Earlier this month, the City Club of Portland released a report – based on a thorough review of academic research, media reports and interviews with stakeholders – concluding what homeless advocates have been saying for more than 20 years: housing is health care. The report recommended doctors receive better training in how to work with homeless individuals, that new Medicaid enrollees receive adequate training in how to access services and that health care funds be reallocated to address one of the root causes of health problems: homelessness.
Dr. David Labby is the chief medical officer of Health Share of Oregon – one of the 16 coordinated care organizations, or CCOs, created as umbrella organizations to oversee physical, mental and dental care in Oregon’s Medicaid population. With more than 236,000 members, Health Share of Oregon is the largest CCO in the state, serving the majority of Oregon Health Plan members in Portland’s urban core.
In addition to being a medical doctor, Labby holds a Ph.D. in cultural anthropology and has a background in community organizing, calling himself an “unrepentant child of the '60s.” He served as a witness for the City Club’s health care and homelessness report.
Labby sat down to talk with Street Roots about the study, the connection between health care and homelessness – and how to act on what we know.
Christen McCurdy: City Club’s report on the connection between housing and homelessness argued that housing should be considered a key determinant of health. That expression, “the social determinants of health,” is thrown around a lot in policy circles right now. Can you talk a little bit about where that concept comes from and unpack what it means?
David Labby: We know that if a person had perfect medical care, it would reduce early death by about 10 percent. So the medical system has a role to play. But it’s obviously not the majority role.
We know that one of the largest drivers is health behavior — whether you smoke, whether you drink, whether you eat well, if you get enough sleep. That’s about 40 percent, so four times as large, in terms of determining your healthy life course, than medical care. Then we know that other things, such as toxins in the environment, play a role. Genetics plays a role. But it’s clear that the major factor that determines health is how we are able to live day to day
Obviously a person who has very few resources and is unable to access healthy food, who lives in a neighborhood where there’s a lot of community violence and is unable to go outside and exercise and has no resources to go to a gym – those things are going to affect whether or not they will have healthy behaviors. The way we construct society, how we give people access to resources, is a huge part of what determines each part of the population’s health.
C.M.: Where does housing fit into that?
D.L.: There’s been many, many, many studies done that show that a person who is homeless will have worse health outcomes than someone who has housing. When you take the person who is homeless and give them access to housing, their health improves. We’ve done a study recently here in our own community at the Bud Clark Commons that shows exactly this: People who are part of the Bud Clark Commons, who are able to live there, have better health. They use the health care system more effectively than when they didn’t have housing, which totally makes sense.
C.M.: One of the things that stood out to me about the Bud Clark Commons study is that it seems like we do have a fair amount of information about the connection between housing and health. I mean, there’s that study, which is very local and very recent, but Housing Opportunities for Persons with AIDS has been around for more than 20 years now. And it was really created with the idea that if you give people with HIV and AIDS housing, they’re more likely to take their medication, they’re more able to access nutritious food because they have places to store and cook it, their outcomes are going to be better and they’re going to be in hospitals a lot less. So I feel like we’ve had some information about this for a long time. And yet I also sometimes wonder about these small studies, whether that’s really going to translate to a major policy change.
D.L.: The question is not whether we have evidence. The question is, how do we make the policy change and the economic change and the business model change to be able to provide housing to those who need it? That’s the hard issue. In Los Angeles the leaders of the Medicaid program are saying that housing is actually a really important factor in health: Since they are Medicaid and responsible for health, they should be able to pay for housing. But federal law basically says you can’t use Medicaid dollars for housing. So the initiative in L.A. is trying to challenge that assumption, but it is not easy to change things that have to happen at the federal level.
CCOs are a major policy change. They are taking the previously separate funding for all medical services, dental services, mental health services, and putting them together in one budget. But this still does not include some of the really important services for the population that is on Medicaid, such as housing. We still have to figure out how we think about a total health organization versus just a coordinated medical care organization. We’re trying to go that direction but the the next step is huge, because it will include things like more housing. It’s a much larger investment. because we also have the problem in our community that there just isn’t enough housing. You have to have a place for people to go. That’s mentioned in the report from our community: that the housing stock is not adequate
C.M.: Part of what’s riding on the Medicaid expansion in Oregon is this idea that if we reach out to more people and do a better job of caring for them within the Medicaid population, we can actually save money. And the state’s goal is just to slow the growth of Medicaid spending. And it makes sense and we have some research, like we talked about, to back up the idea that if you take care of some of these other, simpler problems, that the complicated medical issues will just not arise or will go away. What do you think is going to make the difference and do you think this five-year goal that we have is realistic?
D.L.: Basically, the way Gov. Kitzhaber and the legislature put it on the table was this: We will give you a fixed amount of money to manage a population. We’re going to make it easier for you to manage that population because we’re going to take out some of the inefficienciesof having separate budgets for different services. Mental health dollars are separate. Physical health dollars are separate. Dental dollars are separate. We’re going to put them all together. We’re going to encourage you to figure out new, innovative ways to use those dollars more effectively to make every health dollar count. Basically, health care is being put on a budget and you’ve got to learn to live within your budget. We’re currently at a little over 17 percent of all dollars in our nation’s economy going to health care. That’s double what other countries have, and no one wants to see that become 25 percent. You can’t. It just would derail the economy. It’s not just a question of are we going to be able to decrease costs, it’s really, are we going to be able to work within the budget that society is willing to give us for health?
C.M.: One of the other recommendations of the report is just getting providers better training in how to work with homeless populations, which makes a lot of sense when you look at some of the data that’s pulled out in the report – the fact that more than half of homeless people living in Multnomah County have disabling conditions of some kind. More than 40 percent of women who live on the streets have experienced domestic violence. People of color and LGBTQ people are overrepresented. And so you’re dealing with complex socioeconomic and medical issues to begin with in homeless populations. So how do we get providers better training on a macro or a micro level?
D.L.: We have put a new workforce in primary care practices that serve a lot of people with multiple challenges and who have a high level of need. It’s led by CareOregon and part of a federally funded grant program. It is called the Health Resilience Program and it places this new workforce into the teams within the clinics. This workforce goes out into the community and tries to understand what the life of the people who are coming into the clinic with all these issues is really like and what’s important to them and what they have and what they don’t have. The health rsesilience specialists then bring that perspective back to the clinic providers whose response is usually something like “This person comes in regularly to see me, but I had no idea what their life has been like or what their life is now.” More and more, we are learning about the challenging experiences some people on Medicaid have had throughout their life. Their family situation early on was very difficult.
Lots of families struggling in poverty. Substance abuse among the parents. Families that had to move because they couldn’t find jobs. Lots of stress, violence, abuse. So these individuals just started out without the support that most of us expect from our families, but quite the opposite.
So when they go to school, they’re not prepared and they don’t do well. They drop out, they don’t finish high school. They don’t build supportive relationships; a lot of them become increasingly isolated.
They get involved in substance abuse, they get involved in criminality. It’s just a path that takes them further and further away from being successful by the norms of society. When you’re constantly under stress, when you’re constantly pushed out of things, the way you react to the world, the way you navigate the world, becomes very different. You’re in an environment where you can’t trust anybody. It doesn’t pay to learn to trust people. You have to learn not to trust people. You have to be constantly on your guard. If everything is short term, and just day-to-day survival is the issue, then you have to figure out in the short-term, how to get through the next 24 hours.
But being very distrustful of everybody, getting angry easily doesn’t work in a health care setting., Health care organizations are only beginning to understand how they actually bring out the worst in some people. So some people immediately become “bad patients.” And people say, “What’s wrong with you?” versus “What has happened to you and how do we deal with you in a way that doesn’t make you feel worse, that is respectful to you and is actually helpful to you?”