Health Starts With Housing

by Olivia Eknoian

The unhoused population is consistently at the forefront of public policy discourse, but we haven’t yet been able to meaningfully address the issue. This is in large part due to the many implicated interest groups and the generally complex web of factors that contribute to a person’s unhoused status. Understanding that structural factors interact to create a negative feedback loop that reinforces homelessness, interventions must necessarily be systemic. Wrapped into this is the bidirectional relationship between health and homelessness, such that poor health and a lack of access to health systems can increase the risk of being unhoused, and being unhoused contributes to a myriad of poor health outcomes. As it stands, the unhoused population has a higher prevalence of mental and physical health conditions than their housed counterparts, and have longer lengths of stay as well as higher rates of readmission to hospitals. In short, this is a population that frequently interacts with the health care system, especially straining infrastructures such as the ER. This also means that the healthcare system is a perfect place to start when considering potential interventions. 

  Based on Garcia’s “Homelessness And Health: Factors, Evidence, Innovations That Work, And Policy Recommendations,” there are two main policy avenues that include the health system: measures directly embedded in the healthcare apparatus, and measures that partner housing and healthcare providers. Of the two, partnerships yield potentially better and more “big picture” outcomes but are more expensive and challenging to implement. On the other hand, directly embedded measures have significant empirical backing in terms of health outcomes, but fall short of providing a comprehensive or long-term solution for individuals. 

With all this in mind, a direct investment by healthcare providers into “Housing First” measures is the ideal solution. Housing First programs guarantee housing without any requisites–individuals aren’t asked to be sober or to have been treated for potential mental health issues–which decades of evidence show is highly effective. Individuals housed according to this principle are more likely to be stably housed for longer, struggle less with psychiatric symptoms, and access primary care more often. Most importantly, this intervention directly provides shelter–a perhaps obvious point, but one that is sometimes overlooked as policymakers consider the many perspectives from which homelessness can be addressed.

However, Housing First programs require that there be housing available, and that the entities funding that housing be amenable to an unfiltered method of accepting residents. When such programs are not feasible, directly embedded interventions are an adequate and more attainable proxy. The most effective and evidence-based are social needs screenings and medical respite. Social needs screenings aim to assess the risk or severity of homelessness and then connect patients with relevant resources. It is a relatively simple measure, but one that should be a standard practice because it has the capacity to catch people early in the cycle. Medical respite programs allow for unstably housed people who are still ill but no longer in need of intensive care to remain in hospitals receiving shelter and social services. While this measure doesn’t ensure housing, it has been associated with a reduction in hospital readmissions and lengths-of-stay, improved HIV outcomes, and improvement in post-discharge housing status. 

Homelessness will not be solved by any single hospital ward or housing voucher. But if we accept that health and housing are inseparable, then the healthcare system cannot remain a passive bystander. Providers and health systems at large have both the data and the moral imperative to act. Though Housing First programs demand greater coordination, funding, and political courage than embedded healthcare interventions, they remain the most comprehensive and evidence-based path toward breaking the cycle between homelessness and poor health.

References:

Garcia, C., Doran, K., & Kushel, M. (2024). Homelessness and health: Factors, evidence, innovations that work, and policy recommendations. Health Affairs, 43(2), 164–171. https://doi.org/10.1377/hlthaff.2023.01049