Homelessness Is a Health Care Issue | Opinion

This piece was originally published in the Messenger.

I learned many years ago that only about 10% of one’s health is determined by health care. The other 90% is determined by factors often outside of our control, such as the zip codes we are born in, access to healthy food, and social support. The most critical of these is housing. I have worked for over two decades as an emergency medicine physician and have yet to work a single shift where I have not taken care of people who are homeless on the street, in shelters, or couch-surfing with no guarantee of what the next night holds. I have watched the problem become worse. Homelessness is not just a housing issue; it’s a health care issue.
 
People experiencing chronic homelessness are the most medically vulnerable. These are individuals who have been homeless for at least a year, or who have multiple episodes of homelessness, with a psychiatric or physical disability. They are sicker and typically die far earlier than people who are housed. We admit them from the emergency department to the hospital at higher rates, and when they are discharged, if they remain unhoused (which they almost always do), their discharge plans often fail, bringing them back to us.
 
Their high rates of chronic disease and early death are unsurprising and even predictable. Untreated psychiatric conditions mean that many lack the organizational skills needed to fill prescriptions and attend needed appointments. Medications are lost or stolen. No reliable mailing address leads to lapsed insurance, no access to preventive care, and chronic medical conditions such as high blood pressure can progress to heart attacks and strokes. Those who live outside cannot escape extreme weather, often leading to heat stroke or hypothermia. Rates of violence including homicide and suicide are high. Severe storms can turn into traumatic natural disasters, including death by treefall.  
 
COVID didn’t help. Outbreaks led many shelters to close, creating a severe shortage of already hard-to-come-by shelter beds. Later, pandemic relief funds paid for temporary hotel-based shelter for a subset of especially vulnerable homeless people, but there was serious collateral damage: In San Francisco, deaths among people who were homeless doubled during the pandemic — yet none of these deaths was due to COVID. Instead, most were from drug overdoses, likely due in part to the diversion of already scarce treatment resources toward pandemic relief. 
 
Treating illness against a background of homelessness feels like a no-win situation. Many emergency departments have systems to improve the chances that patients experiencing homelessness can adhere to a treatment plan. We provide an entire course of medications before they leave, lowering the chance that an essential prescription won’t be filled. Social workers create connections to outpatient substance-use treatment for those willing to go. We work with our homeless services and case-management providers to establish connections for ongoing care once patients are discharged. We provide showers, sweatsuits, new socks and shoes. But these actions, while necessary, are merely Band-Aids. We can’t reverse cancer that is diagnosed too late, for example.  

We have no long-term solutions for the person who is seriously mentally ill on the streets, brought to us by police for the 20th time. We have no option other than to discharge the elderly person who is homeless but for whom we cannot find a reason to admit to the hospital. The health care system in general, and emergency departments specifically, cannot solve this problem — we can only respond to its consequences.  
 
Some might say that housing is not health care’s problem, but the opposite is true. Medicaid — health insurance for low-income people — could be part of the solution. Medicaid is now the de facto insurer for people experiencing homelessness and its policies acknowledge the inextricable link between housing and health care. It now pays for some form of housing support, such as case management or substance-use treatment, in 27 states. Yet Medicaid funds cannot be directed toward the greatest need: housing itself. 

While housing is expensive to build and maintain, studies have shown that providing permanent supportive housing for people experiencing chronic homelessness substantially offsets other costs that directly and indirectly impact health, including policing, shelter use, poorly controlled medical and psychiatric illness, and substance-use disorders. 
 
Homelessness causes premature disease and death. We know the treatment, and yet we cannot offer it to our patients. Medicaid-funded housing could help change this. Yet, while Medicaid can be an important part of the solution, it cannot be the only one. Hard hit cities like San Francisco, New York and Los Angeles have put billions of taxpayer dollars toward addressing the problem of homelessness, but none has moved the needle. Legislators must continue to provide funding but demand that it be used toward evidence-based programs such as cash assistance and permanent supportive housing, which includes embedded medical and social supports.  

We regularly give our patients costly medications, perform expensive procedures and surgeries, and provide costly ICU care for weeks on end, because the human lives we are extending or saving are worth it. Isn’t it worth it, then, to prescribe the significantly life-extending treatment of housing?
 
Maria C. Raven is a professor of clinical emergency medicine and the chief of emergency medicine at UCSF Medical Center. She is a Public Voices Fellow on homelessness with the OpEd Project, in partnership with the UCSF Benioff Homelessness and Housing Initiative.