Homelessness during pregnancy or childhood should be unthinkable in a society that treats children and families with dignity. In this issue of Pediatrics, Sandel et al1 provide new evidence from 5 cities on just how damaging homelessness in pregnancy and early childhood are to child health. Their study, “Timing and Duration of Pre- and Postnatal Homelessness and the Health of Young Children,” included >20 000 child-caregiver dyads, and they found that children who had been homeless were more likely to have previous hospitalizations, developmental delay, and worse health overall.1 The effects were largest in families who were homeless both before and after a child’s birth and in families who were homeless for more than 6 months while their child was an infant or toddler. This study addresses a key gap in our understanding, demonstrating the sizable short-term impact of homelessness on child health. It is the latest in a large and growing chorus of evidence on the severe health hazards of homelessness over the life course.2 It is also a call to action for our profession.

Many pediatric practices have made strides to address family homelessness in the 5 years since the American Academy of Pediatrics recommended routinely asking families about whether they have a safe place to call home.3 Homelessness questions are part of most clinical screening tools for poverty-related social needs,4 which are becoming accepted as standard of care. Furthermore, once housing-insecure families are identified, practices are increasingly connecting families with programs and services to help them obtain safe and stable housing. A growing number of health systems have even invested in developing affordable housing units,5,6 supported by financing options for housing-related services from public7 and private payers.8 Momentum seems to be building for further efforts to adapt the structure and financing of health care to address the needs of homeless populations, spurred in part by cost savings potentially achievable through housing homeless adult patients who incur large medical expenses.9,11 But with the number of homeless Americans rising,12 these efforts are not enough to stem the tide. We can and must do more.

First and foremost, we can recognize that the upstream causes of homelessness are alarmingly common and potentially preventable. Although far too many families end up in shelters or on the street because of rising costs of living outpacing stagnant wages,13 this is just the tip of an iceberg of housing-insecure families scraping by in unsafe, overcrowded conditions and whose ranks have nearly doubled over the last decade.14 Clinicians and health systems, therefore, have a tremendous opportunity to develop tools that recognize and address housing insecurity to prevent homelessness before it occurs.

One such prevention tool, just-in-time financial assistance (to help families weather economic shocks like unexpected medical bills or job loss), has been shown to substantially reduce the incidence of homelessness in high-risk populations while saving roughly 2 dollars to society for every program dollar spent.15 This result makes sense, given that homelessness is a symptom of broader financial instability.16 Agencies and municipalities domestically17 and internationally18 are discovering that adopting these homelessness prevention approaches keeps financially tenuous families in their homes while offloading demand and shortening wait lists for crisis response housing agencies and permanent supportive housing units. Pediatricians and health systems are in an ideal position to link families to the right community resources tailored to their individual needs, investing in and using crisis response resources when necessary but also preventing eviction through preemptive legal or financial services to keep families from becoming homeless in the first place.19 The main question health systems face is how best to design and implement, in full partnership with agencies and their communities, these kinds of proven homelessness prevention strategies for at-risk families.

Pediatrics has made significant strides toward addressing family homelessness in just a few years. We can make even faster progress by implementing tools to prevent homelessness that transcend current limitations in care coordination, reimbursement, and clinical convention while reshaping pediatric practice to protect child health. Are we ready to advocate as a profession for these innovations and to collaborate with leaders in other sectors to make not just health care but health itself more affordable for our families? Given the evidence on the harms of homelessness for children, doing anything less would be unthinkable.

Dr Schickedanz conceptualized and drafted the initial manuscript; Dr Chung contributed integrally to and revised the initial manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-4254.

1
Sandel
M
,
Sheward
R
,
Ettinger de Cuba
S
, et al
.
Timing and duration of pre- and postnatal homelessness and the health of young children.
Pediatrics
.
2018
;
142
(
4
):
e20174254
2
Aldridge
RW
,
Story
A
,
Hwang
SW
, et al
.
Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis.
Lancet
.
2017
;
391
(
10117
):
241
250
[PubMed]
3
Briggs
MA
,
Granado-Villar
DC
,
Gitterman
BA
, et al;
Council on Community Pediatrics
.
Providing care for children and adolescents facing homelessness and housing insecurity.
Pediatrics
.
2013
;
131
(
6
):
1206
1210
[PubMed]
4
Chung
EK
,
Siegel
BS
,
Garg
A
, et al
.
Screening for social determinants of health among children and families living in poverty: a guide for clinicians.
Curr Probl Pediatr Adolesc Health Care
.
2016
;
46
(
5
):
135
153
[PubMed]
5
Bartolona
P
;
Kaiser Health News
. Hospitals invest in housing for homeless to reduce ER visits. 2017. Available at: https://www.healthcarefinancenews.com/news/hospitals-invest-housing-homeless-reduce-er-visits. Accessed July 24, 2018
6
Mayors & CEOs for Housing Investment
. Mayors and CEOs for U.S. housing investment. Available at: https://housinginvestment.org/mayors-and-ceos/. Accessed July 24, 2018
7
Cassidy
A
. Medicaid and permanent supportive housing. Health Affairs. October 14, 2016. Available at: https://www.healthaffairs.org/do/10.1377/hpb20161014.734003/full/. Accessed July 24, 2018
8
Scally
C
,
Waxman
E
,
Gourevitch
R
,
Adeeyo
S
. Emerging strategies for integrating health and housing: innovations to sustain, expand, and replicate. 2017. Available at: www.urban.org/research/publication/emerging-strategies-integrating-health-and-housing. Accessed July 24, 2018
9
Gottlieb
LM
,
Wing
H
,
Adler
NE
.
A systematic review of interventions on patients’ social and economic needs.
Am J Prev Med
.
2017
;
53
(
5
):
719
729
10
Lim
S
,
Singh
TP
,
Hall
G
,
Walters
S
,
Gould
LH
.
Impact of a New York City supportive housing program on housing stability and preventable health care among homeless families [published online ahead of print March 12, 2018].
Health Serv Res
. doi:
11
Clark
RE
,
Weinreb
L
,
Flahive
JM
,
Seifert
RW
.
Health care utilization and expenditures of homeless family members before and after emergency housing.
Am J Public Health
.
2018
;
108
(
6
):
808
814
[PubMed]
12
Weber
C
,
Mulvihill
G
. America’s homeless population rises for first time in years. US News and World Report. December 6, 2017. Available at: https://www.usnews.com/news/us/articles/2017-12-06/us-homeless-count-rises-pushed-by-crisis-on-the-west-coast. Accessed July 24, 2018
13
Embleton
L
,
Lee
H
,
Gunn
J
,
Ayuku
D
,
Braitstein
P
.
Causes of child and youth homelessness in developed and developing countries: a systematic review and meta-analysis.
JAMA Pediatr
.
2016
;
170
(
5
):
435
444
[PubMed]
14
Child Trends
. Homeless children and youth. Available at: https://www.childtrends.org/indicators/homeless-children-and-youth. Accessed July 24, 2018
15
Evans
WN
,
Sullivan
JX
,
Wallskog
M
.
The impact of homelessness prevention programs on homelessness.
Science
.
2016
;
353
(
6300
):
694
699
[PubMed]
16
Elbogen
EB
,
Sullivan
CP
,
Wolfe
J
,
Wagner
HR
,
Beckham
JC
.
Homelessness and money mismanagement in Iraq and Afghanistan veterans.
Am J Public Health
.
2013
;
103
(
suppl 2
):
S248
S254
[PubMed]
17
Smith
D
. L.A. County considers another path on homelessness: prevention. Los Angeles Times. May 3, 2017. Available at: www.latimes.com/local/lanow/la-me-ln-homeless-prevention-20170503-story.html. Accessed July 24, 2018
18
Employment and Social Development Canada
. Homelessness partnering strategy. 2018. Available at: https://www.canada.ca/en/employment-social-development/programs/communities/homelessness.html. Accessed July 24, 2018
19
Tsai
J
,
Middleton
M
,
Villegas
J
, et al
.
Medical-legal partnerships at veterans affairs medical centers improved housing and psychosocial outcomes for vets.
Health Aff (Millwood)
.
2017
;
36
(
12
):
2195
2203
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.