The link between housing and health is clear: You can’t live a healthy life if you don’t have a roof over your head.
Without stable housing, people die younger, suffer more and have more severe chronic illnesses, make far more emergency room visits, are more likely to be hospitalized and readmitted, and stay longer in hospital when they are admitted.
So, not surprisingly, a bold new initiative by the University Health Network (UHN) in Toronto to build affordable housing is generating a lot of excitement. If fewer people were homeless or precariously housed, we would save health dollars and maybe even make a little dent in hallway medicine, so the donation of a $10-million plot of land is money well spent.
But let’s not get ahead of ourselves. The journey from parking lot to an affordable-housing project is going to be a long one.
What’s really important in this story is the leadership it demonstrates, the symbolism. When Canada’s largest hospital hired a brilliant young researcher, Dr. Andrew Boozary, as its executive director of health and social policy and then launched a social medicine initiative, it acknowledged the importance of the social determinants of health.
UHN and its leadership have tacitly admitted that, for a healthy population, sickness care alone is not enough. It’s bad policy.
There are, of course, those who will say that social policy is not a hospital’s problem - that it should stick to its lane. But, as Dr. Boozary says: “A postal code is a better predictor of health outcomes than a genetic code.”
That’s why hospitals should see not only individuals, but the neighbourhoods they serve, as the patient. In Canada, we used to have departments of health and welfare. But the welfare part of the equation became unpopular and budgets for social housing, income supports, subsidized food and education and other initiatives that make and keep people healthy were slashed by short-sighted politicians preaching “pull yourself up by the bootstraps” bromides.
A study published last year showed that spending on social programs has fallen steadily for three decades, to the point where we now spend about three times as much on sickness care as we do on social programs.
The result is an everyday absurdity: Patching people up and then sending them back into the conditions that made them sick in the first place: homelessness, poverty, malnourishment and social isolation. It’s a reality that rankles many physicians, nurses and other health-care providers, and even health-care executives can’t ignore it.
Maybe the UHN shouldn’t be – or shouldn’t have to be – investing in social housing and vowing to tackle other problems their patients struggle with daily such as lack of access to healthy food, daycare, quality jobs and livable incomes. But they’re doing so because others are shirking their responsibilities, with both the provincial and federal governments pouring more and more dollars into sickness care and fewer and fewer dollars into keeping people healthy.
We should remember, too, that addressing the social determinants of health – tackling the root causes of illness – is not just a touchy-feely thing to do. It’s good business, too.
In the United States, a number of hospitals, including some of the most forward-thinking, are investing in housing because it gives them good return on investment.
Kaiser Permanente, for example, is building 500 subsidized-housing units for homeless people over 50 in Oakland, Calif., because it will keep them out of hospital and improve the bottom line. The University of Illinois in Chicago, similarly, is moving “super-users” of its emergency room into supportive housing. Nationwide Children’s Hospital in Columbus, Ohio, is renovating dilapidated housing in its neighborhood with the aim of keeping children healthy and out of hospital.
What UHN is doing in Toronto is a charitable initiative; it won’t help the bottom line. UHN receives a fixed budget from the province and most of its physicians are paid on a fee-for-service basis for providing sickness care.
But imagine if, instead, we gave hospitals funds to manage the health of populations in their catchment area and rewarded them for better outcomes. Imagine if we reimbursed them based on results.
Ultimately, that’s where the discussion around a hospital investing in social housing should take us.
As the French philosopher Michel Foucault has famously said: “The first task of the doctor [and perhaps the hospital too] is political: The struggle against disease must begin with a war against bad policy.”
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