I believe the author Marjorie Holmes said that.  The concept of home is vastly different depending on who you are, what you do and where you come from.  It is indeed an extension of oneself--an abode to uphold or a victim of our neglect, and ideally a source of nourishment.  The neighborhood is an even broader encapsulation of one's existence. 

At this festive holiday season, allow me to transgress to bring the realities of homelessness into our consciousness.  We all agree that it has been a stormy year in health care.  The one aspect of the ACA that is relatively popular is the Medicaid expansion and subsidies that allow low-income Americans to obtain affordable health insurance.  Many states are looking for innovative solutions to cut rising Medicaid costs.   New York State is implementing an ambitious supportive housing program targeting Medicaid patients who have high health care costs under the motto Housing as Health Care.

Providing supportive housing for those who experience homelessness and mental illness has been shown to reduce hospital use, decrease health care costs and improved health parameters especially for high utilizers.  Tenants in supportive housing programs have affordable apartments and easy access to a network of professionals to help them stay housed and healthy.  Numerous studies have quantified the disproportionately high service utilization of homeless people with disabilities including hospital-based acute care such as emergency rooms, psychiatric hospitals as well as shelters, jails and prisons.  As mentioned above, a significant and growing burden of this cost is borne by Medicaid funding. 

Studies have shown that supportive housing helped save taxpayers millions of dollars but upfront investment costs lead state and federal governments to embrace these programs less enthusiastically. Evidence of cost effectiveness is not yet available from the NYS program.

We know that housing quality and neighborhood sociodemographic characteristics are associated with mental health. A study by McKenzie in Europe suggests that neighborhood physical quality could counteract the adverse impact of substandard housing.  Lower income individuals and families rely on strong social networks and support in the neighborhood to maintain psychological well-being.  Put it bluntly, even if you place is a dump, having access to positive social interactions (safe green space, gardens, shops, fitness facilities and other community amenities) provides respite and stress relief. 

For 2014, if wishing for everyone to have a cozy home comforted by loved ones is too starry-eyed then we should work to build neighborhoods, develop social ties and safe play areas for our children.  Then the world will be a better place and wishes for good health will come true.  Of course, we need to first end and prevent homelessness. 

Joy and peace to all. 

The socioeconomic impact of immigration is substantial. Between 2001-2011, immigration accounted for 40% of total population growth in the OECD.  According to the International Migration Outlook 2013, high-income countries continue to attract immigrants and students from around the world since the global financial crisis of 2008.  India, China, Poland and Romania are top countries of origin into OECD countries.  In the face of rising unemployment, migrants’ labor market situation has worsened compared to natives over the past years particularly for Latin Americans in the US and migrants from North Africa in Europe.  In a country such as the US, where immigrants are often young and the social safety net is not large, the effect of immigration is often more positive—increasing the GDP by 0.03 percentage points.

Strong sentiments against immigrants particularly unauthorized immigrants in the US and a dysfunctional Congress have delayed immigration reform legislation (S.744) which calls for an eventual pathway to citizenship for undocumented immigrants while ramping up border security measures. Certainly there is enthusiastic support for the recruitment, hiring and retention of highly-skilled foreign workers (H-1B visas) with economic implications.  (How this policy is affecting the global health care workforce crisis is the subject of discussion another time). 

Research and practice have highlighted the increased risk for disease, trauma and social stressors among this population (low-wage immigrants and refugees) from discrimination, substandard living and exploitative labor conditions.  There is a growing public health literature that favors access to health care for immigrants but also one that is concerned with disease transmission (TB, HIV, STI) and national security threats (Viladrich, 2012).  The public discourse on immigration comprises a full spectrum of model to undeserving immigrants, welfare-dependents to drivers of economic growth. 

I would argue for a more “simplistic” view of immigrants.  Migration is an undeniable fact of life.  Of course there are differences in how our society regards undocumented immigrants and the native poor but our policy should aligned with the concern for social inequality and how we treat and provide for those less fortunate—all racial ethnic groups and no matter how they come to live in America.  In hard times (economic or political upheavals), feelings and beliefs about self-sufficiency and individual responsibility trump justice and humanitarian consideration and create ethnic tensions pitching one group against another.  Even the argument to provide immigrants with health care and social benefits for the sake of self-interest and return on investment seems like a weak cover for avoiding the discussion of poverty and social justice.  If we use this same lens to approach vulnerable immigrants and low-income Americans then we are all better off on the road to policy and legislative reform that will benefits all Americans.