Their Values and Ours

By Alicia Fernandez, MD

A really important Perspective piece was published recently in the NEJM, and I am proud to say that one of our colleagues, Margot Kushel, was senior author. 

The authors, all leading health services researchers who focus on homelessness, summarized the literature on permanent supportive housing with the explicit intention of reframing the debate about the value of these services.   They tackled heads-on the issue of justification of supportive housing via the invocation of cost savings.  They acknowledged that the more rigorous trials have failed to show savings except for extreme high users and asked us to consider, or rather, reconsider, why supportive housing needs to be held to this standard when other interventions in the health care system need only show reasonable cost-effectiveness.

The Perspective piece is a must read for several reasons -- I, for one, had no idea of the cost of supportive housing, which apparently runs from $8000-18000 per year -- but the reason I think it is hugely important is that is directly tackles the question of their values and ours.  Amazingly, Kushel and her team actually invoked a moral standard in explaining why permanent supportive housing is important.  This may seem like no big deal but it runs contrary to the predominant strategy of many well-intentioned researchers who work on the relationship between social determinants of health and health outcomes.  We researchers appear to have bought into the framework that we should only spend public monies if they save monies, an argument built on the twin false frameworks of scarcity and deservedness.  That is, that public money is scarce, and that marginal people should only be invested in if it helps the rest of us.  The first is false and the second is a moral argument which Kushel rejects.  Yet the prevailing strategy has been to accept this framing and try to demonstrate savings. 

This accommodative strategy evolved for good reasons.  First, it made sense that the supportive housing could be cost saving and that was certainly a good reason to examine cost tradeoffs.   Second, it was and is the path of least resistance. Rather than get into a big, mushy debate about values, the argument goes, we should simply see if we can make improvements within the dominant framework.  But as this Perspective states, this could be a failing strategy if the facts don’t cooperate.  And, most importantly, it deprives us of the real justification for our work.  And the end of the day, it comes down to one thing: their values and ours.  This article gives me strength to articulate that position. Its publication in the NEJM may signal shifts within the medical mainstream. 

And that is great year end news.