John N. Lozier has been executive director of the National Health Care for the Homeless Council since its founding in January 1990. The Council is a network of more than 10,000 doctors, nurses, social workers, patients and advocates who share the mission to eliminate homelessness. John lives in Nashville, TN with his wife Joceline, and sits on the Board of Healthcare-NOW!
Question 1: Can you start off by talking about how people come to experience homelessness, and whether the healthcare industry plays a role in that?
Medical debt, deeply rooted in the current system, is a major and often overlooked contributor to homelessness. PNHP research shows that over 60% of personal bankruptcies in the US are the result of medical debt. From bankruptcy there is a well-worn path through eviction, followed by temporary stays with family or friends, to sleeping in a car, a shelter or outdoors.
Beyond that driver of homelessness, untreated illnesses play a huge role in selecting who will experience homelessness in an economy that is sorely lacking in affordable housing. Those who are most quickly squeezed out onto the streets tend to be those with so-called “behavioral health” problems – addictions and mental illnesses. Without minimizing the difficulties in treating these diseases, very helpful treatment approaches do exist, but are far from universally available. Uninsurance and underinsurance play a central role in excluding people who need and want treatment. Even when one has a payment source, system insufficiencies create wait lists for people who need to enter treatment at the point when they are ready.
Question 2: Does homelessness and housing insecurity create particular challenges for accessing needed healthcare?
Most assuredly. The Institute of Medicine of the National Academy of Sciences recognized this as early as 1988 in its seminal publication, Homelessness, Health and Human Needs. Beyond the very high uninsurance rates in the homeless population, competing survival priorities can take precedence over seeking health care. Just as people a bit higher in society’s pecking order might have to choose between paying for medicine and heating the house, people experiencing homelessness may have to choose between standing in line for a meal or a chance for a shelter bed and standing in line or waiting for a health care visit. Think about Maslow’s hierarchy of human needs, and what choice you would make.
Transportation is another problem. While public transportation and safety-net services sometimes help, may people without homes must walk to get places, and services are not always located close to areas where people stay. In Health Care for the Homeless, we see terrible foot problems, a result of all that walking, of sleeping sitting up (fluids pool in the lower extremities), and of high rates of diabetes.
Poor provider attitudes toward people who are obviously homeless and distressed – perhaps with poor personal hygiene (hard to control when you’re on the streets!), bad odors and strange behaviors – create new barriers to care. People are pushed away in ways ranging from subtle to brutal.
Question 3: If a single-payer healthcare system were implemented in the United States, how would that effect homelessness?
It would help to end mass homelessness by dramatically improving access to care. It would reduce immense human suffering.
Medical debt would be a thing of the past, closing a front door into homelessness. At the primary care level, the barrier of co-pays and deductibles (an oddly emerging barrier for dispossessed people as they become auto-enrolled in Medicaid managed care programs under the Affordable Care Act) would be eliminated. Specialty care and non-emergency procedures would become available – no longer would people living under bridges have to forego oncology services or cancer surgery for lack of a payer. And reasonable health planning would help ensure appropriate geographical distribution of services.
Question 4: Adequate housing and access to healthcare are both fundamental to quality of life and human dignity, but they are also two massive industries in the United States. Do you see parallels between the social movements to recognize healthcare and housing as rights? Are there spaces where these two movements could work together?
We do work together. We share the theoretical perspective that housing and health care are both human rights, and as such are interdependent and inseparable. Moreover, we recognize on a very practical level that housing is health care: one cannot expect to get well or stay well when living without housing, exposed to all sorts of infectious agents, the harsh elements, parasites, violence, poor nutrition, and poor rest.
One way that insight takes form is in the widely accepted “housing first” approach to homelessness interventions. Usually focusing on people whose health status makes them particularly vulnerable to homelessness, “housing first” moves homeless people into housing without expecting sobriety, employment or other indicators of “housing readiness.” Housing becomes the foundation upon which a person can begin to become healthy.
The National Health Care for the Homeless Council enthusiastically participates in the work of the National Low Income Housing Coalition for a National Affordable Housing Trust Fund to increase the actual supply of housing. The Corporation for Supportive Housing helps to bring our expertise in health care delivery into housing first developments.
Of course, I describe a relatively narrow focus on homelessness, the place where the extremes of poor housing and poor health intersect and offend the conscience. The collaborations among organizations are mostly focused on services and housing initiatives. The challenge is broadening this work to bring the human rights perspective to our well-intentioned colleagues who may have less expansive visions. Ultimately in a democracy, the strength of the profiteers in industry must succumb to a mobilized constituency insisting on basic human rights.
Question 5: Where can we learn more?