Every health care provider—from pediatricians to geriatricians— has seen how homelessness affects health. The disordered lives of homeless patients disrupt appointment-keeping and medication adherence, even as they generate need for more treatment by driving health challenges like depression, high blood pressure, and hospitalizations. 

Some health systems have begun to address the link between homelessness and health. One Boston health system, for example, announced plans to subsidize housing for the patients for whom it is accountable, to give this population some measure of the shelter and stability necessary for good health. 

This is an example of a growing practice among health systems, which are beginning to address the foundational forces that shape health. Their reason for doing so is partly financial. For example, Medicaid, in some states, adjusts payments to hospitals based on whether a patient is homeless—homelessness is treated like any other complicating diagnosis, an additional cost of care. So health systems can lose money if they do not collect and appropriately bill for housing status. But there are also more charitable reasons for health systems’ new focus, including the possibility that collecting information like homeless status can drive new program development and position the health systems to help fix under- lying economic and social problems, toward the ultimate goal of improving patients’ health. 

Perhaps, at core, health systems are addressing health at the level of root causes because they have to. As a society, we tend to forget that health is a public good supported by our collective investment in resources such as education, the environment, and, indeed, housing. Health systems can help us remember, by investing in these resources, to improve the health of patients. 

In many ways, health systems taking on this new role is welcome. Health systems are ubiquitous, touching all our lives. Their administrators are in a position to take the lead on creating new approaches to health. But should the onus for doing so lie solely on them? Should health systems own and run food pantries, or manage apartment buildings? Should they take on the provision of social services as part of patient care? And, in pursuit of these new services, should they risk taking resources from diagnosis and treatment, hitherto the centerpieces of medical care? It seems self-evident that attempting to do all of this could place an undue burden on health systems and allow the responsibility of promoting health to drift from where it should really lie—on all of us. Health is our collective responsibility. Health systems can nudge us toward a better understanding of what truly shapes health, but it is ultimately our responsibility to act on that knowledge and build a world that generates health.

This post is an excerpt from Pained: Uncomfortable Conversations about the Public’s Health, published with permission from the authors and publisher.

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  • Sandro Galea is Dean and Robert A. Knox Professor at the Boston University School of Public Health. He has been named an "epidemiology innovator" by Time and one of the "World's Most Influential Scientific Minds" by Thomson Reuters. A native of Malta, he has served as a field physician for Doctors Without Borders and held academic positions at Columbia University, University of Michigan, and the New York Academy of Medicine. His new book, The Contagion Next Time, was published in fall 2021, and is available to order here: https://www.sandrogalea.org/the-contagion-next-time

    Subscribe to his weekly newsletter, The Healthiest Goldfish, or follow him on Twitter: @sandrogalea

  • Michael Stein MD, is Professor and Chair of Health Law, Policy & Management at the Boston University School of Public Health. He is Executive Editor of Public Health Post, and his latest book is a novel, The Rape of the Muse.