Abstract
Hawaiʻi faces one of the highest rates of homelessness in the nation, driven by a combination of systemic barriers, historical policy failures, and a high cost of living. Governor Josh Green, M.D., advocates a “housing is healthcare” model, positioning stable housing as a cornerstone of public health. This comprehensive approach tackles homelessness through the innovative Kauhale initiative—community-centered, cost-effective housing solutions that integrate supportive services and foster belonging. With the use of emergency powers, Hawaiʻi is addressing immediate crises while building long-term system resilience through legislative and administrative reform. This paper charts the historical, social, and economic roots of homelessness in Hawaiʻi, explores the impacts of state and federal policies, and outlines actionable solutions to stabilize and reduce homelessness while addressing its underlying causes. The state’s homelessness response serves as a potential model for addressing homelessness as a public health emergency.
I. Introduction
As a child growing up in Pittsburgh, Pennsylvania, I had an undiagnosed hearing disability for the first two years of my life. With access to high-quality medical care and parents who would not relent until I was better, I was diagnosed and underwent surgeries to restore my hearing. I missed the first critical years of early childhood development, but with the help of wonderful public-school teachers, I fought my way back on track.
I have imagined what my life would have looked like navigating a major health challenge at a young age if my family had not had a safe and stable home to come back to each night. As an emergency room physician, I spent countless hours watching individuals and families experiencing homelessness coming in and out of our hospital. I watched medical bills pile up for local families, forcing them to choose between paying off medical debt and essential expenses like rent, groceries, and utilities. I watched as our hospital in a rural county with severely strained resources worked to provide care to people falling through our frayed safety net, knowing that it was just a matter of time before we encountered these individuals again.
All of my life and work have underscored the need to view safe and stable housing as a core component of health care. This has been the focal point of my career in public service. As a state legislator I worked on crafting legislation critical to expanding access to quality medical services for low-income families as well as housing options for those experiencing homelessness. Every weekend I would return to my rural area hospital and work a graveyard shift in the emergency room—witnessing first-hand how our policies impacted local families.
Later as Lieutenant Governor, I was at the helm of the state’s response to the COVID-19 pandemic. I worked with our government agencies and healthcare communities to coordinate pandemic preparedness, response, and mitigation efforts. This critical emergency response resulted in Hawaiʻi having the nation’s lowest COVID-19 fatality rate.1 Our innovative approaches were made possible because we recognized COVID-19 as an emergency and mobilized resources quickly and effectively to respond to and mitigate the crisis.
Throughout my life, I have seen how our houseless neighbors disproportionately experience trauma, poorer health and education outcomes, significantly shorter life expectancy, and more frequent emergency room visits. In response, my administration is treating the homelessness crisis like what it is: a public health emergency. Addressing homelessness requires recognizing housing as a pillar of healthcare. In response to the state’s homelessness emergency, my administration launched our Kauhale initiative to provide quick and cost-effective shelter along with robust supportive services to build a sense of belonging and place for our houseless neighbors. We are investing in rapid-response care––meeting people where they are through mobile outreach services to initiate case management and bring people into our Kauhale communities. The Kauhale model represents a scalable framework for quickly and cost-effectively mobilizing resources to respond to homelessness as the emergency it is.
No one should be left without a roof over their head. No one should worry about where they will sleep with their kids from night to night. No one who is struggling should be left without help. We have a shared responsibility to care for our neighbors—housed and unhoused. In Hawaiʻi, we call this our kuleana: both our responsibility and our privilege. It is foundational to the Native Hawaiian tradition that makes our state unique. When our unhoused neighbors have a roof over their heads, without time limits or other conditions that force them back onto the streets, they are healthier. And so are our communities. This is at the core of my administration’s policies to implement a “housing is healthcare” approach to homelessness. This is how we achieve a housed and healthy Hawaiʻi, and a housed and healthy nation.