Homeless in Hawaii

Homeless in Hawaii. Image courtesy of Sen. Josh Green.

With severe threats to the health and well-being of the most vulnerable Americans populating the headlines – from repealing and replacing the Affordable Care Act with a system that would send the number of uninsured skyrocketing, with poorer and older Americans suffering most, to the administration’s proposed FY2018 budget, with its drastic cuts in a social safety net that already lets millions of people fall through it – it is easy to focus only on limiting the damage. Yet even now, there are initiatives to advance health equity and the right to health within the United States. Most far-reaching may be the initiatives in states including California and New York to create a single-payer health system to provide universal health coverage. Perhaps the most innovative initiative comes from Hawaii, with a proposal that could dramatically improve the health some of the state’s most marginalized residents, and serve as a model for the nation.

Many doctors who recognize the underlying vulnerabilities of their patients would like to be able to address them directly. A prescription for economic opportunity for people with depression or substance abuse disorders that appear to stem from economic uncertainties. A prescription for peace to reduce post-traumatic stress syndrome. A prescription for fruits, vegetables, legumes, and whole grains for patients experiencing symptoms of poor nutrition, from childhood stunting and anemia to diabetes and heart conditions. A prescription for housing to address the multitude of health risks that give the homeless population in the United States about 30 years lower life expectancy than that of the overall U.S. population.

This last possibility is suddenly within the realm of possibility thanks to an emergency room doctor and Hawaii state senator, Josh Green. At the beginning of 2017, he introduced two pieces of legislation aimed at enabling doctors to literally prescribe housing and supportive services for chronically homeless individuals. As the Senator said, “The single best thing we can do today is to allow physicians and health care providers in general to write prescriptions for housing.” Senator Green further observes, “We’re already spending the money on homeless people, we’re just paying for it in the most inefficient, expensive way possible.”

One piece of legislation would have required health insurers to cover treating homelessness, though the bill was later significantly amended in committee, and would instead require the state auditor to study using Medicaid funds “for the treatment for homelessness.” The other bill “would have required the state Department of Human Services to create a Medicaid housing benefit plan.” It, too, was amended in committee, and instead would require the department to “continue to pursue efforts to utilize Medicaid to provide supportive housing services for chronically homeless individuals.”

The linchpin for Senator Green’s proposals is the economics of Medicaid, which would be the source of funding. Hawaii’s $2 billion in annual Medicaid spending is not spread evenly across the state’s 362,000 Medicaid beneficiaries. Rather, reflecting health care costs writ large, where most of the spending is directed towards a small proportion of people with the poorest health and greatest medical needs, 60% of Medicaid spending in Hawaii ($1.2 billion) goes towards about 3.6% (13,000) of the state’s most vulnerable residents. Among these are chronically homeless people, whose condition leads to frequent, expensive emergency room visits and other care that would become unnecessary if they were no longer homeless.

Thus, if people who are homeless could be housed, Medicaid costs would fall significantly. Hence the legislation to house the homeless. Senator Green observes that because of the considerably lower health care costs for chronically homeless people who get housing – otherwise often costing Medicaid about $120,000 per year, many times the cost of housing – the legislation could save many tens of millions of dollars per year in Hawaii, if not more.

The humane approach is often not only less costly from a human, moral, and social perspective, but also from a purely economic perspective. Housing the homeless through Medicaid is one example. So is, more generally, the Housing First model to address homelessness – getting homeless people into housing as a first step to ending their homelessness, rather than seeking to address factors that contributed to their homelessness before providing housing. Other examples include providing lawyers to people facing eviction or, a bit further afield from our present focus, establishing education programs for people who are incarcerated.

The proposed legislation would, “essentially, classify [chronic] homelessness as a medical condition,” authorizing Medicaid funding to be used to provide supportive housing to chronically homeless individuals in Hawaii, that is, both housing itself and supportive services, such as coaching on living skills and developing individual service plans. In particular, the funds would be used for patients who “have been homeless for at least six months and suffer from mental illness or a substance addiction.” About 1,800 individuals of a homeless population of more than 7,200 are chronically homeless; Hawaii’s homelessness rate is the highest in the nation.

Hawaii would not be the first state to use Medicaid funds to support housing for the homelessness. Several states are experimenting with ways to do just that. For example, New York is using state Medicaid funding – it does not have permission to use federal funds – to create, and to pay rent and associate costs for, supportive housing units. California received a federal waiver for several approaches to support homeless Medicaid recipients, including funding regional housing partnerships that can create saving pools from reduced costs from lowered health facility use. The partnerships may direct these savings to housing subsidies, among other housing and health care needs. Washington state, while not paying for rent, does providing Medicaid funding to help homeless individuals find and secure housing. Senator Green’s legislation, however, would be the first time a state would use Medicaid funding to house a very large portion of its chronically homeless population, and through the direct approach of a doctor prescribing housing.

Meanwhile, other innovative efforts are underway to give practical effect to the fact that for marginalized populations, the most important health interventions are often those that directly address housing and other social determinants of health. In a federally funded pilot program in Michigan, community health workers visit people with very high health costs, working with them to understand and meet their needs, and connecting them to programs, such as Section 8 housing vouchers,  and community resources to address the factors behind those costs and frequent emergency room visits. An NGO, Health Leads, “trains doctors to ask patients about their social needs and then connects patients with organizations that can meet those needs.”

Meanwhile, Senator Green’s proposals have several steps to go before becoming enacted into law and implemented. The updated pieces of legislation both passed Hawaii’s Senate in March without a dissenting vote (and see here for the second bill), but have yet to pass Hawaii’s House of Representatives. And if Senator Green’s original proposals do become law, the federal government will need to issue a waiver to Hawaii to use Medicaid for housing, not assured under the current administration in Washington – though that this is a money-saver may help.

Yet with the health and economic logic of Senator Green’s proposal, the progress the bills did make within the Hawaii legislature this year, and perhaps above all, the basic humanity it reflects, with the imperative of helping the disadvantaged among us, I believe his proposal has a promising future.

In fact, the PBS NewsHour recently reported that Hawaii “will seek permission from the federal government to spend Medicaid dollars on helping people find and stay in housing” even with the legislation yet to be passed into law. A future where doctors can prescribe housing to the homeless may be very near.