Ending Homelessness Today

The Official Blog of the National Alliance to End Homelessness

Housing is the Common Ground

Written by Guest blogger, Joshua Bamberger, MD, MPH, University of California, San Francisco; Chief Medical Consultant at Mercy Housing

In recent months, the intense healthcare debate has often centered around our individual values: how much autonomy should we have to control our healthcare finances? How do we meet our responsibility to care for people who live with mental illness, poverty, and chronic medical conditions? It’s not surprising that these values have sometimes conflicted with one another.

During this August Congressional recess, we can all take a deep breath knowing that our values can find common ground. In fact, a recent report developed by the Low Income Investment Fund and Mercy Housing for the Kresge Foundation and the California Endowment, shows how nine communities have forged alliances across the health and housing sectors to improve the health of people experiencing homelessness, while simultaneously controlling the run-away-train of healthcare spending.

These communities have used a variety of tools to increase the available number of housing units targeting homeless adults and people exiting institutions. The nine case studies combine strict fiscal controls with innovations in healthcare delivery systems to provide a template that could be replicated in communities across the country. While each case is unique, they all utilize one or more of three main strategies to invest healthcare dollars into housing:

  1. Use of shared savings, reserves, or increased financial flexibility within a capitated healthcare delivery system (either a Managed Care or Accountable Care Organization), in partnership with a local housing authority; and/or
  2. Use of Hospital Community Benefits Obligation; and/or
  3. Local or state investment built upon an expanding and evolving healthcare sector.

I encourage you to review the report and see how communities in California, Minnesota, New York, Ohio, Arizona, Pennsylvania, and Oregon are harnessing the power of innovation and collaboration to reduce costs, improve outcomes, and extend housing to the most vulnerable members of their community.

The Road Ahead

When Congress returns in the fall, Senators Murray and Alexander will lead a bipartisan effort around healthcare reform. These case studies can help guide coordination between the health and housing sectors. Each example started at the local level and expanded housing stock for high users of the healthcare system, despite regulations that restrict the use of Medicaid for “room and board.”

Congress will have the opportunity to provide leadership so that local communities can continue to innovate within a fixed budget. For example, when managed care organizations (MCOs) invest in housing for high healthcare users, Federal expenditures from Medicaid are often reduced. Despite the return on investment, MCOs are then punished by having a reduction in their annual capitated rate, because housing funds are not considered to be “medically necessary.”

Healthcare reform could allow, under certain circumstances, MCOs to invest in housing without this penalty.

In addition, the Federal government should single out hospital systems that prioritize housing to meet their Community Hospital Benefits Obligations as examples that other communities should emulate. Finally, supportive housing should become an acceptable alternative to institutional care so that services in supportive housing could be covered by a day rate from Medicaid through 1915c Assisted Living Waivers.

The cases described in our report show that successful strategies can work, despite the barriers in place by the Federal government. In fact, healthcare reform could reduce these barriers. In doing so, it will create more opportunities to deliver the life-saving treatment called housing to those whose basic survival depends on it.

Joshua Bamberger, MD, MPH is Assistant Clinical Professor of Family and Community Medicine at the University of California, San Francisco and Chief Medical Consultant at Mercy Housing.  For re-prints of the Innovations in Health and Housing report or for more information, please write to joshdbamberger@gmail.com