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Two essential social drivers of whole health, homelessness and housing instability, are linked with substantially increased healthcare spending. These experiences disproportionately affect people of color, children, people who identify as LGBTQIA+, people with disabilities, and older adults.

Healthcare Spending Is Higher for People Experiencing Homelessness

In a recent study published in Health Affairs, researchers analyzed data from the Boston Health Care for the Homeless Program (BHCHP) Database, a program which is estimated to serve about 70% of the homeless population in Boston. They determined that the average healthcare spending incurred for a person using the program over a three-year period was $18,764 per year. That is two-and-a-half times greater than a low-income Medicaid member (average $7,561 per year).

“When people on the street are trying to meet basic survival needs every day, it is understandable that healthcare is not prioritized or accessible, making people less likely to attend appointments, adhere to a medication regimen, or focus on nutrition and a healthy lifestyle,” said the study’s first author Katherine Koh, instructor in the department of psychiatry at Massachusetts General Hospital and Harvard Medical School and practicing street team psychiatrist at the BHCHP. “Therefore, if we just depend on homeless people to come into clinic, many of them are not going to get preventative care.” Koh therefore advocates for non-traditional models of care that bring healthcare to people experiencing homelessness, such as street outreach of clinics embedded in shelters.

Individualized Permanent Supportive Housing Can Lower Costs

Koh advocates for permanent supportive housing, which provides individualized services and interventions to help a person thrive once they have been housed. “Each person needs individualized housing plans, much like an individualized psychiatric treatment plan or medical treatment plan, which take into account what the person's unique risk factors, needs and goals are,” said Koh.

Different models for permanent supportive housing can include scattered site housing (where people have housing spread throughout a community) and congregate housing (where formerly homeless people live together in one site and one building with onsite supportive services). While the literature does not show a clear difference in terms of which is more effective, choosing the right model for a specific individual can make a significant difference on the personal level.

“The best housing policies with the most impact for homeless or housing unstable people are cross-sector collaborations that recognize the unique needs of different populations,” said Koh, focusing on investment in affordable housing accessibility, rental assistance, ending discriminatory policies, and providing robust and tailored services to those who have been chronically homeless.

Housing Solutions Lab

One organization looking to identify the best community housing policies is the Housing Solutions Lab at the NYU Furman Center. Launched in 2020, the Lab helps cities to plan and evaluate local housing policies to reduce racial inequity, with the aim of advancing residents’ long-term health and well-being. A key part of their focus is coordinating housing with other sectors including health, education, economic, and community development to reach these goals.

“Affordable and stable housing is critical but not sufficient for improving the health of communities,” said Camille Watson, director of strategy and policy at the Lab. “Attention must also be paid to the location and quality of housing, as we know the economic, environmental, and social features of neighborhoods have a profound impact on health and life course outcomes.”

The Housing Solutions Lab also emphasizes the need to address housing disparities related to issues including housing affordability, homelessness, and homeownership which persist despite the Fair Housing Act. “Housing disparities persist by income, race, and disability status,” said Watson. “Our organization helps cities to establish metrics that identify and track local housing disparities, in order to help shape more equitable housing programs and policies.”

Watson suggests several strategies:

  • greater investment in affordable rental housing programs (e.g., housing vouchers, emergency rental assistance programs)
  • expansion of affordable home ownership opportunities
  • zoning reforms that increase access to affordable housing in well-resourced communities

The Lab has developed a racial equity toolkit to help cities identify key housing indicators related to advancing racial equity and measures that cities can track over time. The Lab is also developing a public-facing, interactive map and database that will assess a county’s risk of homelessness based on key economic indicators. This predictive tool should allow for more targeted resource allocation at the community level.

Barriers to Progress

The barriers to addressing housing concerns for these populations are not insignificant:

  • insufficient and unreliable funding to create enough affordable, permanent, supportive housing
  • political will and regulatory policies, such as zoning laws regarding multifamily housing or minimum lot size
  • disparate funding agencies that often operate within silos with different policy frameworks
  • community opposition

 “Successful community support for homeless individuals is more than housing,” said Koh, adding that the trauma, poverty, and other hardships that lead people to becoming homeless cannot be easily undone simply by moving into housing. “We need to also address the whole individual, including the upstream factors throughout the lifetime that lead to homelessness in the first place.”

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