ACP commits to finding health care for unhoused people

April is one of my favorite months, not only because it is my birth month and the month of the NCAA tournament's Final Four, but also because it is when ACP holds our Internal Medicine Meeting. For someone who loves to learn and is an extroverted health care and health policy junkie, attending a multiday educational meeting with thousands of incredible internal medicine physicians is truly up my alley!

This year, we will be gathering in Boston, a historic town for many reasons, including some notable health-related ones. The first polio virus was cultured in 1949 at Boston Children's Hospital, the first successful live donor organ transplant occurred at what is now Brigham and Women's Hospital in 1954, the isolation of the first hereditary cancer gene happened at Massachusetts Eye and Ear in 1986, and the discovery of the role of the T cell in the immune system took place at the Dana-Farber Cancer Institute in the 1980s.

Another development in the 1980s in Boston was the formation of the Boston Health Care for the Homeless Program. A coalition of community shelters, health centers, city and state governments, medical schools, hospital systems, advocacy groups, and unhoused persons received a pilot grant from the Robert Wood Johnson Foundation that was matched with state funds to determine how to address the health care needs of the city's unhoused population. This program now provides services to more than 11,000 people each year and is one of the programs highlighted in ACP's recent policy paper, titled "Meeting the Health and Social Needs of America's Unhoused and Housing-Unstable Populations" and published in Annals of Internal Medicine in February.

I am often deeply proud of the policy work that ACP takes on, and this paper is no exception. I have known a family member who was homeless for an extended period of time, even with a large family support system and access to a robust health care system (the Veterans Health Administration), so this position paper speaks to me and likely to many of our members who care for this population. In fact, data show that the population of unhoused older adults has increased from 11% of all unhoused persons in 1990 to more than one-third of the total population of unhoused individuals.

You may be wondering why I and the ACP policy paper at times use the term "unhoused," as it does not roll off the tongue as easily as "homeless," and this has been a subject of recent debate. The terms "unhoused" and "houseless" are generally considered more appropriate, as they better convey the concept that many who are unhoused may lack access to a physical structure that would be considered a permanent dwelling yet still feel at "home" in the places and communities where they live. However, we also use the term "homeless" since it is the more common term and is frequently used in academic literature and by government agencies.

The first recommendation that the College makes in this paper builds on another recent position paper that was developed by ACP's Ethics, Professionalism, and Human Rights Committee, which stated that "ACP views health as a human right based in the intrinsic dignity and equality of all patients." Therefore, ACP's Health and Public Policy Committee stated that "access to safe and affordable shelter is an essential component of recognizing and implementing that human right." The paper then goes on to state that "ACP recognizes the essential role of stable housing on well-being and the negative impacts of homelessness and housing instability on health and health outcomes." When one looks at Boston, those who are unhoused have an average life expectancy that is 27.3 years shorter than that of housed persons. That simply cannot be acceptable in our society and country where there is so much abundance.

So how do we begin to address this? One mechanism is to advocate for policymakers to commit to addressing the underlying structural drivers of homelessness. A huge challenge with this approach, however, is that there is no one social or structural factor that is responsible for causing homelessness. As ACP outlined in a 2021 policy paper titled "A Comprehensive Policy Framework to Understand and Address Disparities and Discrimination in Health and Health Care," numerous interacting factors, including social drivers of health, racism and discrimination, economic and educational disadvantages, health care access and quality, and individual behavior, impact a person's overall health. These same factors also impact whether a person becomes homeless at some point in their life.

However, with this said, one key structural factor is the lack of affordable housing in the United States. Between 2010 and 2022, average housing costs increased by 75%, while average wages only grew by 54%. Therefore, one set of policies that could be pursued are those that would increase purchasing power and enhance earnings for low-income individuals via improvements to minimum wage and new or enhanced tax credits. There are also policy approaches that involve the direct or indirect funding of affordable housing construction. Additionally, inclusionary zoning policies that require developers to sell or rent a certain percentage of new residential units to lower-income individuals should be explored. Massachusetts, Virginia, Maryland, and California have implemented such inclusionary zoning policies, creating nearly 173,000 new affordable housing units.

Another important policy approach is supporting and adequately funding programs that seek to meet the immediate health care needs of unhoused individuals. A local example of this is the Boston Health Care for the Homeless Program mentioned earlier. From a federal perspective, there is the Health Care for the Homeless Program, which provides dedicated funding through the Health Resources and Services Administration for community health centers to provide low- or no-cost care to this population. Medicaid expansions, authorized by the Affordable Care Act, have also been shown to increase access to health care services for the homeless.

The federal government could build on these successful programs by implementing and evaluating Medicare and Medicaid demonstration projects that provide housing supports and targeted medical services to those who are unhoused or at risk of becoming unhoused. States can seek out Section 1115 waivers to conduct demonstrations aimed at supporting these objectives. Massachusetts, Arizona, Arkansas, and Oregon have implemented such waivers to provide new health-related social needs services to unhoused beneficiaries.

Perhaps one of the more controversial of ACP's recommendations in the new position paper is that we support laws and regulations that decriminalize symptoms of housing instability and homelessness to allow those individuals to undertake life-sustaining activities in public in the absence of available safe shelter. However, we state that this should be done in a manner that sufficiently balances the greater public health interests. Also, of course, this is only a short-term stopgap measure that must be pursued alongside the upstream approaches described earlier to help prevent homelessness. Enforcing laws that criminalize symptoms of homelessness, like camping, begging in public, and rummaging and scavenging, is expensive and does not address the underlying conditions that perpetuate homelessness.

The bottom line is that the U.S. needs an effective, evidence-informed, sustainable, and sufficiently funded long-term national strategy to address homelessness. Congress and the administration need to work together to ensure that the necessary authorities and appropriations are in place to implement this strategy, which should also be regularly reviewed and updated to reflect changes in the environment.

So, if you are attending Internal Medicine Meeting 2024 in Boston, look around to see if the policies to address homelessness that the city has implemented seem to be effective. Perhaps consider what more should be done and/or what ideas you could take home and pursue in your home state or locality. If there are relevant bills or regulations in your home state, please let ACP National know and we can help your chapter advocate for them via grassroots alerts, tips, or other resources. I hope to see you in Boston!