Housing as Healthcare
How can we better integrate supportive housing services into our healthcare system?
There is an inextricable link between one’s housing stability and one’s healthcare issues. Though I believe our healthcare system should not be ultimately responsible for housing affordability, housing insecurity is inherently a healthcare issue. Consider this internal dialog that many emergency doctors wrestle with during this time of year:
“Discharging Mr. Green means he will spend the night on the streets. How can I send him to endure the same brutal conditions I was so thankful to escape from? Providing compassionate care means letting him sleep until daylight when the shelter doors open.
Except the waiting room is filled and every bed is occupied, some by patients who are being evaluated and most by those who are boarding in the ED until beds open up in the hospital’s wards and ICUs. The exodus to hospital beds won’t happen until late morning and early afternoon, so we need every bed possible to tend to those who are waiting to be seen and those who continue to arrive.
The crisis of emergency department crowding turns the bed occupied by Mr. Green into a scarce resource. But it also forces physicians like me to allocate compassion. — Dr. Jay Baruch, STAT News
As the full article touches on above, patients who chronically experience homelessness face substantially higher morbidity from physical and mental health issues. Acute trauma and chronic stressors that these patients face result in persistently high healthcare costs due to emergency department (ED) and inpatient hospital use.
On the flip side, there’s numerous programs that have meaningfully shown how placing patients experiencing homelessness into affordable housing services ultimately decrease healthcare expenditures - with one program reporting up to $29,000 in savings per patient per year after accounting for housing costs.
So what’s the hold up? Why aren’t we creating more of these programs that can provide supportive housing services to close these gaps in inequities in our healthcare system? It’s a lot like the overflowing garbage can that none of the roommates want to take responsibility for - a responsibility that may shift around but no one ultimately owns.
Challenges
To outline the underlying problems specifically, there is(1) a huge supply issue of affordable housing (2) lack of alignment between state housing and healthcare departments and (3) incomplete integration of affordable housing services into our healthcare system.
Housing Supply
The Housing Urban Development’s Housing Choice Voucher (also referred to as “Section 8 Housing”) program is not an entitlement program like Medicaid, so only 1 out of 4 households that are eligible actually receive assistance. When 71% (7.8 million) of the nation’s 11 million extremely low-income renter households have to spend over half their income on rent and utilities, it means they’re cutting back on needed prescription medications or healthcare treatment.
Misalignment between Housing vs Healthcare Departments
Accountable Care Organizations (ACOs) have historically been the paragon of the value-based care model; however Medicaid ACOs have displayed limited investment in addressing housing insecurity. Outside of ACOs, there has been very limited collaboration across state Medicaid programs and housing programs. The root of this misalignment are two separate funding mechanisms and operational structures:
The federal government and states jointly finance Medicaid, and subject to federal minimum standards, states design and operate their own programs. As a result, Medicaid benefits, delivery and payment systems, and other aspects of program design vary widely by state. On the housing side, federal dollars often flow through local governments and public housing agencies to housing providers, adding to the complexity that Medicaid-Housing collaborations may face. Partnerships require the two sectors to gain understanding of each other’s operations and develop new relationships and systems to support coordination. — KFF’s Medicaid & Supportive Housing Brief
Lack of Social Services Integration at the Point of Care
At the point of care, our healthcare providers are vastly understaffed to best support our patients in all non-medical social services. The vast majority of emergency departments where patients experiencing homelessness frequent do not employ a social worker. The ones that do have extremely limited bandwidth and a shrinking supply of available services to offer their patients.
Universal Affordable Housing
Perhaps the single best thing to reduce homelessness is to address the supply gap we have above in #1 is to expand Section 8 Housing vouchers to all eligible households. Part of President-Elect Joe Biden’s housing platform is to do exactly this — “Provide Section 8 housing vouchers to every eligible family so that no one has to pay more than 30% of their income for rental housing”
Though I hold out measured optimism that may come to fruition, creating more affordable housing doesn’t fully address this gap between housing and healthcare. So here are some potential models we could explore further.
Models for Housing <> Healthcare Integration
One of the most interesting state partnerships around supportive housing that I’ve found is Louisiana’s Permanent Supportive Housing Program who initially financed affordable housing for low-income individuals with disabilities through Low-Income Housing Tax Credits (LIHTC) and disaster recovery funding in the wake of Hurricane Katrina. Longer term, Louisiana made some strategic decisions to provide Medicaid reimbursement for services that enabled the longevity of the program to outlast the initial block grant funding. This suggests an interesting opportunity for states to better connect housing and healthcare needs while we wait for universally affordable housing— what would it look like to reserve LIHTC incentives in partnership with Medicaid agencies to build affordable housing for specific patient communities?
As more local model that could drive better health-related tenancy supportive services, there is a lot we can learn from the success of Bronx Housing Consortium model which brought together a group of stakeholders to create a self-sustaining model driven by membership dues. Such consortiums bring together health systems (e.g., Montefiore’s hospitals), medicaid managed care organizations, health homes, and state organizations (e.g., NYC Correctional Health Services). KFF did an amazing job covering other locally integrated initiatives including one launched by a city (Philadelphia) and one by a Medicaid MCO (Mercy Maricopa Integrated Care in Phoenix, Arizona) if you want to learn more here.
Half-baked Idea: Housing Consortium as a Service
As with all of these ideas I pose at the end of each post, these ideas are intentionally not meant to be a fully fleshed out concept that addresses all the issues I present above. I want to freely share these thoughts to challenge others to think critically about how they might address some of these issues themselves. Since I’m not a policymaker, I opted to focus on how to provide more integrated supportive housing services to healthcare providers/payers - what would a next-generation “housing consortium as a service” concept look like if it could scale to multiple regions/cities?
Differentiated access to affordable housing options through partnerships with LIHTC developers or healthcare-oriented Qualified Allocation Plans bids for state affordable housing contracts.
Brings together 3 key stakeholders (e.g., health system, a community-based organization like Bronxworks, and a Medicaid managed care organization) that are the founding partners in a net-new region
Uses technology to stratify and optimize utilization and placement into affordable housing options
Trains and deploys social workers that are experts in affordable housing options that can be consulted and connected to patients experiencing homelessness
Provides targeted clinical services that drive cost reductions specific for the housed patient population (e.g., Philadelphia’s Housing First program saw significant reduction in behavioral health costs by stably housing patients experiencing severe psychiatric and/or substance use disorders)
Next Steps
Would love your feedback on this very first post and encourage folks to subscribe if you’re interested in hearing about more issues and ideas. Upcoming posts will feature healthcare issues like bone marrow donor registry disparity, food insecurity, value-based delivery of urgent/emergency care, and Medicaid Drug Rebate Program 340B pricing challenges:
If any of this post resonates with you to think more critically about housing as healthcare, please fill out the short survey below - I’d love to invite you to actively learn from others that have much more lived experience than I do working on these challenges:
Dr. Kelly Doran - a tireless Social Emergency Medicine advocate for patients experiencing homelessness
Rachael Meiers - manages the Thriving Communities Fund, Kaiser Permanente's $200M investment commitment to addressing housing and homelessness crises, and supporting equitable community development
Bonnie Mohan - executive director of the Health & Housing Consortium and founder of the Bronx Health & Housing Consortium
With enough interest, I’d love to set up a fireside chat with these 3 amazing women and organize some questions in partnership with you to connect in more depth and learn how we can contribute our diverse perspectives and skill-sets to this issue.
Huge thanks to Aneeqah in particular for her thoughtful feedback on an early draft of this first post and Dr. Thomas Byrne who kindly responded to a cold email while on paternity leave asking for his thoughts on the topic. Shout-out also to Alex, Emma, and Jared for encouragement in launching this passion project and feedback on the overall concept of Margins of Medicine