When I was completing an MPA I took a couple of classes out of the MPH (Public Health) program. In one of the classes our professor assigned a group of us to a project focused on ways in which public agencies can access Medicaid funding for housing assistance programs for homeless individuals. The basic idea was that homeless individuals utilize healthcare resources and are unable to pay for any services they receive. The government, usually the local city or state government, ends up covering the cost of care provided to homeless individuals. The alternative would be that homeless individuals cannot access healthcare, and that they become more likely to spread communicable diseases or to die from preventable causes wherever they manage to find shelter.
This means that local governments end up paying a lot for the healthcare needs of their homeless (Malcolm Gladwell once wrote a story about “Million Dollar Murray” who happened to live in my hometown of Reno). Our project was to see what was permissible under Medicaid guidelines to allow hospitals and local public health entities to access Medicaid funding to provide housing for individuals who would otherwise drive huge healthcare costs. Accessing Medicaid funding would shift part of the costs to the federal government and bring in more federal funding to allow more individuals in the area to receive support. The ultimate goal was to get people established with basic housing and in the long run cut down on the number of emergency room visits and medical services that people would need.
Being homeless can drive up healthcare costs by driving people into worse health states. This is something that is often overlooked when we think about the homeless. As Elliot Liebow wrote in Tell Them Who I Am, “In many cases, the very conditions of homelessness produced poor health care as well as poor health. On the one hand, the women sometimes failed to tell the doctor that they were homeless; on the other hand, even when doctors knew their patients were homeless, they often failed to appreciate the significance of that fact.”
As my small team of fellow graduate students completed our project, we focused a lot of thought on housing individuals with diabetes or asthma. If you are homeless and have either condition, managing your health becomes dramatically more challenging. Doctors have to spend additional time with homeless individuals to help ensure they know how to use their medications and have secure and temperature controlled places for them. But as Liebow’s quote notes, this doesn’t always happen, even if a doctor knows the patient is homeless. A person without a fridge may not have a place to store insulin without it going bad. They may not then be able to access insulin when needed, and may end up in the ER for an emergency that would never happen if we had simply ensured they had a place to live and keep their medicine. Homeless individuals with asthma may find themselves sleeping in a car in a parking lot, or under a freeway overpass. This means they are in a place where they are exposed to more car exhaust and dust, potentially triggering a severe asthma attack and necessitating another entirely preventable ER visit. In both cases if the had been given a place to live that wasn’t densely inundated with vehicle pollution or had a way to safely store their medication, they wouldn’t have had to go to an ER. Society could have have paid the cost of their housing, but instead we chose to let them be homeless and pay for thousands of dollars in medical costs after they had a problem.
The question our team looked at is how many ER visits does it take to offset the costs of simply providing a house first? And what types of services will Medicaid allow to be billed that help secure and individual in the housing they are provided? As it turns out, Medicaid does offer assistance for housing search, coaching on how to be a successful tenant, and other basic services to help ensure someone can live within any housing they are provided. It doesn’t, however, allow any reimbursement for rent or direct housing costs. Nevertheless some hospitals and some local governments are beginning to invest in housing first strategies. Any efforts that keep people out of the ER will save money in the long term, even if it is more expensive up front to provide someone with a place to live. The returns and benefits to a persons health ultimately outweigh the costs of providing housing as fewer healthcare services are needed.