Wednesday, August 26, 2009

Health Care, Homelessness, and 2 Rules of Thumb

I was listening to NPR the other day as I drove to my favorite coffee shop to pick up the New York Times. The report was yet another sad description of the seemingly endless loop we're stuck in these days, debating the question of health care--or actually not debating, but instead posturing and hurling angry accusations at each other.
But this report made a special connection: health care and the homeless. As a small back-story, I've been tracking the issue of homelessness for about 6 years now, ever since my friend Rosanne Haggerty, whom I admire enormously and wrote about in Rules, introduced me to her work in New York to end homelessness through Common Ground. Under her tutelage, I've served as moderator for a number of national gatherings of mayors and homeless advocates who are seeking not just to make a dent in the problem, but to end chronic homelessness in America's big cities.
So when the NPR turned to homeless and health care, I listened a little more carefully. What I heard was distressing and depressing.
A U.S. Senator was explaining in a town hall meeting why it made sense for us to extend Medicare benefits to homeless Americans--there's a bill before Congress right now to do this, and he was describing why it was good public policy and good human services. The angry crowd was booing and shouting him down.
Never mind the facts that 1 out of every 4 homeless Americans is a veteran and that there are almost 200,000 homeless veterans--men and women who we take care to honor in our words, but then neglect when they need help the most.
Think instead about the obvious benefits that would accrue to all of us if we also did the right thing for these homeless Americans.
Think first about the link between health and homelessness. It seems obvious that homeless people are likely to suffer serious health problems. What is less obvious is that often serious health problems are what make people homeless in the first place. Because they are sick and lack adequate health care coverage, many Americans who are working poor find they lose their jobs, lose their income, and then lose their homes--that's how they end up on the street in the first place.
Once they are homeless, living without shelter, they are more likely to suffer even worse health care problems, problems that land them in emergency rooms. The treatment there isn't designed to cure them--it's often just good enough to get them back out on the street.
We end up paying for the treatment, which isn't really adequate, and then we pay again when they're back out on the street but still sick. It's a depressing and expensive circle that Malcolm Gladwell chronicled a few years ago in a brilliant New Yorker article on homelessness called "Million-Dollar Murray." Malcolm explained how the good taxpayers of Arizona spent $1 million on a single homeless man--Murray--by paying for a system that only worked to keep Murray homeless!
There are two Rules of Thumb that I immediately thought of as I listened to NPR: Rule #4 says "Don't implement solutions. Prevent problems." How much money could we save and how much suffering could we avoid if we treated health care as a way of keeping people healthy rather than treating them after they get sick?
And Rule #7 says "The system is the solution." Health care and homelessness is so obviously an issue that needs to be addressed in a systemic way. The only way health care reform makes sense is to see it as a system, not a series of disaggregated choices or random unconnected episodes. Systems thinking saves money, devises solutions that are internally consistent, and avoids unintended consequences. Which is what the Senator was trying to explain to his voters.
If only we could find a way to listen to each other and learn from experience. We'd actually come up with compassionate solutions that make economic sense! Which takes me to Rule#52: "Stay alert! There are teachers everywhere."

All Rights Reserved 2009 (c) Alan Webber, Rules Of Thumb