‘Where do you live?’


I’m a doctor in East Harlem, where residents die, on average, 10 years earlier than their neighbors just a few blocks south on Manhattan’s Upper East Side. Many of my patients worry more about paying the rent than buying the medication they need to manage their diabetes or high blood pressure. That’s why I’ve learned that one of the most important questions I can ask my patients during an exam is, “Where do you live?” In recent years, research has demonstrated that there’s a strong relationship between safe and affordable housing and improved health. The findings of a 2013 Federal Interagency Working Group further reinforced the conclusion that improving housing conditions can have a dramatic impact on patients’ health. But despite all we know, our health systems do not address patients’ housing needs as a matter of course. That’s not what they were designed to do.However, we now have a unique opportunity for change. President Donald Trump has put physicians in charge of both housing and health — Ben Carson at the Department of Housing and Urban Development and Tom Price at the Department of Health and Human Services — and together they are positioned to address this linkage, improving health and lowering the costs of health care at the same time. Let me explain how the connection between housing and health works in practice. The questions I ask my patients have to be precise. They include: “Are you worried that in the next two months, you may not have stable housing?”“Do you think you are at risk of becoming homeless?”“How often in the past 12 months were you worried or stressed about having enough money to pay your rent or mortgage?”“Do you have trouble paying your heating bill in the winter?”Many of my patients move from couch to couch. Some who have housing get sick from the leaks or mold in their rooms. If their housing situation is stable and adequate, we can talk about everything else. If it isn’t, I know they have an issue that makes their health — or their family’s health — a secondary concern. I recently ran into a patient whom I had not seen in sometime. She had just been discharged from the emergency room for “high sugar,” which she was told was due to uncontrolled diabetes. I was surprised, because when she came to see me in clinic, her diabetes was well controlled due to her own self-management. But she explained that she had recently started spreading out her insulin to save money for rent. The price of insulin has tripled over a decade, while wages have stayed the same and housing costs have increased in many markets. Given this, it’s no surprise people can’t afford housing, and often, the cost of medical care is a major reason why they can’t. The homeless, low-income Americans, the elderly, and families in substandard housing conditions suffer the most.This isn’t just an urban issue. More than 30 percent of homes lacking hot and cold piped water are in rural communities. Given the current design of health insurance and health systems, patients’ housing issues are usually beyond my scope as a clinician. However, as wages continue to stagnate and housing affordability declines nationwide, recognizing the relationship between housing and health outcomes is imperative. For my patient, I know what is likely to happen if we do nothing: her health will deteriorate while the costs of her care will skyrocket. Rather than paying for supplemental support to make rent, or keeping heat on in winter, or removing environmental hazards from homes, we instead pay many more tens of thousands of dollars in needless emergency room visits and hospitalizations that feed into a downward cycle of poor physical and mental health. At the same time, health systems can’t simply divert scarce medical resources to solve a bigger social challenge. Numerous federal and state regulations ensure that most of the $3 trillion America spends on healthcare is stuck in clinical systems alone. As a result, we miss obvious opportunities to combine health care and housing spending. We need a better way forward.We already know about some interventions that work outside of clinical systems. Some communities have adopted the “Housing First” approach of providing stable housing to the homeless without preconditions, such as addressing substance abuse issues. The state of Utah found that the average cost of health care for a chronically homeless person was more than $20,000, but providing permanent housing cost the state just $8,000. On the healthcare side, a Medicare initiative called Independence at Home showed that providing primary care for seniors at home (including assessing their home environment) saved an average of $3,070 per patient. While these efforts are promising, bolder action is necessary. Housing is a national issue with implications beyond healthcare, so where should Dr. Carson and Dr. Price focus their efforts? First, give states more flexibility to use Medicaid funds together with non-healthcare spending. Fortunately, states are in the best position to decide how to rebalance healthcare spending through the use of Medicaid waivers, which were created under the Affordable Care Act to accelerate state-led innovations. States can then use Medicaid funds to support housing-related health programs. The federal government should ensure that we’re learning from their success and challenges, by resolving the significant barriers to sharing data between healthcare and social services. Second, increase the use of health impact assessments. We already know that certain populations are more sensitive to housing-related health impacts. Looking through the housing lens, it’s possible to quantify the positive or negative impacts of a proposed project or policy on residents’ health. If a housing project has a favorable health impact assessment, we should increase the availability of tax credits to support it.Third, encourage the mixing of public and private resources at the local level to improve housing availability, affordability and quality for populations that would result in reduced hospital visits and better health outcomes. In Maryland, Local Management Boards are used to find the right mix of funding to build collaborations that cut across silos and funders. Ultimately, the right combination of infrastructure development, programs that bridge the health and housing divide, and supportive policies are best determined at the state and local level. However, Dr. Carson and Dr. Price have a critical role to play in removing the payment, data and policy roadblocks that make addressing health care and housing needs in an integrated fashion nearly impossible. Without a more comprehensive approach, physicians like myself will continue to watch people needlessly suffer. It is my hope that before too long, I’ll not only be able to screen my patients for housing challenges, but that all clinicians will have immediate solutions to offer them. Prabhjot Singh, MD, Ph.d, is director of the Arnhold Institute for Global Health and chair of the Department of Health System Design and Global Health at Mount Sinai Health System in New York. He is author of “Dying and Living in the Neighborhood: A Street-Level View of America’s Healthcare Promise” (Johns Hopkins University Press, 2016).


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