Is a bill that treats homelessness as a medical condition flawed? Or is it just what the doctor ordered?
With a few big-hearted exceptions, Honolulu’s treatment of its surging homeless population has been less than ideal, even cruel at times. Historically, the Hawaiian capital city’s approach to combating homelessness could best be described more along the lines of “sweeping under the rug” than “lending a helping hand.”
But things are improving in Honolulu and across Hawaii, a far-flung island paradise with the highest rate of homelessness per capita — 487 homeless for every 100,000 people as of 2015 — in the United States, as lawmakers continue to learn that kindness, compassion and creative thinking can really go a long way.
One new and decidedly novel approach to tackling homelessness in Hawaii was introduced last month as a piece of legislation by Sen. Josh Green, a state senator who also happens to be a physician trained in family medicine. The bill introduced by Green takes a two-pronged approach by focusing on the life-altering power of transitional housing while also aiming to slash the exorbitant cost of treating Hawaii’s homeless population in local hospital emergency rooms.
For example, at Honolulu’s largest private nonprofit hospital, Queen’s Medical Center, homeless people accounted for roughly 6,958 ER visits at the end of the 2013 fiscal year. By the end of the 2016 fiscal year, that figure topped 11,000 visits according to Hawaii News Now. Per hospital records, 39 homeless people accounted for a total of 734 total ER visits from Sept. 1 to Nov. 30, 2016. One homeless patient landed in the ER a total of 60 times during this 90-day time period.
The annual cost for Queen’s Medical Center to treat homeless patients, many of them arriving by ambulance or being brought in by Honolulu police, is in the ballpark of $90 million. In total, roughly $1.2 billion of Hawaii’s annual $2 billion in Medicaid funding is being consumed by a disproportionately small chunk of the population: homeless and at-risk of homelessness individuals who are being treated for mental Health issues and drug addiction.
So what exactly does the astronomical cost of treating homeless patients in Hawaiian emergency rooms have to do with housing?
In Green’s opinion, transitional housing is a cure for homelessness and, furthermore, Hawaiian physicians should treat homelessness as a medical condition. Green’s bill would enable doctors to continue to diagnose and treat homeless patients for various acute and chronic ailments. At the same time, doctors would also be permitted to write prescriptions … for housing. That's right, housing.
A 'paradigm shift for sure ...'
As detailed in an insightful article published by the Guardian as part of its excellent Outside in America series, the law would enable Hawaiian physicians to prescribe housing alongside traditional medicine to patients on a case-by-case basis. To be eligible, patients must have experienced homelessness for at least six months and also be undergoing treatment for mental illness or substance abuse-related issues.
In support of his bill, SB7, Green points to research that demonstrates that when homeless people struggling with mental illness and addictions are provided with housing and transitional support, their healthcare spending drops by roughly 43 percent. In turn, the increasing costs of treating homeless patients incurred by Hawaiian hospitals is dramatically slashed while the patients themselves are provided with a new and effective means of healing: a roof over their heads.
Writes the Guardian:
Green said many of the individuals he hopes to house cost the healthcare system an average of $120,000 annually, yet the annual cost to house an individual is $18,000. He thinks that the total savings to the state could be hundreds of millions of dollars a year.
“We’re already spending the money on homeless people, we’re just paying for it in the most inefficient, expensive way possible,” elaborates Green, a Big Island Democrat and outspoken critic of the Trump administration who crafted the bill based on his own personal experiences with homeless patients in the emergency room. “We have a lot of capacity, but lack the political will."
“It is paradigm shift for sure, but the single best thing we can do today is to allow physicians and health care providers in general to write prescriptions for housing," Green tells the Associated Press.
The bill, which Green believes could free up $300 million per year in medical costs for the state while redirecting some Medicaid funds toward housing, already has the support of at least one emergency room physician, Daniel Cheng of Queen’s Medical Center. Calling SB7 a “great idea,” Cheng goes on to explain to the Guardian that “when emergency medical services are being heavily overused by a population that’s being poorly served, it costs everybody.”
“Instead of paying for an antibiotic, let’s take that $5,000 visit and pay for housing. We’d be way more ahead,” Cheng says.
While a much-needed shift from punishment to outreach has helped remedy Honolulu's tourism-impacting homelessness crisis, the Hawaiian metropolis still has work to do. (Photo: Nicholas Kamm/AFP/Getty Images)
A big-hearted vision that's not without flaws
Of course, not everyone is behind Green’s life- and money-saving vision of classifying homelessness as a medical condition.
Connie Mitchell, executive director of Hawaii's largest homelessness-dedicated social services organization, the Institute for Human Services, has made clear to the Associated Press that "housing is health care because it does afford a person a much greater chance of sustaining their health." As such, the institute isn't entirely opposed to the underlying vision outlined by Green in SB7. The institute is, however, wary of the potential for healthier homeless people to take advantage of the system. Simply, if everyone sleeping on the streets of Honolulu was given a Medicaid-funded six-month prescription for housing, the scheme’s money-saving benefits would disappear.
“You don’t want to broaden it so much that everyone is eligible,” notes institute spokesperson Kimo Carvalho.
And although good things and improved health usually follow once a homeless individual is provided with housing, Carvalho tells the Guardian that getting a large number of these individuals to stay put is a challenge. That is, a majority of those who most need and would benefit most from transitional housing tend to refuse it.
“If you give mentally ill people housing, nine out of 10 will just walk away and go back outside,” he explains.
At a recent hearing, socially conservative Republican Rep. Bob McDermott, a member of the House Committee on Housing, also expressed apprehension over SB7.
“You have got to have some integrity in the laws you pass. Words mean things,” McDermott said. “There is a population of homeless [for whom] it is clearly a medical condition — the substance abusers and the mentally ill — but other than that, it seems to be a stretch. Very creative, though. I give him credit for creativity.”
Homeless Honolulu-ites themselves — or at least one who spoke to the Guardian — acknowledge that Green's bill would have a positive impact. “It’s very clear to that if I could get a place to stay, I wouldn’t have to go to the hospital so often,” says Stephen Williams, who has visited emergency rooms 21 times over the last four years with potentially deadly staph infections triggered by an existence spent almost entirely outdoors, often in adverse conditions.
Trouble in paradise? Hawaiian lawmakers think outside the box
Aside from SB7, which will advance to the House of Representatives if it passes a senate reading on March 2, Hawaiian lawmakers have thrown their support behind another Green-drafted bill that would fund a pair of roving mobile medical clinics. Staffed by a doctor, nurse, psychiatrist and driver, the vans would provide services to homeless individuals living on Oahu while taking the pressure off of overburdened emergency rooms.
“This is an attempt to address the nexus between homelessness and the intense pressure that it’s putting on downtown and across the state so we can get people care in a much, much, much, much more affordable setting,” Green tells the Honolulu Star-Advertiser of the mobile clinics, which would cost $1.4 million per year to maintain and operate. “We could do it 20 times cheaper.”
It should be noted that Green’s health care-related benevolence dates back well before he ascended to public office in 2004 when he was first elected to Hawaii House of Representatives. (In 2008, Green was elected to the Hawaii State Senate and currently serves as chair of the Committee on Human Services.) According to the good doctor's bio, after finishing medical school he worked as a volunteer physician in remote African communities struggling with AIDS and malaria. And before becoming an emergency room physician on the Big Island, Green, a Pittsburgh native, joined the National Health Corps to provide care to those living in rural, underserved areas of Hawaii.
State lawmakers are also currently mulling over bills that propose the creation of designated “safe zones” in which homeless people could set up camp on state-owned vacant land without fear of being ousted by authorities. These safe zones would remain in place until lawmakers are able to signal that the state’s homelessness crisis has been remedied to a point where they are no longer necessary.
Like Green’s homelessness-as-a-medical-condition bill, the safe zone-related legislation has faced push back by the powers that be, including the office of Hawaii Gov. David Ige.
"Some of these areas that are being identified as potential homeless campgrounds are very isolated, difficult for people to get to, so it's not necessarily a given that even if you provide it that people would go there,” explains the governor's state homeless coordinator, Scott Morishige.
As for Rep. Bob McDermott, a vocal opponent of SB7, he has co-sponsored a bill that would allow homeless Hawaiians to "rent" private driveways and yards for encampments. “I think everyone's just trying to nibble away at the edge of this homeless issue, providing as many alternatives as possible," he tells the Associated Press. "Most states, there's plenty of land. We're ocean-locked, we're on an island, and there's only so many places you can go."
Matt Hickman ( @mattyhick ) writes about design, architecture and the intersection between the natural world and the built environment.