First Steps Toward Repeal of ACA and What Communities Really Need

January 9, 2017; Hospital and Health Networks

Late last night, the U.S. Senate approved the first step towards repealing the Affordable Care Act with many proposals but no apparent clear ideas about what needs to be put in its place. Once again, the United States circles the drain on this issue, and yet it is not for a lack of creative ideas or technological advancements. The blockades appear to be more about the moral will for equal access and effective health approaches.

For well over four decades, health systems and hospitals have experimented with expanding their purviews to address the social causes of poor health rather than just the immediate symptoms. This has led to some creative partnerships and programs that involve access to, for instance, fresh food or access to legal advocacy. In all of that, a body of research indicates that housing is a significant factor under the penumbra of healthcare. This argument has been central to the justification of Housing First programs. Housing provides a number of safeguards against the spread and progression of disease, which is a point often made to uphold the Housing First paradigm via an ROI (or return on investment) argument—pay now, or pay more later on.

Quite simply, it stands in strong contrast to the cost of providing medical care to roofless people who are on the streets and often frequent fliers to hospital emergency departments. For instance, Shannon Nazworth, executive director of Ability Housing in Florida, tells the story of one homeless woman who was constantly in and out of the hospital. The physicians would treat her and send her back out, only for her to return a short while later with the same symptoms. The problem? A side effect of her prescriptions was drowsiness, which made her vulnerable while living on the streets. Naturally, she did not adhere to her medication and ended up back in the hospital.

Once she was placed in stable housing, however, her health dramatically improved. “In the year after she moved in, she went to the hospital once for a couple of days. The other factors that were affecting her health were addressed by just getting her housing. She needed a place to sleep at night, a place to store her medicine and the security of a door to lock,” Nazworth says. What is even more surprising is that in just a couple of years, the hospital spent over $750,000 on her medical care. The hospital could have easily purchased a home for far less than that amount, and hospitals in general are finally catching on to this idea.

When looking at healthcare spending by population, patients who frequent the emergency room actually make up a disproportionate percentage of U.S. healthcare costs. Avijit Ghosh, CEO of the University of Illinois Hospital, where a new housing-first strategy that places patients into permanent homes has been implemented, indicates that hospital care generally costs about $3,000 per patient, per day, as opposed to $1,000 per month for housing. Even without crunching the numbers, this is a clear win-win for both patients and hospitals.

The ROI argument is certainly one way to integrate the social causes question into healthcare, but why aren’t the vast disparities in healthcare indicators between communities just as powerful an argument based on equal justice and racial justice?

An article by Health and Hospital Networks points to a recent report from the Brookings Institution called “Time for Justice: Tackling Race Inequalities in Health and Housing,” which details the disparity drivers and makes it clear that just saving the Affordable Care Act is insufficient without a larger vision of justice in the health of communities:

The Affordable Care Act has expanded access to health care for nearly three million newly insured African-Americans. This is a great success. But the hard fact is that enormous morbidity and mortality gaps remain between blacks and whites. Access is necessary, but it is not sufficient. Health disparities resulting from racial inequality will persist as long as our nation continues to tolerate a separate and unequal health care system for black Americans.

Health and Hospital Networks concludes:

Unfortunately, the disparities may be getting worse. Health care reform, which expanded access to care for millions of the disadvantaged, is in serious jeopardy. In addition to ending Medicaid expansion and marketplace subsidies, President-elect Donald Trump’s picks to lead Health and Human Services and the Centers for Medicare and Medicaid Services have also taken issue with the provider-side reforms of the Affordable Care Act. Should those be jettisoned as well, it would mean the end of higher funding for community health centers as well as provisions aimed at increasing racial and ethnic diversity of primary care physicians and health professionals, improving the cultural competence of providers and establishing medical homes for Medicaid beneficiaries with chronic conditions.

The time has come for health care leaders to look more deeply at these issues, with a goal of change from within. This is both an issue of social justice and a business imperative.

We might suggest that those programmatic partnerships with community and philanthropic leaders that have been built over time need to be mobilized to advocate for a more just system of health care as part of a drive towards equal access to the basic necessities of our lives.—Sheela Nimishakavi and Ruth McCambridge