In a 2019 episode of the medical drama New Amsterdam, the ever-innovative medical director Dr. Max Goodwin gives a nontraditional prescription to one of the emergency department’s “frequent fliers.” Andy, a man experiencing chronic homelessness, was costing the hospital $1.4 million dollars each year. Dr. Goodwin’s solution is to write a prescription for housing. The hospital rents an apartment in New York City for Andy, saving millions in healthcare costs over the next few years. The idea of prescribing housing sounds too good to be true, the exact kind of thing you would expect to see on a medical drama. It couldn’t possibly work in real life … or could it?
According to the United States Interagency Council on Homelessness, California has more individuals experiencing homelessness than any other state in the country. Over 150,000 people in California are experiencing homelessness on any given day with over 41,000 experiencing chronic homelessness. In other words, California accounts for one-fifth of the total homeless population across the entire United States.
While it may be tempting for many to think of homelessness as a consequence of addiction or personal choices, over 66% of personal bankruptcies are related to health care costs. In fact, 60% of Americans are not able to afford emergency expenses of $1,000, and medical debt is often far more costly than that, averaging around $5,000 for the nearly 140 million Americans who have an outstanding medical bill.
The relationship between housing and health is not strictly linear, but rather cyclical. Housing insecurity can worsen health status by exacerbating malnutrition, exposing individuals to violence and lessening control of chronic somatic and mental health illnesses. However, declining health can also lead to decreased capacity to work and subsequent loss of wages and health insurance, which in turn generates housing insecurity.
As a result of this cycle, individuals experiencing homelessness have life expectancies that are nearly 30 years shorter than their housed counterparts. It is estimated that nearly 80% of emergency department visits for those experiencing homelessness are for preventable conditions. However, lack of housing often coexists with lack of access to reliable transportation and an inability to safely store and regularly take prescription medications often necessary for managing chronic conditions. In an attempt to provide more preventative care, some medical schools and emergency departments have ‘street medicine’ teams that regularly travel to encampments and offer free health care services. These teams provide necessary care for those experiencing homelessness, but do not address the underlying barriers to access.
To address this health care disparity, the relationship between housing and health status must be disrupted. If we can dissociate loss of income with loss of housing, not only will the health of affected individuals improve, but public health care costs will also decrease, especially as the unhoused population grows older. In Los Angeles County, for example, providing stable housing for those facing housing insecurity resulted in a 75% reduction in inpatient days and a 67% reduction in visits to the emergency department. This amounts to an overall reduction in healthcare costs, better outcomes for affected individuals and a decreased burden on emergency departments.
In Los Angeles County, the 10th Decile Project aims to connect the most frequent users of emergency medical services to housing. They found that on average, there is a total public cost saving of around $35,000 per year per person who is given stable housing. Additionally, some cities like North Hollywood have created villages of tiny homes that are aimed at providing a path out of homelessness for residents. Each unit cost $7,500 to build, which is a price easily outweighed by the expected savings in health care costs alone.
Bridging the gap between homelessness and stable housing requires buy-in from county and state-level officials as well as hospital systems, health insurance companies and community organizations. As a result of the undeniable health quality and cost benefits to housing programs for those experiencing homelessness, Inland Empire Health Plan launched a collaborative housing initiative in 2018, and more health insurance plans need to follow suit. The number of people experiencing homelessness in California is not just a housing crisis, but equally a health care crisis, and the solutions should therefore come from both housing and health care sectors.