Linking Housing and Health
Terry H. Schwadron
Feb. 15, 2024
Viewing access to housing as integral to health care — and to health care costs — is about to move from the theoretical to a couple of good-size, practical experiments.
It’s an idea that comes from a dual belief that government should exist to help address social problems and that creative thinking has a place in governing — two principles that increasingly seem in short supply in our increasingly divided, partisan country.
Indeed, the whole idea that government should be involved in this level of problem-solving feels left behind in our election campaigns. The visible campaigns we see are much more concerned with money-raising, the mechanics of winning, and the reliance on more and more extreme ideology than on taking the smaller steps towards making life a little more livable.
But a lesser-known program launched by the Biden administration in a 2022 policy change might just give us a glance at a different kind of thinking about the role of government and in taking a bite out of twin social ills — homelessness and public health costs.
Vox News reporter Rachel M. Cohen has taken an interesting, if renewed look at a policy waiver that now is being extended to allow states to test out using Medicaid funds towards making housing available to those who can’t afford shelter, at least for a few months.
Health problems linked to homelessness can be physical, mental, or emotional; the current emphasis on loneliness in society clearly is reflected in homelessness.
The specific experiments will track whether there are measurable results in homelessness or on reduced hospital health costs that Medicaid must cover by law.
By using federal Medicaid dollars toward rent for selected poor groups — long barred by congressional regulation, we can see practical testing of whether housing indeed is fundamental to health care. We also can test whether government continues to have a role in real problem-solving.
A Desire for Rule Changes
The Medicaid rules are vast, and generally only address housing if you’re poor and in a nursing home or hospital. With homelessness rising and rents growing, the Vox report details that, some states are preparing these new experiments of whether health improves as housing stabilizes.
Since 2015, the Centers for Medicare and Medicaid Services has said Medicaid funds could go toward services that help people move into new housing, like moving costs or security deposits. In 2018, a commission said it has long been known that poor housing conditions can worsen health outcomes and advised looking at providing supportive housing to chronically homeless people to reduce emergency room visits. That thought was amplified by covid, as shown by suspending evictions as part of disease response. In 2022, the Biden administration encouraged states to consider using Medicaid dollars for “health-related social needs” like housing, nutrition, and transportation, with a cap of about three percent of state costs.
The why is easy. Housing and health are two cost that are rising substantially and drive inflation.
Basically, what all this means is that state pilot programs will aim to spend Medicaid money on up to six months of rent if the state can show improvements in health outcomes of cost savings. The side benefit would be to urge more creative use of public dollars for directed improvements in both health and housing.
The Pilots
The two first states this fall will be Arizona and Oregon, each of which is targeting different groups and different health outcomes.
Oregon, which pays Medicaid to 1.5 million, is looking at up to 125,000 people at risk of becoming homeless, in effect using the funds as a preventive tool against economic, physical, and mental harms that come with losing a home. As Vox notes, individuals will get a “prescription” for housing by referral from community organizations. Issues include whether there is available housing, of course, as well as tracking health care outcomes and costs.
In Arizona, the target will be people designated as having a serious mental illness, building on a smaller program which state officials say has reduced emergency room visits by 31 percent, hospital stays by 44 percent, and reductions of more than $5,500 per recipient per month. Arizona wants to use the money to authorize new housing that will involve private developers.
Other states that have applied to use federal Medicaid dollars for rent include New York, California, Hawaii, and Washington, each seeking to assemble private-public-community organization cooperation that has proved elusive in the past.
There are plenty of pitfalls ahead, including from homeless advocates who see some advantage going to Medicaid patients over those seeking placement in otherwise subsidized housing. Just how receiving Medicaid help might affect other aid packages is unclear, for example.
Another is whether any successful housing program could or would force levels of Medicaid support altogether, particularly in states that have been resistant to federal health care programs or expanding Medicaid rolls.
And there is disagreement about measuring results. A California permanent supportive housing program resulted in a roughly 20 percent net savings of total public cost but competing studies have found more mixed results. A new study found participants had no difference in emergency room visits, inpatient use, or chronic disease control, but did report real mental health improvements, particularly from housing providers who showed them compassion.
What seems evident here are the broader implications for our politics: Rather than spending so much time knocking the Other Guy or on winning today’s partisan skirmish, we’d be far better off with focus on solving real problems, whether in housing and health, immigration, education, environment, or international peace.
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