Opinion
“Health care for the homeless” is just a start. People need housing.
On a sweltering July morning last year, I met a new patient. His cracked and calloused feet suggested he had spent nights awake and wandering the streets, afraid of falling asleep on a park bench and getting mugged, and I noticed a weariness in his gaze. He’d been admitted to the hospital with dangerously high blood pressure and pains in his chest.
Two months earlier, he’d undergone a thorough workup at this very hospital, and been discharged with medications to lower his blood pressure and treat his heart conditions. But he’d lost his medications when his backpack had been stolen, he told me, and it had been nearly impossible to follow a regimen that required him to take pills four times a day when he didn’t have a place to store his medications or even a watch.
After a day in the hospital, his blood pressure returned to normal and his chest pain disappeared. Our team tried to find him housing, but we could only arrange an urgent referral to the city’s overburdened social services programs. I felt powerless as I discharged him to a nearby shelter, anticipating he’d be admitted again.
This story is typical for many people experiencing homelessness—a population that has been on the rise in the United States since 2016. The most recent national survey estimated 650,000 people experienced homelessness on a single night in 2023, up 12 percent from 2022. People experiencing homelessness seek medical attention for ailments directly attributable to their living conditions—and yet the health care system fails to address the underlying problem, which creates a cycle of hospitalizations. Without more housing that people like my patient can afford, the care that doctors like me provide can be futile.
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As the number of people who are unsheltered—living in tents or on the street, not in shelters—has increased, so have attempts at displacement. The Supreme Court is considering whether a law in Grants Pass, Oregon that bans sleeping on public property or in public parks constitutes cruel and unusual punishment. Around the country, cities regularly clear encampments of people experiencing homelessness. Research suggests that encampment sweeps worsen the health of the displaced inhabitants.
In their book Homelessness is a Housing Problem, authors Gregg Colburn and Clayton Page Aldern argue that affordable housing scarcity is driving rising homelessness. Rents and home prices soared during the COVID-19 pandemic, exacerbating an already dire housing market situation. Creating affordable housing will not end homelessness—unmet behavioral, mental, and physical health needs are both the cause and consequence of homelessness, and they will need to be addressed—but affordable housing is a necessary step.
Several studies have shown the cost benefits of supportive housing for homeless people with chronic illness, mental health issues, and substance abuse. The savings are highest when housing programs target individuals who are frequent users of health care. For example, a housing program for people experiencing homelessness and severe alcohol problems in Seattle saved about $43,000 in health costs per person each year, while the housing provided cost about $13,000. However, not all studies have found the same results. We need more research to understand the most cost-effective ways of implementing housing programs.
Health care systems have traditionally focused on providing and improving health care for people experiencing homelessness. It’s time for them to do more. A few innovative health systems have already begun to do so. In New Jersey, St. Joseph’s Health financed the development of 56 units of affordable housing on land that the hospital owned. In New Orleans, the managed care organization Aetna invested $26.7 million in a 192-unit affordable housing complex. In Toronto, where a large number of people are experiencing homelessness, the University Health Network partnered with the city to build 51 units of affordable housing on a parking lot it owned. And Kaiser Permanente has committed $400 million to creating or preserving 30,000 affordable housing units in parts of California, where the homeless population is the country’s highest, by 2030. Since health care systems are primary partners in these developments, they frequently provide residents with on-site health care and social services.
More hospitals, provider networks, insurers, and government agencies should take on a role in directly addressing the housing shortage. They should invest in housing development, especially projects that create affordable or supportive housing units, and donate unused land to further this goal. For too long, players in health care have focused on mitigating the consequences of homelessness, rather than addressing the root problem. Now, it’s time for them to be a part of the solution and create healthier communities for all.
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<p>Otherwise, cycles of hospitalization will continue.</p>
<p>Written by Jeremy Cygler</p>
<p>This <a rel="canonical" href="https://harvardpublichealth.org/policy-practice/affordable-housing-is-key-to-end-cycles-of-homeless-hospitalization/">article</a> originally appeared in<a href="https://harvardpublichealth.org/">Harvard Public Health magazine</a>. Subscribe to their <a href="https://harvardpublichealth.org/subscribe/">newsletter</a>.</p>
<p class="has-drop-cap">On a sweltering July morning last year, I met a new patient. His cracked and calloused feet suggested he had spent nights awake and wandering the streets, afraid of falling asleep on a park bench and getting mugged, and I noticed a weariness in his gaze. He’d been admitted to the hospital with dangerously high blood pressure and pains in his chest.</p>
<p>Two months earlier, he’d undergone a thorough workup at this very hospital, and been discharged with medications to lower his blood pressure and treat his heart conditions. But he’d lost his medications when his backpack had been stolen, he told me, and it had been nearly impossible to follow a regimen that required him to take pills four times a day when he didn’t have a place to store his medications or even a watch.</p>
<p>After a day in the hospital, his blood pressure returned to normal and his chest pain disappeared. Our team tried to find him housing, but we could only arrange an urgent referral to the city’s overburdened social services programs. I felt powerless as I discharged him to a nearby shelter, anticipating he’d be admitted again.</p>
<p>This story is typical for many people experiencing homelessness—a population that has been on the rise in the United States since 2016. The most recent national survey estimated <a href="https://www.huduser.gov/portal/sites/default/files/pdf/2023-AHAR-Part-1.pdf" target="_blank" rel="noreferrer noopener">650,000 people experienced homelessness on a single night in 2023</a>, up 12 percent from 2022. People experiencing homelessness seek medical attention for ailments directly attributable to their living conditions—and yet the health care system fails to address the underlying problem, which creates a cycle of hospitalizations. Without more housing that people like my patient can afford, the care that doctors like me provide can be futile.</p>
<p>As the number of people who are unsheltered—living in tents or on the street, not in shelters—has increased, so have attempts at displacement. The Supreme Court is considering whether a law in Grants Pass, Oregon that bans sleeping on public property or in public parks constitutes cruel and unusual punishment. Around the country, cities regularly clear encampments of people experiencing homelessness. Research suggests that <a href="https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2024/01/16/displacement-of-encampments" target="_blank" rel="noreferrer noopener">encampment sweeps worsen the health</a> of the displaced inhabitants.</p>
<p>In their book <a href="https://www.jchs.harvard.edu/blog/rents-have-soared-across-country-home-prices-grew-even-faster" target="_blank" rel="noreferrer noopener"><em>Homelessness is a Housing Problem</em></a>, authors Gregg Colburn and Clayton Page Aldern argue that affordable housing scarcity is driving rising homelessness. Rents and home prices <a href="https://www.jchs.harvard.edu/blog/rents-have-soared-across-country-home-prices-grew-even-faster">soared during the COVID-19 pandemic</a>, exacerbating an already dire housing market situation. Creating affordable housing will not end homelessness—unmet behavioral, mental, and physical health needs are both the cause and consequence of homelessness, and they will need to be addressed—but affordable housing is a necessary step.</p>
<p>Several studies have shown the cost benefits of supportive housing for homeless people with chronic illness, mental health issues, and substance abuse. The savings are highest when housing programs target individuals who are frequent users of health care. For example, a housing program for people experiencing homelessness and severe alcohol problems in Seattle <a href="https://www.tn.gov/content/dam/tn/health/program-areas/NHC_Invest_Housing_Save_Health_Care_2016.pdf" target="_blank" rel="noreferrer noopener">saved about $43,000 in health costs per person each year</a>, while the housing provided cost about $13,000. However, not all studies have found the same results. We need more research to understand the most cost-effective ways of implementing housing programs.</p>
<p>Health care systems have traditionally focused on providing and improving health care for people experiencing homelessness. It’s time for them to do more. A few innovative health systems have already begun to do so. In New Jersey, St. Joseph’s Health financed the development of <a href="https://www.huduser.gov/portal/pdredge/pdr-edge-inpractice-030524.html" target="_blank" rel="noreferrer noopener">56 units of affordable housing</a> on land that the hospital owned. In New Orleans, the managed care organization Aetna invested $26.7 million in a <a href="https://www.nytimes.com/2024/03/12/business/affordable-housing-hospitals-investment.html" target="_blank" rel="noreferrer noopener">192-unit affordable housing complex</a>. In Toronto, where a large number of people are experiencing homelessness, the University Health Network partnered with the city to build <a href="https://www.thestar.com/news/gta/why-a-hospital-network-is-turning-a-parking-lot-into-affordable-housing/article_7c0f2782-fced-5bbf-b0c9-144a6440a032.html" target="_blank" rel="noreferrer noopener">51 units of affordable housing</a> on a parking lot it owned. And <a href="https://about.kaiserpermanente.org/commitments-and-impact/healthy-communities/improving-community-conditions/housing-security" target="_blank" rel="noreferrer noopener">Kaiser Permanente has committed $400 million</a> to creating or preserving 30,000 affordable housing units in parts of California, where the homeless population is the country’s highest, by 2030. Since health care systems are primary partners in these developments, they frequently provide residents with on-site health care and social services.</p>
<p class=" t-has-endmark t-has-endmark">More hospitals, provider networks, insurers, and <a href="https://www.vox.com/2024/2/13/24064445/medicaid-rent-housing-homelessness-healthcare">government agencies</a> should take on a role in directly addressing the housing shortage. They should invest in housing development, especially projects that create affordable or supportive housing units, and donate unused land to further this goal. For too long, players in health care have focused on mitigating the consequences of homelessness, rather than addressing the root problem. Now, it's time for them to be a part of the solution and create healthier communities for all.</p>
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