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.
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Key Features of Health and Housing Collaborations |
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New York MRT Supportive Housing Initiative |
Housing with Services |
Integrated Care for the Chronically Homeless |
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Brief Description |
A multi-pronged approach to connect vulnerable populations to health care, housing, and related supports through the implementation of Medicaid Health Homes, a comprehensive, integrated model of care for persons with chronic disease; investment of state Medicaid savings into the construction of supportive housing and rental subsidies, and pilot grants to test new supportive housing models. |
An LLC of nine partners, including housing providers and health and social services providers, was established to coordinate health care and social services for low-income seniors and individuals with disabilities residing in federally subsidized housing. |
A collaboration among a health center, a homeless services provider, and a housing provider to bring integrated health care and social supports to individuals experiencing chronic homelessness and are frequent hospital emergency services users. |
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Geographic Scope |
New York State |
Portland, Oregon |
City of Houston and Harris County, Texas |
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Partners |
State agencies, including the Department of Health, the Offices of Temporary and Disability Assistance, Mental Health, People With Developmental Disabilities, and Alcoholism and Substance Abuse Services; the AIDS Institute, the Division of Long Term Care, and Homes and Community Renewal (the state housing agency). |
Housing: Cedar Sinai Park, Home Forward (Housing Authority of Portland), REACH Community Development. Insurance: CareOregon. Service Providers: Asian Health and Service Center, Cascadia Behavioral Healthcare, Jewish Family and Child Service, Lifeworks Northwest, Sinai Family Home Services. |
The Houston Health and Human Services Department, the Houston Housing Authority, and the City Housing Department. Lead providers are Healthcare for the Homeless - Houston Health Center, SEARCH Homeless Services, and New Hope Housing, Inc. |
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Target Population |
High-need, high-cost Medicaid beneficiaries, including those experiencing or at risk for homelessness, and residents in nursing facilities. |
Low-income seniors and individuals with disabilities residing in HUD-subsidized housing who opt-in to the program. |
Individuals experiencing chronic homelessness with at least three ED visits over the past two years. |
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Services |
Care coordination and links to services and supports, including housing, rental subsidies, tenancy advocacy, supportive services, including case management, counseling and crisis intervention, employment and vocational assistance, educational assistance, life skills training, and building security services. |
Health care, mental health and substance abuse counseling, prescription medication management, wellness services, food insecurity prevention and nutrition counseling, and social engagement program. Health care navigators and care coordinators help link residents to needed services. |
Primary care, substance use, and behavioral health counseling. Community Health Workers assist in managing participants' health needs. Clinical case management is provided in a supportive housing environment. |
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Funding |
State share of Medicaid redesign-related savings, bonds for construction, Health Home program. |
LLC partners' equity contributions, SIM grant, and grants from foundations and private organizations. |
Medicaid 1115 Waiver DSRIP payments, HRSA Health Center Program, and various grants. Rental subsidies are provided through the Houston Housing Authority. |
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