As primary care physicians, we are accustomed to receiving hard news from our patients. A recent message came in the form of a text message, a string of crying emojis, from a patient who had already suffered so much. Jean (name changed for privacy), though only in her mid-30s, has suffered from uncontrolled diabetes, high blood pressure, an early heart attack, and a long history of trauma, and was recently diagnosed with HIV. Though Jean has made great strides in her health — intensive therapy for her trauma, new medication regimens for her diabetes, high blood pressure, and now HIV — stable housing was the one key element to her health that had proved elusive.
But the emojis in Jean’s text message, it turned out, were not tears of sadness but tears of joy. In a series of photos, she shared her new Boston Housing Authority apartment. Good housing can make a world of difference for Jean and others, just as a lack of housing can be devastating. In hospitals like Boston Medical Center, we see this every day with the patients who come to us.
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The United States has long struggled with a legacy of homelessness. The number of people experiencing homelessness in our country was estimated to be more than 567,000 as of January 2019, and these numbers are climbing ever higher, exacerbated by the high rates of unemployment during the COVID-19 pandemic. In fact, a Columbia University analysis predicts that the nation could see a 45 percent jump in homelessness in 2021. This is an alarming prospect, since homelessness and housing instability not only fuel the high rates of COVID-19 infections, especially in Black, Latinx, and immigrant communities, but also accelerate chronic illnesses and lead to higher rates of all causes of mortality. Conversely, successful models of stable, affordable housing save lives and ultimately drive down overall medical costs.
One such model is Housing First, an initiative of the National Alliance to End Homelessness, which was started in the late 1980s and through nonprofits such as Pine Street Inn has supplied 2,100 units in Massachusetts over the last 15 years. Rather than providing a shelter or transitional housing to people experiencing homelessness, it offers a lease to permanent housing with supportive services such as treatment for substance use disorder and psychiatric illness.
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A recent study led by Blue Cross Blue Shield of Massachusetts Foundation demonstrated that people enrolled in the permanent supportive housing in Massachusetts’ Housing First model received more mental health services, had significantly fewer rates of hospitalizations and emergency room use, and had lower overall medical costs when compared with those who remained chronically homeless.
Another model for a person like Jean who has housing instability and multiple illnesses (but is not considered chronically homeless), is a supportive housing partnership between health care systems, such as the one between Boston Medical Center’s Complex Care Management programs and the Boston Housing Authority. These models are built on the well-founded premise that getting people with complex medical diseases into housing is critical to stabilizing their health.
The good news is that Boston and Massachusetts have been leaders in taking proactive steps to address the crisis of homelessness and housing insecurity. Mayor Marty Walsh has set ambitious goals of 53,000 new housing units, and though it is not clear what proportion of these will be affordable, the City Council and the mayor recently announced that Boston will become the first major city in the country to require the affirmatively fair housing standards outlined in the Fair Housing Act. This rule would require future developers to ensure that more developed units become accessible to low-income individuals, people with disabilities, and people with families. Furthermore, the recently passed state economic development bill has promising housing provisions, including housing choice and extra funding for building housing near public transportation.
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There is also good news on the federal front. In one of his first acts as president, Joe Biden signed an executive order extending the eviction moratorium through the end of March. Indeed both Massachusetts’ and federal policy makers should be commended for their recent efforts to address homelessness. However, as front-line physicians who see first-hand the devastating impacts of homelessness and housing insecurity on our patients’ lives, we think it is clear that these efforts do not go far enough.
In the short term, policy makers and advocates must prolong the national moratorium on evictions until at least next fall. The pandemic will not be over this spring, preventing stable incomes for individuals and families and all but guaranteeing future evictions. As physicians, we are also advocating another $30 billion for national housing rent and mortgage assistance as well as a robust federal housing emergency fund, which could go toward helping individuals and families affected by the pandemic cover rent, mortgage, and down payments.
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We also urge lawmakers to address one of the largest root causes of homelessness and housing insecurity in our city: extreme wealth gaps. In Boston, the assets in the pocket of a typical Black family is $8 versus the median net worth of a typical white family, which is almost $250,000. It is only in providing real solutions to bridge these vast wealth gaps that we can truly begin to solve the health impacts of homelessness and housing instability in our city. Though the road ahead is dark, long, and difficult, we know that with these measures we can improve the health of the Jeans of our city, our neighborhoods, and our communities. And, as National Youth Poet Laureate Amanda Gorman so eloquently penned for her inaugural poem, “there is always light/if only we’re brave enough to see it.”
Dr. Katherine Gergen Barnett is the vice chair of Primary Care Innovation and transformation director in the Department of Family Medicine at Boston Medical Center, associate clinical professor at Boston University School of Medicine, and a fellow at Boston University Institute for Health Systems Innovation and Policy. Dr. Megan Sandel is codirector of the Grow Clinic for Children and co-lead principal investigator at Children’s HealthWatch at Boston Medical Center.
