Treating the disease we simply won’t insure

There is a condition affecting tens of thousands of Canadians.

In 2024, one national measure estimated that almost 120,000 people had the condition. The estimate captures only part of the problem.

The same data show its chronic form becoming more common. In 2017, an estimated 28,900 people met the definition for its chronic form. By 2024, there were 36,058, an increase of almost 25 per cent.

This condition carries an unfortunate prognosis.

A Toronto study conducted during the pandemic found that, even after researchers accounted for differences in age, existing illness, mental illness and substance-use disorders, people with this condition had a mortality hazard ratio of 2.2.

A hazard ratio of 2.2 means that, during follow-up, the rate of death was 2.2 times as high in the affected group as in the matched comparison group.

A recent British Columbia study found a similar pattern. Even after closer matching for income assistance and underlying health conditions, mortality remained about twice as high.

Another disease with these numbers would get a response. We would track it, study its causes, prescribe treatment and manage its complications.

The condition is homelessness.

Nearly one in three people who used an emergency shelter in 2024 met the criteria for its chronic form.

Compare this with diabetes. A large contemporary study found that people with type 2 diabetes had a mortality hazard ratio of 1.65. The Toronto homelessness study found a mortality hazard ratio of 2.2.

Both conditions were associated with substantially elevated mortality, but the reported association was larger for homelessness.

We have built an enormous clinical infrastructure around reducing the risks that come with diabetes. That infrastructure includes screening, laboratory testing, medications, specialists and longitudinal care.

When effective treatments emerge, public plans can insure them. Canadian public drug plans spent $807 million on Ozempic in 2024.

We do this because diabetes causes illness and premature death and because treatment reduces that risk.

Now imagine a treatment for the most severe form of homelessness.

The people receiving it are medically and socially complex. Before treatment, many required acute care repeatedly.

In early results, emergency visits fell by 52 per cent and hospital bed days by 79 per cent.

If those were early results from a new diabetes drug, they would get our attention immediately.

The treatment is housing.

More specifically, it is permanent supportive housing. Those results come from Dunn House, which University Health Network and its Toronto partners opened in October 2024: 51 permanent, rent-geared-to-income supportive homes for people experiencing homelessness with significant health needs.

Ask of housing what we ask of any clinical intervention: What exactly does it treat?

Housing does not cure addiction, schizophrenia, diabetes, heart failure or the accumulated consequences of poverty and trauma.

Then again, Ozempic doesn’t cure diabetes.

We do not ask a diabetes medication to cure every condition affecting the person taking it. We ask whether it treats the condition for which we prescribed it and whether doing so improves outcomes.

Housing treats homelessness remarkably well.

In Canada’s five-city Housing First trial, participants assigned to Housing First spent 73 per cent of the two-year followup stably housed, compared with 32 per cent among those receiving usual care. For the 10 per cent with the highest service-use costs at entry, every $10 invested generated $21.72 in average savings elsewhere. The trial showed that housing successfully treats homelessness.

For some, housing alone suffices. For others with severe mental illness, substance dependence, disability or complex chronic disease, supportive housing becomes combination therapy: a home plus the services required to keep it.

The question is not simply how much more governments should be spending on shelters, but what outcomes that spending should purchase.

Should Canada insure the treatment? We already insure much of the damage.

An emergency department treats the frostbite, drains the abscess, reverses the overdose, stabilizes the psychosis and adjusts the insulin.

A hospital may spend thousands getting someone well enough to leave, then discharge them into the condition that helped make them sick.

We insure the complication. We do not reliably insure the treatment.

Parliament’s National Housing Strategy Act already recognizes adequate housing as a fundamental human right.

What we lack is a way to turn that commitment into a dependable benefit when being without a home threatens someone’s health.

We have solved a version of this problem before, imperfectly.

The Canada Health Act does not put Ottawa in charge of hospitals. Provinces and territories deliver care. Ottawa helps pay and attaches conditions.

Perhaps chronic homelessness deserves a similar approach.

Provinces and territories could deliver the benefit through housing organizations, with health systems providing clinical supports and Ottawa sharing the cost. The trigger would be the federal definition of chronic homelessness. The benefit would be a supportive home and the services to keep it.

We currently treat homelessness largely as a social problem, the health consequences of which eventually arrive at the hospital.

What if we treated it instead as a condition whose treatment lies outside the hospital?

Dunn House’s broader contribution was to ask what kept bringing patients back to hospital and then act on the answer.

Should a Canadian who develops chronic homelessness have a reasonable expectation that effective treatment will be available?

That is what medicare does. It pools the financial risk of an unpredictable individual catastrophe across all of us.

If homelessness is a disease, housing is the treatment.

We already know how to write the prescription.

The question is whether we are prepared to insure it.

Rafiq Andani is an assistant professor at the University of Manitoba Max Rady College of Medicine in the Department of Family Medicine.