Jan 2 2013

Housing is Health Care

Kelly Doran, MD, is an emergency physician and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholar at Yale University. This post is part of the "Health Care in 2013" series.


Around this time of year I think a lot about my friend Hank.  He is one of only two people to whom I reliably send a Christmas card each year, and just as reliably I receive a holiday package from him containing thoughtfully chosen gifts.

When I first met Hank he was homeless, living out of a van he parked near Golden Gate Park in San Francisco.  Hank had multiple serious chronic medical conditions, and the homelessness certainly did not help any.  He was very sick and, sadly, though he was barely 50 years old I thought he had maybe five years left, tops. Well, 10 years have passed and Hank is still ringing in the New Year… in his own apartment.  This is no Christmas miracle, but rather a predictable result of supportive housing.

Hank now lives in a small yet comfortable studio apartment with his dog named Hobo (can’t say the guy doesn’t have a sense of humor!)  He is a whiz in the kitchen, his skills perfected during his time working as a cook on a Navy submarine.  He also has an artistic side, and is often the winner of his building’s holiday door decorating contest.  His building provides supportive services, including personalized case management, for its residents.  Hank still has some ups and downs but is currently in good health.  He takes his medications religiously, attends his outpatient medical appointments, and stays out of the emergency department and hospital except in rare instances.        

Each night in the United States more than 600,000 people are homeless.  Homelessness is associated with high rates of chronic illness, unmet health needs, and even mortality.  These health risks come with a correspondingly high price tag for the health care system, as brought to the public attention by stories such as Malcolm Gladwell’s “Million-Dollar Murray.”  

But this is not a problem for which we have no solution.  Hank’s story has been played out in the results of research, which suggests the benefits of supportive housing.  Supportive housing has been associated with reductions in emergency department visits and hospital days, increases in outpatient care, and reductions in costs

My New Year’s resolution for the U.S. health system is that we recognize homelessness as a health crisis and housing as a medical intervention.  Health systems and social systems need to work together toward this goal; only by engaging in meaningful discussions and fruitful collaborations will we be able to truly address the pressing health needs and high health care costs of people experiencing homelessness, particularly those who are chronically homeless. 

I have reason to be hopeful for 2013.  Chronic homelessness is on the decline.  Supportive housing is increasingly being realized by mainstream entities as a health intervention that makes sense. For example, New York State’s Medicaid Redesign Team submitted a 1115 Medicaid waiver in August 2012 that requests to re-invest $750 million in supportive housing, recognizing the importance of supportive housing in meeting the “Triple Aim” of better care, better health, and lower costs. The Veterans Administration continues innovative work around health care and housing, and is dedicated to ending homelessness among veterans.  Leaders from the U.S. Department of Health and Human Services and the U.S. Department of Housing and Urban Development recognize the clear connections between housing and health.

Here’s to a 2013 that brings many more people like my friend Hank “home” for the holidays.   

Tags: Clinical Scholars, Emergency Care, Family and Social Support, Health Care in 2013, Social Determinants of Health, Underserved Populations, Voices from the Field