People who work in health care know firsthand that housing is health. Those experiencing homelessness have higher rates of emergency room visits, and that rate only seems to be increasing, according to data from the Department of Housing and Urban Development. This is a vulnerable population of individuals who have high rates of chronic illness, mental health disorders, substance use disorders, injuries, infections, respiratory diseases and various others. In our country, it is difficult to parse out if an illness caused homelessness, if homelessness caused the illness, or if homelessness made a controllable illness deadly.
When I care for those who are unhoused in the hospital, I am deeply moved, disturbed and saddened by the limitations of my work. I cannot dole out medications as I would want to for treatable conditions because my patients often have no way to store them, pay for them, get them refilled or continue seeing doctors as an outpatient. Some treatments are not even offered for patients. Transplant surgeries, for example, require patients to have excellent social support. Although unhoused individuals can donate organs, they are rarely eligible to receive one. Unhoused individuals, by nature and by definition, already receive second-class care.
When health care institutions prioritize Housing First initiatives, health — and health care costs — improve. This was seen in 2019 when Kaiser Permanente provided housing to people in Oakland, California, and Portland, Oregon. There was a 37% decrease in use of emergency rooms and a 27% decrease in health care costs. This led to building a dedicated program to support high health care utilizers with full-service social service care coordination, which resulted in incredible success for its participants.
When the Department of Veterans Affairs took on a Housing First approach for the care of its veterans, there was a 52% reduction in veteran homelessness. This approach is rooted in evidence and has had significant success in promoting the well-being of our unhoused people. However, this approach is now at great risk due to the federal government’s 180-degree shift in approach to managing the crisis of homelessness.
The executive order passed on July 24 titled “Ending Crime and Disorder on America’s Streets” will do anything but. This executive order, framed as a new and innovative approach, effectively promises to end federal support for Housing First initiatives, ties housing assistance to mandatory substance use treatment and rewards jurisdictions that criminalize individuals living on the streets. It villainizes and punishes our most vulnerable people. This, too, at a time when homelessness is thought to amount to 770,000 people in a single night — the highest in our history.
In Baltimore, the Assistance in Community Integration Services (ACIS) pilot program, which started in 2017 and ends in 2026, has the goal of reducing avoidable health care spending through housing case management services. In 2023, 611 people, the majority of whom were homeless when they enrolled, were able to obtain stable housing. Remarkably, 83% of people had no hospitalizations and nearly half had no emergency room visits. This is a program that is authorized by the state’s Medicaid HealthChoice Waiver that uses state expenditures and subsequent federal matching with a total of up to $7.2 million in funds to care for 900 people statewide. The new cuts to Medicaid compromise the federal matching rate, squeeze state budgets and force local governments to renegotiate their expenditures. Programs like the ACIS pilot are at grave risk of ending, even with their undeniable success.
Homelessness in America is a crisis of humanity. In Baltimore, 1,600 people are homeless on any given night. We need creative, thoughtful and humanizing solutions like the ACIS pilot program to meet them where they are. We cannot tackle health without housing first.
Bhavya Ancha is an internal medicine resident physician at Johns Hopkins Hospital.
