Why Hawaii bill would treat homelessness as a medical condition

A bill introduced by a Hawaii state senator could free up Medicaid dollars to use on a proven approach for ending homelessness.

First Look

On Monday, lawmakers in Hawaii plan to debate whether to classify homelessness as a health problem.

With nearly 54 out of every 10,000 residents homeless, Hawaii has the highest homeless rate of any state, according to the National Alliance to End Homelessness. Democratic state Sen. Josh Green sees the Aloha State’s $2 billion Medicaid budget as a source of funds to address this problem.

Senator Green’s bill, which faces its first public hearing Monday, would classify homelessness as a medical condition allowing doctors to prescribe housing, and for Medicaid to pick up the tab.

"It is paradigm shift for sure, but the single best thing we can do today is to allow physicians and health care providers in general to write prescriptions for housing," he told the Associated Press. Dr. Green, who works as an emergency room physician, says homelessness often compounds other medical issues.

Describing social issues as public-health problems isn’t unheard of. For years, researchers have analyzed gun violence through an epidemiological lens, because shootings, like some diseases, tend to occur between individuals in close social contact.

But classifying homelessness as a health issue is slightly different. Rather than applying biological concepts to understanding the problem, Green’s bill establishes that, because homelessness compounds so many other health problems, it needs to be researched and addressed as part of the treatment process.

This approach has gained traction in recent decades. As far back as 2000, an editorial in the American Journal of Public Health argued, “Addressing upstream causes is essential in confronting public health issues.”

In the case of homelessness, it cautioned that a pitfall to this approach could involve focusing on the individual traits of homeless people – such as drug abuse and mental illness – rather than on the chronic lack of affordable housing at the root of the problem.

More recently, other states have reduced their homelessness rates by prioritizing permanent, not temporary, housing. The “Housing First” approach often involves giving people homes or apartments, no strings attached. Doing so, proponents claim, gives the homeless with the stability they need to address other problems and rebuild their lives.

Such a program in Utah cut the state’s chronically homeless population by 75 percent. In 2015, Mother Jones reported that “Utah's Housing First program cost between $10,000 and $12,000 per person, about half of the $20,000 it cost to treat and care for homeless people on the street.”

Expect to see statistics like these marshaled in support of Green’s bill, the first of its kind in the country. In 2015, Honolulu’s Queen’s Health System billed $89 million for treating homeless people, according to the Associated Press.

Some observers caution that it might not always be possible to draw a direct line between housing and health. "You need to really look at when that's appropriate, because there's a lot of people that become homeless," Connie Mitchell, executive director of Hawaii’s Institute for Human Services, told the AP’s Cathy Bussewitz. "Just because they become homeless doesn't mean it entitles [doctors] to write a prescription for a unit."

But across the country, a consensus is growing that housing can reduce the costs of keeping vulnerable groups healthy. "Housing is health care,” Ms. Mitchell explained, “because it does afford a person a much greater chance of sustaining their health.”