social service needs of their patients. Working at the nexus of the health care system and homelessness service systems, the National Health Care for the Homeless Council can link health systems and providers, payers, and housing and shelter providers to nearby HCH programs. It also creates and shares resources, and conducts training and technical assistance on adapted clinical guidelines, medical respite, and best practices that are informed by the experiences of service providers—and consumers—on the front lines of this crisis.
More and more hospitals and health providers are addressing housing directly. In recent years, hospital systems in Florida, Oregon, and other states have helped develop affordable housing. In Chicago, the University of Illinois Hospital and Health Sciences System provided permanent housing to chronically homeless patients who frequently used the ED to lower overall health care costs. In Los Angeles, California, a program called Housing for Health lowered ED visits among patients experiencing homelessness by 68 percent and hospital stays by 77 percent.
States are getting involved, too. New York and California have leveraged Medicaid dollars to support housing services, thanks to approval by the Centers for Medicare and Medicaid Services in 2015 to deploy funds for that reason. Preliminary results from New York State show these investments to the health system achieved cost savings. And payers are participating as well.
As the nation’s largest integrated health system, nonprofit Kaiser Permanente has a vested interest in solving this problem. Nearly one-quarter of all people who are homeless in the US live in California, where Kaiser Permanente has its largest presence. Locations there also have some of the highest costs of housing nationwide.
For its part, Kaiser Permanente recently partnered with the mayors and CEOs for U.S. Housing Investment, a bipartisan coalition, to support policies that provide affordable housing. The decision came largely in direct response to the growing need to bolster efforts to provide affordable housing that can prevent homelessness in the first place.
Additionally, Kaiser Permanente has established the Thriving Communities Fund with an initial commitment of up to $200 million in impact investing to address housing stability and homelessness, and other community needs. The first investments will be hyperlocal programs to prevent lower- and middle-income families from becoming displaced, while ensuring that existing homes and neighborhoods are healthier and more environmentally efficient. The fund will target Kaiser Permanente communities across its footprint where 68 million people live. In addition to supporting affordable housing, Kaiser Permanente also provides aid to not-for-profit partner organizations that assist people experiencing homelessness.
But impact investing is only a single step in the right direction. Any policy debate about how best to address the health of people experiencing homelessness should start with reforms aimed at where the problem originates: lack of affordable housing.
Our strategy as health care professionals should be to step outside the walls of our institutions and advance the cause of public health at the grassroots level, recognizing that matters of health often go beyond the health care system. Healthy People 2020 focused on social determinants of health, and if we are to have a healthy country and society, we cannot afford to ignore the need for housing for our homeless neighbors. Housing not only directly affects health but also other factors that influence overall health and development—to eat nutritiously, get adequate rest, and for children to be able to complete their education.
Ideally, the commitments outlined here—and the potential policy interventions described in recent Health Policy Briefs—will stimulate a broader national conversation, particularly among policy makers, and keep the focus on the connection between health and homelessness as an issue increasingly urgent for many cities. Ideally, too, businesses will join in investing in housing for this purpose. As a nation, we need to increase our speed and capacity to respond to community housing needs and achieve equitable health outcomes. Only then can we expand our ability to identify, incubate, and implement solutions to this stubborn community health challenge. We believe that health care and housing are human rights. When everyone in the US has a place to live, all of us can live in a healthier society and feel better about the place we call home.