A Prescription to End Homelessness
By Joshua Bamberger, MD, MPH
Last week my world slowed down enough so I could escape for a leisurely walk in the green hills of Berkeley, California. As is my habit, I listened to one of my favorite podcasts called Radiolab. In this episode, the hosts discussed a fundamental topic: the value of human life. They told the story of a group of doctors who decided that they would protest the $30,000 price tag expected for the cost of a new anti-cancer medicine, and refuse to prescribe the medicine unless the pharmaceutical company lowered the price.
Why were these doctors protesting? To reduce the cost of a medication that, on average, would extend the lives of their patients with colon cancer a whopping 42 days. Wow, I thought, these must be some incredible humans if they are worth almost $1000 a day. Then again, if I were looking death in the face and could postpone it for 42 days, would I spend that kind of money? I suppose I would. What else would I be saving it for?
For the past twenty-five years, I have provided primary care to homeless adults in San Francisco. I have done my best to provide the highest quality of medical care for my patients. I try and am expected to achieve the performance metrics equal to any other primary care provider in the country, most of whom are serving a population with considerably more financial means and many fewer concurrent illnesses of substance abuse, daily trauma and mental illness.
Unfortunately, for my patients who remain on the streets and in shelters, I have failed. Local and national data tell us that homeless adults with mental illness die on average twenty-five years younger than the general population. No new medication, no diet, no complementary therapy has been shown to change that predicted outcome. Only one thing has been shown to bend that mortality curve: housing.
While pharmaceutical companies such as Genentech and Vertex spend billions of venture capital dollars to come up with new chemicals to sell to the medical system, my patients will rarely be able to benefit from what medical care has to offer without something that is much more low tech and much more fundamental, something that every animal on earth understands the value of: a safe place to rest. In a study that my colleagues and I at the San Francisco Department of Health conducted, we followed a cohort of homeless adults with AIDS, we found that the health department’s supportive housing program extended life an average of 36 months per person, with only two out of forty-four housed subjects dying in the five years of the study.
Unfortunately, most ill homeless adults cannot get the healthcare system to pay for housing unless they end up in the hospital or in nursing homes. At that stage, the system steps in and pays the thousands and sometimes millions of dollars necessary to house them in these institutions. Yet if they get well enough to return to the street, the healthcare system typically only pays for the medications and the tests, none of which have been shown to improve life expectancy in this population.
With the roll-out of the Affordable Care Act, most homeless adults in expansion states will now be covered by federal health insurance. With governments and managed care agencies now on the hook to pay for hospital and nursing home care, some local governments and private insurance companies are recognizing that paying for supportive housing will reduce their overall annual expenditures. Study after study has shown that housing mentally ill, homeless adults is less expensive than leaving them on the streets.
This cost abatement argument has been a powerful force to bring the healthcare industry to the table to begin to pay for some or all the costs of supportive housing. The affordable housing industry is taking note of this change and is trying to develop housing, outside of traditional subsidy sources like the Low Income Housing Tax Credit, which can feed this new appetite of the healthcare industry to save money by utilizing a healthcare treatment called housing. In many ways this is “back to the future,” as we used to use public expenditures to house people with psychiatric disorders in locked mental institutions. Supportive housing gives us the opportunity to provide high quality care to my patients with one big difference compared to the days of the asylums: we provide this care without robbing people of their dignity or their freedom.
As I reached the top of the hill on my walk, it struck me: we never expect a medical intervention to reduce overall governmental expenditures. In fact, we go out of our way to pay for new treatments that may very well cost a lot—even $30,000 to extend the life of someone for 42 days. So what is the value of a day of life of someone who has auditory hallucinations, someone who drinks every day to the point of intoxication, is infected with HIV, someone who has burned every personal bridge in their life so their only alternative is to sleep in a doorway?
Evidently, this value is less than zero.
We need to recognize that we all have deep, hidden biases against people whose illnesses are not easily understood by something measured in a laboratory or seen on an x-ray machine. Leaders in Los Angeles, the Veterans Affairs Medical System, New York State, and Salt Lake City are all working to overcome these biases and generate novel strategies to use public dollars to pay for housing. If we only provide a service because we want to have a return on investment, we will continue to denigrate the value of the lives of the humans around us. Instead, we need to act not only because it will save us all money, but because every life matters.
Dr. Joshua Bamberger is Associate Clinical Professor of Family and Community Medicine at UCSF, and a Medical Consultant to Mercy Housing.