Housing is Health Care

From the National Health Care for the Homeless Council

The primary and essential function of housing, to provide a safe and sheltered space, is absolutely fundamental to the people’s health and well being.– Dearbhal Murphy

Human rights theory holds that all particular rights are universal, indivisible and interdependent and interrelated. As Americans begin to pay more attention to human rights as the proper conceptual framework for our struggle to end homelessness,2 we are coming to understand the interdependence of human rights in very practical – not just theoretical – terms. In particular, we are recognizing that housing is health care, and that extension of both rights, together, is necessary for ending homelessness.

The centrality of housing to issues of homelessness is no news. The earliest stirrings of the movement to end homelessness in the United States was the “Housing Now” march in Washington DC in 1989. The movement’s mantra was “Housing! Housing! Housing!”

The US faced an emergent crisis that was firmly rooted in huge reductions to the budget of the federal Department of Housing and Urban Development under President Ronald Reagan; between 1980 and 1987, $45 billion for subsidized or publicly-owned housing was lost.3 Advocates sought restoration of major public investment in housing for the poor, but won only the shallow victory of the McKinney Homeless Assistance Act, intended to provide emergency shelter and services to the masses, who were now living on the streets.

In the decades since, most activists’ energy has focused on responding to the emergency needs of homeless people, and a gargantuan homeless services industry has emerged – now well over $2 billion in federal expenditures, and growing; the writer admits to being part of that industry as Executive Director of the National Health Care for the Homeless Council.

Housing has not been altogether forgotten in those intervening decades. The National Low Income Housing Coalition has stood stalwartly for the creation of new affordable housing on a necessarily massive scale. The real action, however, has been in the federal tax system, which provides housing subsidies through tax write-off for mortgage interest deductions for homeowners – an entitlement for the wealthy that was worth $122 billion in 2006.

Meanwhile, rental housing has become steadily less affordable and scarcer for poor people, and the crisis of homelessness has deepened. In 2005, for the first time, there was no jurisdiction in America where a full-time, minimum-wage worker could afford a one-room apartment.

Meanwhile, homelessness and ill health have been locked in an on-going cycle of cause and effect, spiraling constantly downward.

• Poor health puts one at risk for homelessness. Half of all personal bankruptcies in the US are caused by health problems,6 too often and too quickly leading to eviction and homelessness. Dispossessed people often land with friends or family at first, but their living arrangements are tenuous, and break down particularly quickly for those with mental health or substance abuse problems.

• Homelessness puts one at risk for poor health. Exposure to infection, to the elements, and to the violence of the streets is common. Lack of control over nutrition or personal hygiene or sleep demeans and debilitates homeless people. Risky survival behaviors are the currency of the streets. The psychological toll is as dire as the physical.

• Furthermore, homelessness complicates efforts to treat illnesses and injuries. Neither health care financing nor the structure of the health care delivery system is attuned to the particular needs of homeless people.

The outcomes are disastrous: homeless people suffer all illnesses at three to six times the rates experienced by others, have higher death rates, and have dramatically lower life expectancy.

The McKinney Act provided the same sort of partial response to the health needs of homeless people as it did to their need for shelter and housing. It provided funding for a system of safety-net clinics that has steadily grown to 185 projects throughout the nation, worth $170 million and serving 600,000 homeless persons per year. The system is vital to their wellbeing, but it reaches only a fraction of the 3.5 million persons thought to experience homelessness each year, and it does not provide specialty care or hospitalization. Major deficiencies remain in mental health and substance abuse care for homeless persons and others.

Although the majority of Americans support a system of universal health insurance that would pay for comprehensive health care for everyone, 15.9% of the population, 46.6 million Americans, are uninsured: a million more are added each year. 71% of Health Care for the Homeless clients are uninsured. The growing rights-based movement for universal health care faces strong resistance from insurance, pharmaceutical and other industries that profit obscenely from the current inhumane system.

A new and widely-accepted approach to these problems has emerged. “Housing First”declares that first, and above all, a homeless persons needs housing.10 This new emphasis differs from “Housing! Housing! Housing!” in its focus on resolving individuals’ homelessness, rather than on the broad systemic deficits and political decisions that drive mass homelessness.

The US government promotes Housing First approaches in its “chronic homeless” initiative, which targets single individuals who have been homeless for a long time and who have a disabling condition (that is, a health condition, and likely several health conditions). Housing First moves homeless people directly from the streets into Permanent Supportive Housing where treatment services are readily available, but participation in such services is not mandatory.

The premise of Housing First is that housing will improve the new tenants’ health and social status, will improve their use of primary care and outpatient services, and will reduce their utilization of hospitals, jails and emergency services (thereby reducing costs). At its heart, Housing First claims that housing IS health care.

The HIV/AIDS community in the US has long promoted the notion of housing as health care, and research from that constituency is beginning to validate this common-sense idea.. The 2005 National Housing and HIV/AIDS Research Summit concluded that “recent studies . . . show strong correlations between improved housing status and reduced HIV risk, improved access to medical care and better health outcomes.”

Preliminary findings of a major study by the Centers for Disease Control and Prevention, reported at the same Research Summit in 2006, suggest that, controlling for all other variables, housing itself may improve the health of persons living with HIV or AIDS.

National AIDS Housing Coalition. Housing is the foundation of HIV prevention and treatment: results of the national housing and HIV/AIDS research summit. Washington DC, 2005.

Housing improves health for the same reasons that homelessness is deleterious. A clean, dry, secure environment is fundamental to personal hygiene (including wound care and dressing changes), medication storage (refrigeration of insulin, safe storage of needles), and protection from assault and the elements. Private space allows for the establishment of stable personal relationships; housing has been shown to reduce risky sexual behaviors.12 A stable residence facilitates effective interaction with others, including treatment providers and social support systems, and increases adherence to treatment plans including regular meals and keeping appointments. Housing may reduce anxiety and consequently reduce stress-related illnesses.13 In these ways, housing both promotes healing and prevents the onset of new illnesses.

Housing must be considered a first-line response to the personal health problems of homeless individuals. Moreover, the creation of additional affordable housing must be understood as a critical public health responsibility, for the control of communicable disease and for efficient and effective health care planning and spending. Public health has long understood the role of housing as a determinant of health, and has played an historic role in developing and enforcing housing standards.14 The known health effects of modern mass homelessness demand that public health renew and broaden its advocacy role to insist that affordable housing is a necessary prerequisite to eliminate homelessness.

A practical and comprehensive understanding of health necessarily includes housing and other social factors. Ultimately, these factors must be considered together in the political and funding arenas. Divided funding streams and uncoordinated policy-making must yield to unified budgets and synchronized policies which will promote – in the language of the World Health Organization – “a state of complete physical, mental and social well being”.15 A growing human rights movement offers new hope that this can be accomplished.

John Lozier / Executive Director
National Health Care for the Homeless Council
PO Box 60427 / Nashville TN 37206 USA
www.nhchc.org