Homelessness and Behavioral Health Care Coordination Act (H.R. 773)

Impact

Problem: Supportive housing services are not always available for people experiencing homelessness with acute needs caused by substance use or behavioral health issues.    

What are supportive housing services? 

Some people who experience homelessness need more than rental assistance.  They need additional help to become housed and stay safely and securely housed because of more acute needs, perhaps resulting from chronic homelessness, a term which is used to describe people who have experienced homelessness for at least a year — or repeatedly — while struggling with a disabling condition such as a physical ailment, mental illness, or substance use.   

In short, they need supportive housing services, which might mean help finding a suitable rental unit, working with landlords to address concerns, case management, or other services.  However, supportive housing services are not normally available with housing vouchers, including the emergency housing vouchers provided by the American Rescue Plan Act. 

Permanent Supportive Housing is becoming less of an option.

There is permanent supportive housing (PSH), which combines vouchers with supportive housing services and is largely paid for through the Department of Housing and Urban Development’s (HUD) Continuum of Care (CoC) program grant process, which itself is funded by annual appropriations.  Often, Continuums of Care (CoCs), the regional bodies which oversee federal homelessness funding, can only maintain existing PSH arrangements, not get new people into units of PSH, because of inadequate resources. 

In fact, after a long period of growth, the number of PSH units declined in 2021, for the second year in a row, even though the number of people experiencing chronic homelessness continues to increase.  In 2015, the national count for people experiencing chronic homelessness was 83K on any given night; in 2020, the last year for which a complete count is available, the number was 110K on any given night. 

Landlords and PHAs want supportive housing services before accepting people with acute needs.

Congress creates housing vouchers, whether pursuant to COVID relief or annual appropriations, that cannot easily be used for chronically homeless people, arguably the people who need help the most, because they don’t come with supportive housing services.  Public Housing Authorities (PHAs) can be averse to using vouchers on people experiencing homelessness with acute needs in the absence of supportive housing services; landlords can also be reluctant to accept vouchers in such circumstances. 

Medicaid pays for supportive housing service but is often inaccessible to local homelessness systems.  Supportive housing services are often available through Medicaid, but for a variety of reasons, often dependent on local conditions and capacities, the homelessness and the health care systems don’t work well together.  Integration of health and homelessness services to achieve optimal outcomes for people with acute needs experiencing homelessness can be challenging for state and local governments, CoCs, and local service providers. 

Capacity-building is needed to create systems-level linkages between the two sets of services to allow for smoother pathways and simpler navigation.  Homelessness services providers usually have administrative structures built on grant funding, not on Medicaid billing.  To leverage new resources, providers will need to become better versed in government funding processes; moreover, state and local players will need to build their capacities for referral and collaboration.

H.R. 773 would establish in the Department of Housing and Urban Development (HUD) a program to provide grants to homelessness organizations that would help them to develop the capacity to access supportive housing services, including billing Medicaid or paying a third party to bill Medicaid.   

1. Interagency collaboration: HUD would chair an interagency working group to provide advice in the administration of the program, which would include the Department of Health and Human Services, the Interagency Council on Homelessness, the Department of Agriculture, and the Bureau of Indian Affairs.
2. Flexibility: Given that the incompatibility between the health care and the homelessness sectors can have different causes and different remedies, the capacity-building grant process would emphasize flexibility.
3. Amounts: Grants awarded to an entity to develop capacity would not exceed five years in length and $500,000 in amount.
4. Grantees: Eligible grantees include a governmental entity, an Indian tribe, a PHA, or a continuum of care or non-profit designated by that continuum of care, which is responsible for homelessness, can ensure that services will be culturally competent and trauma-informed, and demonstrate how its capacity to coordinate health care and homelessness services through
   1. the designation of a governmental official as a coordinator,
   2. improvements in infrastructure at the systems level,
   3. improvements in technology for voluntary remote monitoring capabilities
   4. improvements in connections to health care services
   5. efforts to increase the availability of Naloxone, and
   6. any additional activities identified by the Secretary.
5. Cost: The legislation would authorize to be appropriated $20M for each of fiscal years 2023 through 2028.

Summary

H.R. 773 would establish in the Department of Housing and Urban Development (HUD) a program to provide grants to homelessness organizations that would help them to develop the capacity to access supportive housing services, including billing Medicaid or paying a third party to bill Medicaid.  Very similar legislation was considered at a 2022 hearing of the House Committee on Financial Services and approved by a vote of 27-22

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