Exploring new opportunities to connect health services in housing for both individuals and families recovering from homelessness

By David Wertheimer, Bill & Melinda Gates Foundation, and Bill Pitkin, Conrad N. Hilton Foundation

Not long ago, a homeless mother was asked if, due to the expansion of Medicaid coverage under the Affordable Care Act, she would like to receive insurance that could meet the full range of her family’s healthcare needs. “I already have a doctor,” she responded. “He’s at the local hospital emergency room.”

While it’s reassuring for all of us to know that emergency room visits are available to address a health crisis, hospitals were not designed to provide ongoing primary care and are neither an effective or efficient setting in which to receive basic medical treatment. With daily per patient costs that can climb well into four figures, we need better ways to meet the health care needs of vulnerable and at-risk individuals and families who are homeless.

These new pathways to quality health services for people who are or have been homeless was the subject of a day-long workshop at the National Academies of Sciences on November 12th in Washington, DC. Convened in partnership with the National Alliance to End Homelessness, National Health Care for the Homeless Council, and Institute of Medicine (IOM) Roundtable on Health Equity and Health Disparities, it was a ground-breaking event, bringing together a group of national experts on homelessness, housing, and healthcare policy and delivery. Exploring new opportunities to connect health services in housing for both individuals and families recovering from homelessness, it was the first time the National Academies had taken on the subject of homelessness in any significant way since 1988.

The experts agreed that the basic equation is no longer all that controversial: Housing is healthcare. We know that poor health can lead to homelessness. We know that homelessness is a major cause of poor health. We know that homelessness interferes with effective health care delivery. Study after study has documented not only that housing people who are homeless significantly increases their health outcomes; we also know that it dramatically reduces the costs of homelessness to the taxpayer.

Multiple studies in Seattle demonstrated that, for high users of crisis services such as emergency rooms, jails, and detox facilities, providing permanent housing reduces costs from more than $4,000 per person per month to less than $1,000. The program being studied served 75 individuals a year, and clearly documented annual savings of more than $4 million. Research in Los Angeles on 163 homeless persons in the highest cost decile of health services shows that every $1 spent to house and support these individuals results in public cost savings of $2 in the first year and $6 in subsequent years.

As obvious as the solution of permanent housing is to the challenge of spiraling healthcare costs associated with homelessness, taking this solution to scale presents a daunting challenge due to multiple factors: The fragmentation of funding and service delivery across multiple systems, the rigid, inflexibility of existing funding streams, and eligibility standards for access to services that are inconsistent with the needs of those who could most benefit from them.

Nevertheless, solutions are clearly within sight. We can now rapidly identify those clients with the greatest healthcare needs who represent the most expensive cost burdens. We know what housing and service packages will most help these individuals stabilize and recover, while cutting the cost burden of leaving them untreated. We know that housing and health providers can successfully work together to tailor services precisely to the unique needs of each clients.

The challenge is largely a by-product of the history of homelessness and housing systems that have not been effectively linked to health care services, and a health care system whose work has been narrowly defined in terms of treating specific illnesses, rather than promoting the overall health and well-being of individuals and families. With increased attention from policy makers, researchers and funders to the social determinants of health, it is in opportune time to reconsider the linkages between housing and health.

It was exciting for both of us to be part of the National Academies conversation, with other Funders Together to End Homelessness members such as Melville Charitable Trust and Kresge Foundation, listening to seasoned professionals from multiple systems agree that the science of both ending homelessness and promoting health have come to the same conclusion about an essential component of the solution to homelessness. When we define housing combined with the needed supportive services as a basic form of health care, the path forward to improved housing and health outcomes becomes immediately clear to us all.

David Wertheimer is the Deputy Director of the Pacific Northwest Initiative at the Bill & Melinda Gates Foundation in Seattle, Washington, as well as the Board Chair of Funders Together to End Homelessness. Find him at @DavidWSeattle.  

Bill Pitkin oversees the planning, development, implementation, and evaluation of the Conrad N. Hilton Foundation’s domestic priority areas. Find him at @billpiktin.

Photo above: (L to R) Declan Wynne, Building Changes; Dr. Jim O'Connell, Boston Health Care for the Homeless Program; Dr. Mitch Katz, LA County Department of Health Services; Jennifer Ho, HUD