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In this podcast episode of Clinical Changemakers, Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, spoke with host Jonathan Hoogerbrug, MD about the moral injury of being a frontline clinician and having to discharge people back onto the streets. Dr. Kushel also elaborates on her landmark research into Homelessness in California, highlighting the moral, medical, social and economic impact that that this issue has on those individuals, their families and society as a whole. Dr. Kushel said, "The people who are most impacted, obviously, are those experiencing homelessness and the impacts for them are just incalculably horrible. But it impacts everybody." She adds, "There are huge costs to society. There's the intangibles, like loss across the business, community, to tourism. There's the moral injury. What do we say to our children about what does it mean to grow up in a place where so many people are so visibly suffering?"

Some homeless shelters now offer resources so that people can squeeze in with family members. This diversion approach was pioneered by the Cleveland Mediation Center around 20 years ago. The approach is not for everyone, but it is meant to catch people before they slip into the shelter system. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "Even if it doesn’t work for everybody, if it works for a certain percentage, it’s likely worth it."

Research has demonstrated that homelessness is associated with poor health outcomes. However, there are fewer studies that show that gaining housing is associated with improved health outcomes. In a recent study published in early February was hypothesis-generating and found an association between housing and improved survival. Hannah C. Decker, MD, of the University of California, San Francisco and lead author, said, "Unhoused veterans who gained housing in the year after diagnosis had better outcomes than people who remained unhoused."

The perception of people experiencing homelessness is often based on anecdote. In the first episode of WPLNs 9 part housing series, In My Place, Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, joins host Khalil Ekulona to talk about the causes of homelessness, the misconceptions and myths of homelessness, and what cities can solve the problem. As the conversation moved to the misconceptions of people experiencing homelessness, Dr. Kushel said, "I think the single biggest misconception is that homelessness is synonymous with mental health and substance use problems." Dr. Kushel adds "At its heart, homelessness is a problem of housing cost."

In San Diego, people 55 and older make up at least 29% of the people experiencing homelessness. The seniors experiencing homelessness face tough choices with many of them on a fixed income and unable to afford housing costs in the city. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "When talking about homelessness, 50 is the new 75."

The mortality rate for people experiencing homelessness in America has increased in recent years. People are dying at increased rates because of overdoses, but also of things that may have been avoided if the individual had a home or regular access to preventative medical care. Furthermore, the population of people experiencing homelessness are getting older. In California, the number of people 55 and older who sought homelessness services increased 84%  between 2017 and 2021. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "As the homeless population continues to age, you’re just going to see death rates keep going up and up and up."

About two-thirds of those who were kicked off state Medicaid rolls lost it for technical reasons like incorrectly filling out paperwork. In Montana, 120,000 people lost Medicaid as the state re-evaluated everyone's eligibility. Homeless service providers and experts have stated that many unhoused people have lost their Medicaid coverage. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "It doesn’t seem like such a big deal to fill out paperwork," but "Put yourself in the position of an elder who’s experiencing homelessness and has lost their vision, who has no access to [a] computer, no access to [a] car, doesn’t have [a] cell phone."

Deciding to live with intimate partner violence (IPV) instead of choosing a shelter is a complex decision. The UCSF Benioff Homelessness and Housing Initiative recently released a special report on IPV and homelessness. Anita Hargrave, MD, assistant professor at UCSF and co-author on the report, said, "Intimate partner violence can precipitate homelessness for many people, and is particularly dangerous for those that are at the economic margins."

Housing is linked to lower cancer mortality in US veterans, a recent study found. Hannah C. Decker, MD, of the University of California, San Francisco and lead author of the study, spoke about the study, the pervasiveness of veteran homelessness, and how homelessness affects health. Dr. Decker said, "We are really interested is getting a deeper understanding of how the VA gets veterans into housing, especially those that are diagnosed with serious chronic diseases, like cancer."

There is an overrepresentation of Black people in people who experience homelessness in California. A recent special report released by the UCSF Benioff Homelessness and Housing Initiative on Black Californians' experiences homelessness highlights the systemic racism. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "This didn’t just happen by accident and it didn’t just happen because there were a few bad people. This was organized." Dr. Kushel further adds in regards to reparations, "That feels like a conversation that, if we are being honest, we need to have."