Now Is the Time for Steadfast Collaboration

The Affordable Care Act (ACA) and other health care payment and delivery system reforms have provided new or expanded opportunities at the state and local levels to forge collaborations between health care and housing providers. The expectation is that partnerships will result in fewer people experiencing homelessness, preventable institutional living; a more stable tenant population for housing providers; a better platform for effective delivery of health care; and better care, better outcomes, and lower health care costs for vulnerable populations.

The current environment is more positioned than it has been in decades to take advantage of the ACA’s opportunities and incentives for health care systems to address social determinants of health, including housing. With the Biden Administration’s focus on Home and Community Based Waivers and affordable housing, we are seeing funding for policies like Section 811, which is the only federal program that funds supportive housing exclusively for persons with disabilities. Section 811 is a true collaboration between housing and health systems. Since the ACA's passage, housing and health systems have struggled to align their disparate bureaucracies, regulations, and funding. However, the Section 811 collaboration demonstrates that strong leadership and shared vision can overcome these obstacles.

While health care stakeholders welcome the idea of connecting their patients to housing, it is one of many nonclinical supports competing for health care investment. Those involved in the health care system, including state Medicaid agency staff, managed care plan administrators, and local health care providers, also face a steep learning curve in understanding the affordable housing landscape and how it relates to their mission. Despite these barriers, some states, counties, and provider networks have taken the opportunity to use aspects of the ACA and other new health care reforms to integrate housing and health services for vulnerable populations. While their methodologies are very different, they share strong leadership and commitment from key stakeholders to making the collaboration work.

Forging successful partnerships between housing and health care systems takes time and patience. Without solid and committed leadership, it is difficult to get the critical partners to the table and keep them there. National advocacy and advisory groups can also be instrumental in supporting the development of partnerships.

Health care and housing providers have different priorities, incentives, and funding streams, are guided by different regulations, and answer to different authorities. A careful and deliberate planning process can facilitate learning and relationship building and minimize conflicts, mainly as stakeholders must agree on a wide range of issues, from defining the program mission and partnership structure to developing a service package and staff roles and responsibilities to delineating the details of day-to-day operations.

The three programs that have received accolades for their collaboration are New York Medicaid Redesign Team (MRT) Supportive Housing Initiative, HWS in Portland, Oregon, and Integrated Care for the Chronically Homeless in Houston, Texas.

Challenges to health and housing integration are significant but not insurmountable, as evidenced by the examples above, which are just a sample of the many collaborations established or being developed around the country. States and localities have many opportunities. Providing Medicaid-reimbursable supports and housing-related services to individuals who are already housed to help them maintain stability would seem to be readily available to any Medicaid program.

State and local governments have tools at their disposal to foster health system integration with housing and social services. They can create incentives for health plans to address social determinants of health, create linkages between state and local agencies and providers on the ground, encourage integration by establishing outcome measures (e.g., the proportion of beneficiaries who have stable housing), and alternative payment methodologies (e.g., an opportunity for providers to share in savings that have resulted from improved outcomes as a result of housing).

The federal government also has a part in fostering cross-system collaborations by providing guidance and resources to states and localities on tools and authorities available. Substantial policy changes that may further support health and housing collaboration include revisions to or clarifications of the Medicaid managed care rate-setting methodology and expanding federal programs, e.g., Section 8.

Source: Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services