2020’s Converging Housing, Health Care, and Racial Inequity Crises

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The current pandemic has shined a spotlight on pre-existing structural problems that lie beneath the massive inflow of people into homelessness and how federal policies perpetuate them.  In a brief slide deck, I recently highlighted for Congressman Derek Kilmer how federal labor and housing policies seed homelessness, particularly for Black, Indigenous, and People of Color (BIPOC), making it virtually impossible for many communities, even those with robust homeless services systems, to keep up with the inflow of new people losing their housing and needing shelter and other assistance. 

The Sisyphean task facing local governments and their homeless services partners has been front-of-mind every day over the past few months as I’ve supported local homeless services systems across the country in responding to the pandemic.  An example that highlights the scale of the problem:

Seattle and King County in 2019 saw its homeless services system exit 19,600 people, but had a net increase in homelessness as 21,200 new people entered the system.  The King County homeless services system’s data show that Black residents are 5 times more likely than Whites to become homeless and American Indian-Alaska Natives 7 times more likely.

Until federal policy squarely takes on the intertwined and mutually compounding inequities created by systemic racism, stagnant wages for low-income workers, and the dramatic growth (pre-pandemic) in the number of renter households teetering on the verge of eviction, communities will continue to struggle to focus sufficient resources and services on the people who need the most assistance in exiting homelessness–those with acute and chronic medical and behavioral health conditions, histories of trauma, and other stubborn barriers to personal stability. 

Link to the slide deck here.

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Stories like the one related by Dr. Leslie Enzian during a panel discussion at this month’s annual Washington Conference on Ending Homelessness have helped me appreciate the critical role that medical respite care (aka recuperative care) plays in homeless response systems. Medical Director of Seattle’s Edward Thomas House medical respite program, Dr. Enzian joined Washington Health Care Authority Deputy Chief Medical Officer Dr. Charissa Fotinos, Ben Miksch of United Health Care, and myself to talk about medical respite care’s unique approach and contributions to local COVID-19 responses. We also discussed efforts to bring medical respite care to a scale that can better meet community demand — in Washington and around the country. Early in the discussion, Dr. Enzian described the experience of Edward Thomas himself, the African-American formerly homeless man for whom Seattle’s medical respite care program is named and who granted permission to share his background and path to stability. Depicted in the photo above, Mr. Thomas…

The Capitol

A Public Health Lens on Homelessness Exposes Problems with the Trump Administration’s Proposed Approach

A recent
University of California study titled Health
Conditions Among Unsheltered Adults in the U.S.
brings into focus
public policy blind spots that make progress challenging for clinicians and
other professionals working to end homelessness.  Personally, the study’s findings evoke a
question that preoccupied me during my tenure as director of a 10-agency
health care network
treating over 21,000 unduplicated homeless individuals
per year: Why do policy debates about homelessness pay such scant attention
to significant health needs that both precipitate the loss of housing and
create daunting obstacles to regaining stability after an individual or family has
become homeless?

A top view of homeless beggar man with belongings outdoors in city.

Housing is Health Care. Yes, And…

As Public Health thought leaders push for greater understanding of the social determinants of health, they increasingly focus on stable, affordable housing as a critical piece of the puzzle for reducing the risk of worsening chronic health conditions, frequent and/or avoidable hospitalization, increased costs, and early mortality for vulnerable populations.   Kaiser-Permanente Chief Community Health Officer Bechara Choucair and National Health Care for the Homeless Council CEO Bobby Watts persuasively argue in Rx for Health: A Place to Call Home that “homelessness itself can accurately be characterized as a dangerous health condition.”[1] The statistics they cite demonstrating dramatic health outcome and mortality disparities for people experiencing homelessness strongly suggest that increasing access to safe and secure housing would, at a population health level, have an enormous impact. [2]  Simply stated, preventing people from losing their housing in the first place also prevents poor health outcomes.  In turn, re-housing people who have become homeless reduces the danger of rapidly deteriorating health that is part and parcel of homelessness.  Yet there are thousands upon thousands of people across the U.S. whose unmanaged chronic conditions have already been exacerbated by homelessness.  Effectively and sustainably addressing their needs entails grappling with an array of policy and operational challenges.