Should Physicians 'Prescribe' Housing for the Homeless?

Marcia Frellick

February 27, 2020

California Gov. Gavin Newsom's proclamation in his State of the State address on February 19 that "doctors should be able to write prescriptions for housing the same way they do for insulin or antibiotics," set off a backlash on social media.

In his speech, Newsom called California's homeless problem "a disgrace" and said, "Healthcare and housing can no longer be divorced."

While a few agreed with the sentiment, and some programs are actively promoting "housing first" solutions, the vast majority of comments on social media platforms either mocked the proposal or rejected it out of hand.

Jason Helgerson, MPH, former director of the Medicaid program in New York — the state with the largest homeless rate in the country at 46 people per 10,000 according to a report from the US Department of Housing and Urban Development — told Medscape Medical News that while he admired Newsom's intent, doctors filling out a prescription for housing will just not happen.

He shares the governor's passion that the nation is at a crisis point with stable housing, but "writing a script doesn't solve the problem," he said.

The Challenges With Housing

Housing is a very expensive solution, Helgerson noted, and is in short supply, unlike some other forms of social prescribing such as healthy food, which is (as Newsom pointed out in his speech) prescribed in some areas of the country, including Geisinger Health System in Pennsylvania, as reported by Medscape Medical News.

Homelessness is also a complex issue, even in its definition, as some people are 'underhoused' — perhaps sleeping on someone's couch, for instance — a situation similar to being underemployed.

The practicality of what to do with a prescription for housing is another stumbling block. Programs such as Housing Choice Vouchers/Section 8 in most localities have waiting lists so a person with a prescription may very well have nowhere to go right away.

People also have different needs for housing, Helgerson noted. Some may never be able to earn an income that could sustain their housing and would need indefinite support. Some just need temporary, transitional housing.

So far, with a few exceptions, Helgerson said, the Centers for Medicare & Medicaid Services (CMS) has been reluctant to get involved in covering or subsidizing rents.

"I think they're worried about opening up Pandora's box," he said.

But Helgerson adds that he personally has argued to CMS that they are already paying for housing.

"It's called a nursing home," Helgerson said. "Nursing homes have already been a mandatory service in the Medicaid program since the law was enacted. If they are worried about crossing the Rubicon into housing — they've already done it."

Government Needs to Stock the Pharmacy

Megan Sandel, MD, MPH, a pediatrician at Boston Medical Center (BMC) in Massachusetts, told Medscape Medical News, "I do believe that housing is a prescription for health. I believe, though, that the [entity that needs] to stock the pharmacy for housing is really the federal government."

She said creating partnerships across federal, state, and local lines will be crucial in producing more affordable housing.

"While maybe for a subset of very high-cost patients, it may make sense for a hospital or health insurer to pay for housing, I think in the long run for most people that prescription is going to have to come from public–private partnerships," she said.

Boston Medical, she said, is piloting on a small scale a housing prescription program where it pairs a housing program through the Boston Housing Authority, a public housing agency, with services paid for by BMC. They are focusing on medically complex families and high-cost, high-need adults. Some of the data will be detailed in the journal Health Affairs in April, Sandel said.

"That pairing of a housing dollar with a health dollar for supportive services, I think, is a model that could be scaled," she said.

However, Sandel pointed out, "Only 1 out of 4 people eligible for affordable housing are getting it. We need to stock the pharmacy with a lot more housing to have healthier communities."

She emphasized that there is a nuance with housing in that "first and foremost it gives you a home. The magic medical property of it is that it gives you a home AND makes you healthier. AND it makes your kids do better in school. AND it helps you keep a job. It's the 'AND' that's important."

Some see housing prescriptions as needing to pay for themselves by reducing healthcare costs, but that misses the true scope, Sandel said.

"Prescriptions never have to show they save money, but just that they improve health. Homes pass that test. But it's not that we should put that on a healthcare dollar, we should put it on a 'public-good' dollar, an infrastructure dollar," she said.

"The solution isn't for doctors to write prescriptions without the federal government getting back into building the affordable housing business," Sandel emphasized.

Healthcare Issue or Government Issue?

The debate continues over whether homelessness needs a healthcare solution or a government solution.

Helgerson said while there is wide agreement that the social determinants of health need attention, he questions how much opportunity there is for the healthcare system to be part of the solution to housing.

There's more that the healthcare system can do, he said, because for certain subsets of the population, healthcare savings from being stably housed would be enough to cover the extra costs for housing.

In Hawaii, which has the second-highest rate of homelessness per 10,000 people in the nation according to HUD, a 2015 report on the initiative Helping Hands Hawaii noted: "Through the pilot program and our relationship with the State Housing First program, we found that after obtaining stable housing, the estimated health care cost for our consumers dropped from $10,570 to $5980 per client per month (a 43% decrease in costs) as of Sept. 2015."

Hawaii Lieutenant Gov. Josh Green, MD, an emergency department doctor, introduced legislation when he was a state senator in 2017 that would classify chronic homelessness as a medical condition and require insurance companies to cover treatment for it.

He now is promoting a plan for allowing up to six states to use up to 2% of their Medicaid budget to house the chronically homeless for 5 years.

"Healthcare can't solve the entire housing problem," Helgerson said. "Ultimately, I think it needs to be led by the government."

Helgerson and Sandel have disclosed no relevant financial relationships.

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