Lozier is the leader of the National Health Care for the Homeless Council, which is holding its national conference in Portland
The fact that safe, stable and affordable housing is an essential factor for a person’s good health is increasingly acknowledged among housing and health care providers, policymakers and advocates.
It is a conviction John Lozier has held for decades.
Lozier is the founder and executive director of the National Health Care for the Homeless Council , a national nonprofit and membership organization that provides comprehensive health care to homeless people at primary care clinics the council either established or partners with. On May 31, the council will hold its annual national conference in Portland .
The council was founded in 1986 and since then, its network has grown to include more than 10,000 doctors, nurses, social workers and advocates. The council provides support, training and mentoring to more than 200 public health centers and hundreds of organizations throughout the country that receive grant funding from the federal government’s Health Care for the Homeless program.
Encouraging people experiencing homelessness to become actively involved in their health care is one of the council’s most important accomplishments. The council was one of the first organizations to have a consumer advisory council; membership is entirely made up of homeless people who have received care at a clinic supported by the council. In its trainings and work with clinicians, council staff emphasize case management and close relationships between providers that ensure effective referrals and continuous care.
It also helps homeless people regain their sense of humanity, Lozier said.
“It’s a great thing that desperately poor people and their providers are able to work so closely and so lovingly together,” he said.
Lozier will retire at the end of this year. He spoke with Street Roots about how providing health care to homeless people has evolved and what still needs to happen to help the country’s most vulnerable citizens, including creating universal care.
Amanda Waldroupe: When you started the organization, how radical of an idea was it to create a program specifically designed to provide health care to homeless people?
John Lozier: It was an important initiative. The approach evolved from interest in the Robert Wood Johnson foundation. They established some demonstration programs that sought to establish something very simple – which was probably a radical idea at the time – that homeless people can be effectively engaged in primary care services. There were 19 original projects, and we served tens of thousands of people.
We’ve understood from the beginning that housing is the core problem. Housing is health care. You can’t be well if you’re sleeping on a sidewalk or in a crowded shelter. One of the main things that has happened is that we have refined those understandings. When we think about violence, we think about trauma and trauma-informed care. And we think about cultural humility, an increasingly important approach to health care for the homeless.
A.W.: It seems largely accepted that homelessness is a public health problem – not a public safety one, for example. But it took a long time, even, for public officials and the public to understand how much harm – physical, mental and otherwise – can be caused from being unable to get a full night of sleep.
J.L.: Right. Sleep science is another place where our knowledge base has increased really dramatically in recent years – even more recently than the awareness about trauma. I think I would have to take issue with homelessness being a health issue. It’s predominantly an economic issue. It has to do with the lack of affordable and appropriate and available housing for people, which in turn drives health problems. In 1987, the Institute of Medicine of the National Academy of Sciences published a report called “Homelessness, Health and Human Needs.”
It found that there are three relationships between homelessness and health. One is that poor health causes homelessness, for two reasons. One reason is economic: Most personal bankruptcies are health care bankruptcies. The other has to do with symptoms of illnesses and people who get squeezed out of housing.
Secondly, homelessness, in turn, causes more health issues, with exposure to diseases in shelters and vermin on the streets and violence on the streets. And the elements.
The third is that homelessness complicates all the elements and all the things you need to do to treat people. Add those up, and it’s a major public health problem.
A.W.: You talked about how our understanding of the health issues faced by homeless people has been refined. What do you think caused that refinement of understanding to take place?
J.L.: Science is part of it. The science has evolved. That’s not unimportant. Brain chemistry, neurology, the understanding about the effects of trauma in particular has gotten much deeper in the last decade. For us, a more important part of it has been asking people who have experienced homelessness to help define the issues. Our focus on violence, for example, achieved a new clarity for us when the National Consumer Advisory Board put together a survey it does for people experiencing homelessness and across the country on violence. Almost everyone on the streets had witnessed violence in the course of their homelessness.
FURTHER READING: The trauma of housing instability
A.W.: By involving homeless people so much – asking for their perspective, their input, their opinions – is to genuinely treat them as human beings, something I think a lot of people forget because of their appearance, because they live outside.
J.L.: That’s true. Yes. We have tried to involve our patients at every stage of our work, and that starts with outreach and really being sensitive to people’s situations in the exam room. Much earlier in our career we talked about what’s now patient center, self-determination and goal setting. It goes on and on to patient satisfaction surveys to consumer advisory boards, which operate on a consensus model, so that their voices carry every bit as much weight as everybody else’s.
A.W.: I was reading the council’s most recent quarterly newsletter, In Focus, about the importance and effectiveness of case management. The reason good case management is so effective is that it creates a one-on-one relationship and treats homeless people with compassion and respect.
J.L.: Absolutely. It’s not just compassion. It’s respect. Those two together are what makes the difference.
A.W.: How so?
J.L.: Just feeling sorry for somebody – one way to express compassion – can be condescending, for lack of a better word. But feeling respect for somebody is an expression of justice. It’s an expression of understanding. It’s an expression of the quality of all human beings in the face of our mortality. It’s giving a fellow human being his or her due.
We’re not about charity. We’re about justice. Ultimately, that bleeds over to our understanding of what health care reform still needs to be. It needs to be universal. At best, with the Affordable Care Act fully implemented, there’s still 27 million who are uninsured in this country. A lot of those will be homeless people who for one reason or another aren’t eligible or not enrolled. That goal we set for universal health care coverage and accessibility to quality care still remains elusive.
A.W.: You’ve advocated for many years that housing is an essential part of health care, yet the funding for housing and health care are entirely distinct. How do you think health care programs, like hospitals or Medicaid, should use some of their funding to ensure their patients live in affordable housing?
J.L.: Not enough is happening yet, but we are beginning to see some glimmers of the understanding that housing is health care and that it is a wise health care investment to make sure that patients are adequately housed. Some managed care organizations are spending their money on housing, or a less profound but equally important intervention like respite care. New York state is beginning to spend some of its Medicaid dollars. The problem is that we have siloed social and health needs apart from each other in the major federal streams. HUD (Department of Housing and Urban Development) and HHS (Department of Health and Human Services) spend money on very different things. A lot of people have tried to put those together at the local level. We need to get out of the silos and understand that housing is health care, and that if we want a healthy population, make sure that it is adequately housed.
EDITORIAL: Housing is health care, worthy of equal attention
A.W.: There are at least two competing values for delivering good and effective health care. One is doing it out of the kind of compassion you’re talking about. But health reform has generated a lot of conversations about creating health care programs that are “evidence based” or have “measurable outcomes,” a way of measuring effectiveness, etc. Do you think anything is lost when we talk about health care like that?
J.L.: It does matter. It has to do with the quality of those services. A lot of the focus of the ACA is on patient-centered medical homes. That’s what we have been doing for 30 years now. We have been developing medical homes for people who are pretty much excluded anywhere else, (homes) that are compassionate and respectful. We look to what is achievable within the patient’s own frame of reference. When we make a referral, we fully recognize the case management (needed) to help make that referral really work – that there are warm hand-offs, careful care transitions, discharge planning so that one person moves from one sort of provider to another.
A.W.: What do you think needs to change in this country – socially, politically – for the United States to create universal health care?
J.L.: It’s the political power of the insurance companies and the for-profit health care providers. That’s clear and simple, I think, to anybody who looks at it. They command something like 17 or 18 percent of the nation’s economy. Somewhere between 20 and 30 percent of their profit goes into shareholder profit and other wasteful administrative costs. Health insurance executives are among the richest people in the country. It’s the 1 percent defending itself.
A.W.: The vacancy rate in Portland, like many other West Coast cities, is lower than 2 percent. The rental market is incredibly tight, and landlords are raising rent. Housing, even though it is something that everyone needs to survive, is driven by capitalism.
J.L.: Absolutely. It’s capitalism run amok. Our economy treats housing and health care as commodities, as things to be bought or sold for profit, not as the fundamental human right that we understand they are. They are necessary for our survival. They’re so basic. I try to talk about Abraham Maslow’s needs hierarchy. Shelter, food and clothing are right there at the bottom, before you can advance economically or psychologically. It’s a fundamental need that the capitalist system does not accommodate willingly.
The McKinney-Vento act got passed in 1987 because Mitch Snyder was starving himself to death (in Washington, D.C.). Many people were expressing a lot of outrage of this sudden influx of homelessness when Reagan cut the HUD budget by 75 percent. What we lack now is that sort of powerful grassroots movement. We need to see more on that political front around housing.
