The final panel session was devoted to a conversation about the future of affordable and accessible housing, next steps, policy implications, and research needs. Emily Rosenoff, the manager of and a program analyst with the U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation in the Office of Disability, Aging and Long-Term Care Policy, moderated the panel, which included the following reactors: Dara Baldwin, a senior public policy analyst for the National Disability Rights Network (NDRN); Anand Parekh, the chief medical advisor at the Bipartisan Policy Center; Robyn Stone, the senior vice president for research at LeadingAge; and Uchenna S. Uchendu, the chief officer for health equity at the U.S. Department of Veterans Affairs (VA). Each reactor had 5 minutes to share his or her thoughts, and the discussion was then opened to the workshop participants.
Senior Public Policy Analyst
National Disability Rights Network
Dara Baldwin of NDRN began by explaining that NDRN is the national organization for the Protection & Advocacy Network (P&A Network), which provides legal representation and advocacy for people
with disabilities. The network is funded by the Administration for Community Living and has 57 programs, one for each state, the District of Columbia, and every U.S. territory, along with one that specifically serves Native Americans. Housing and employment are two major areas of focus for the P&A Network and NDRN. Baldwin noted that NDRN belongs to the Transportation Equity Caucus1 and works with the National Council on Independent Living2 in efforts related to housing, particularly issues centered on the concept of visitability.3
Baldwin said that veterans’ groups are potential partners in housing efforts but were not mentioned during the workshop. While the perception is that these organizations only work with veterans, Baldwin said she has seen examples around the country where these groups help individuals who are not veterans but do have a disability.
Baldwin also noted several areas of research that were not addressed during the workshop:
- Disaggregating data on intersectionalities.4
- Reentry for those who were formerly incarcerated, many of whom are older when they are released, experience the onset of disabilities, and are also searching for housing. NDRN is working on a bill with the Reentry and Housing Coalition5 related to reentry, but it needs data to support the proposed policies and to show that the programs that exist really do help formerly incarcerated individuals. The issue of housing is often lost in the criminal justice reform conversations. Baldwin noted that Medicaid expansion under the Patient Protection and Affordable Care Act made formerly incarcerated individuals eligible for Medicaid benefits. “We need the data on how Medicaid services helped those people who were formerly incarcerated,” she said.
- Accessibility of playgrounds and recreation centers.
- Access to public housing and the public pathways that those with disabilities have to traverse to get from the street to their homes.
3 Visitability is a movement to build houses that include a zero-step entrance, doors with 32 inches of clear passage space, and a bathroom on the main floor. For more information, see www.visitability.org (accessed March 15, 2017).
4 Intersectionality, a concept developed by Columbia University law professor Kimberlé Williams Crenshaw and originally articulated on behalf of African American women, is a term used to refer to overlapping social identities (e.g., race, gender, sexual orientation, religion, age, disability, etc.) and related systems of discrimination and oppression.
Chief Medical Advisor
Bipartisan Policy Center
Accessibility is critical, said Anand Parekh of the Bipartisan Policy Center, if for no other reason than that it helps address the public health challenge of falls in the home. One in four older adults fall every year, accounting for 2.8 million emergency department visits, 800,000 hospitalizations, and $31 billion spent annually in Medicare expenditures, he said. Parekh, who is himself a physician, said he was hopeful that the two cabinet nominees for the U.S. Department of Housing and Urban Development (HUD) and HHS, who are both physicians, might be able to find common ground in their work to accelerate integration of housing and health. He suggested that state and local officials raise their visibility on health and housing integration to help drive home the message that there are opportunities for these two federal agencies to make a significant impact in the lives of older adults and individuals with disabilities.
Parekh noted that the Bipartisan Policy Center organized a senior health and housing taskforce in 2015 headed by two former HUD secretaries, Henry Cisneros and Mel Martinez, and two former members of Congress, Allyson Schwartz and Vin Weber. In May 2016 the task force released its report Healthy Aging Begins at Home (Senior Health and Housing Task Force, 2016), which contains 30 recommendations to bring the housing and health care sectors closer together in order to improve health outcomes and reduce preventable health care costs for American older adults. The task force directed its recommendations to the executive and legislative branches of the federal government with the goal of expanding the supply of affordable housing, facilitating home and community-based modifications, and accelerating health care and housing integration in order to improve outcomes and reduce cost. Furthermore, the task force report recommended that federal efforts focus on the 1.3 million Medicare and Medicaid dual-eligible beneficiaries who live in publicly assisted housing and go beyond what HUD is doing with their supportive services demonstration. The idea would be to invite managed care organizations, accountable care organizations, and other providers to be accountable for the total cost of care and outcomes for this population. “To achieve these outcomes,” Parekh said, “they would need to partner with housing providers and provide these evidence-based models you have heard about today [at the workshop], whether it is SASH [Support And Services at Home], CAPABLE [Community Aging in Place—Advancing Better Living for Elders], or other models. They would receive advanced payments, and if there are cost reductions they would share savings with housing providers and with Medicare and Medicaid.”
Another recommendation in the task force’s report was for states to take more advantage of Medicaid coverage for housing-related activities and services for older adult beneficiaries and those with disabilities. “We do not really have a clear picture of how states are utilizing these permissions, and I think there is a research opportunity there that can inform both federal as well as state policy,” Parekh said. Rosenoff added that the Centers for Medicare & Medicaid Services (CMS) has been running an innovation accelerator program with a number of federal partners. This program has provided intensive technical assistance to eight states and less intensive technical assistance to some 30 other states to help them focus and strengthen their housing and health partnerships. As a result of this effort, Rosenoff said, approximately 10 states have applied or will soon apply for Medicaid waivers to provide supportive housing services as part of Medicaid benefits.
For Congress, the task force called for expansion of the low-income housing tax credit. One concern is that corporate tax reform could make this credit less valuable for private developers. Parekh noted that over the 30 years that this tax credit has been available, it has enabled construction of nearly 3 million low-income housing units at a cost of $100 billion. Another proposal calls for the Administration for Community Living to better coordinate the nine different federal programs run by five executive branch departments that help older adults modify their homes. “These programs are doing good work, but are not very well connected, nor are they coordinated,” Parekh said. This proposal also called for using the aging network and the Aging and Disability Resource Centers to disseminate information to older adults about the availability of these programs. Parekh added that a number of U.S. senators have introduced a bipartisan bill calling for these same steps. Parekh concluded by saying that there will be opportunities for Congress to help low-income Americans by integrating health and housing. “As much as I think we do need more efforts at the local and state level, we remain optimistic that there might be movement at the federal level in 2017 and beyond,” he said.
Senior Vice President for Research
Robyn Stone of LeadingAge said that many countries see housing as a right, not like the lottery it seems to be in the United States. In Singapore, for example, housing was the bedrock of that country’s development in the 1950s, and housing is seen as essential for well-being. This idea is relevant to the United States from a policy perspective because so many of the federal dollars that go toward housing are discretionary, which makes
future federally funded support for housing for low-income older adults and younger adults with disabilities uncertain. She also reflected on housing becoming a “social determinant of health buzzword.” “Coming out of public health as I do,” she said, “we always knew that housing was an essential determinant of health.” However, she said that in her opinion housing is much broader than only a social determinant of health. It is an often unrecognized public health issue for low-income older adults, adults with disabilities, and other vulnerable populations, which is different than talking about it just as a social determinant of health. Housing is shelter, which is a social determinant, she said, but it is also quality and accessibility and a platform for the effective delivery of services, supports, and prevention. This workshop, she said, brought together all of these aspects of housing and focused not just on moving toward the goal of the Triple Aim of health care but also on enabling people to live as independently as possible in the community.
Stone applauded the recent report from Harvard’s Joint Center for Housing Studies (Joint Center for Housing Studies, 2016) and the workshop discussion about meeting the housing needs of older adults and younger people with disabilities. She said that they clearly highlighted the fact that there is a large low- and modest-income population which is growing, so the current stock of housing available is unacceptable and untenable for the future. “How are we going to solve that?” Stone asked, while also agreeing with Parekh about possible cooperation between HHS and HUD when they are both headed by physicians.6 She noted, however, that “we are going to have to continue to look a lot at public–private partnerships and a more significant role for the private sector.”
Together with her colleague, Stone is conducting a study on the feasibility of using social impact bonds7 to boost health and housing partnerships for low-income elderly adults in Los Angeles. Most of the use of social impact bonds has been for individuals who are homeless or formerly incarcerated, which she said are populations at such risk that almost any investment will generate savings. “That is where private investors want to put their money,” she said. “For the populations we are talking about today [at the workshop], it is much more nuanced in terms of where you get cost savings and how those dollars would ultimately go back to a private investor.”
6 The current secretaries of HHS and HUD are physicians Tom Price and Ben Carson, respectively.
7 Social impact bonds are a form of funding whereby private investors provide the upfront capital for a project and the investments are repaid only when and if the targeted outcomes for the project are achieved.
Where it may be possible to influence the new administration is by framing this problem as part of the infrastructure needs of the country, and not just in metropolitan areas but in rural communities too, Stone said. “Perhaps thinking about this in terms of infrastructure will be a way to keep [housing] on the [national] agenda and also think about ways in which we can get money into these models and these programs other than through the health care route,” she said. Stone concluded her comments by noting she does not believe that there is enough of an evidence base to persuade the government to invest in these housing programs. Her team’s evaluation of SASH, which has continued through three cycles to find a slowing of the growth curve in Medicare spending, is the kind of evidence that health plans want to see, she said. Similarly, she said, there are promising signs with CAPABLE and some of the other models discussed during the workshop, but there is still a need for more evidence. “I think the potential is there, but the evidence base needs to be built,” she said. Stone also expressed optimism that the move to value-based payments in health care will not go away, given that it has bipartisan support, and that the housing and health model will be shown to provide some of the best opportunities for value-based payments to have a positive impact on health outcomes and on improving delivery of services to high risk older adults and younger adults with disabilities.
Uchenna S. Uchendu
Chief Officer for Health Equity
U.S. Department of Veterans Affairs
Noting that she agreed with most of the comments of the three reactors who spoke before her, Uchenna S. Uchendu of the VA reiterated Baldwin’s recommendation to reach out to veterans organizations and to begin asking the individuals who participate in the programs discussed at the workshop if they or their family members have served in the military. This is important, she said, because while there are many services that the VA can provide, it is only doing so for approximately 9 million of the estimated 22 million living veterans. “We cannot afford not to include all of them,” she said. “We have a duty to honor Abraham Lincoln’s promise—‘To care for him who shall have borne the battle, and for his widow and his orphan.’ Today, we say ‘for their families and their survivors’ because women now serve in the military.”
Uchendu said that part of her job in championing health equity and the elimination of health disparities for all veterans, but especially the most vulnerable, is to be the liaison to other agencies that are also working toward health equity. She noted that because less than 2 percent of the U.S. population serves in the military, veterans are a minority by num-
bers. Additionally, veterans’ unique military experiences and exposures in different military periods or eras8 add another layer of vulnerability. A combination of these factors increases the likelihood of health disparities for veterans.
The VA is a good model of where health care and social determinants such as housing intersect, Uchendu said. Veterans’ benefits administered by the VA include education through the G.I. Bill, housing via VA loan guarantees, and housing the homeless through its partnership with HUD and other stakeholders. In addition, the VA will provide home modifications for veterans whose service has made it impossible or difficult for them to function in their homes. Because the VA brings income, housing, education, and health under one umbrella, it has data to support the effectiveness of programs such as homeless patient-aligned care teams and other person-centered programs that work at the intersection of health and various social determinants of health.
Rosenoff remarked that the efforts of the VA, HUD, and her department at HHS to address veteran homelessness are having great success. Since 2010, when the focus on homeless veterans began and Congress provided the necessary resources, homelessness among veterans has been cut by 50 percent, and three states—Connecticut, Delaware, and Virginia—have ended veteran homelessness, as have 33 communities across the nation. Baldwin added that the VA has been sensitive to listening to women veterans, many of whom have expressed their frustration that much of the supportive housing that is available has only one bedroom even though many veterans—women and men—are parents who need space for their children.
Uchendu then commented on the need to have a common language in the health equity field, particularly when talking about disability and vulnerable populations. She suggested that when organizations develop new interventions, they proactively build evaluation into their program in addition to setting SMART (specific, measurable, actionable, replicable, and time-bound) goals. She said that she was concerned that during the workshop she did not hear much discussion about data being broken down by race and ethnicity. At the VA, collecting data on race, ethnicity, gender, geography, age, and other demographic features is routine, which, she said, “makes it possible for various stakeholders to take their piece of the puzzle and be able to dissect it further in order to engender action.” Those data also underscore the intersectionality that was mentioned repeatedly throughout the day because humans do not exist as monoliths, and they do not thrive in silos. Uchendu added that there is
8 For more information, see https://www.va.gov/HEALTHEQUITY/docs/Period_of_Service_Timeline_OHE10212016.pdf (accessed March 15, 2017).
an opportunity for health care and public health to come together around the issue of housing in particular and health disparities in general. While that may seem to be a cliché, she said, in fact health care and public health are still largely operating in parallel lanes.
Uchendu also noted the importance of incorporating social determinants of health—e.g., housing, education, and economic stability—into electronic health records. While she said that she is not expecting health care providers to conduct home assessments, she said that there should be ways of outsourcing that type of information gathering. Community health workers, for example, could collect such information, as could family members. Technology could be leveraged to do this effectively, without encumbering clinical staff or impeding timely access to health care, Uchendu concluded.
Ben Bolton from the Social Security Administration asked if anyone could comment on the intersection between housing and transportation, particularly for people in non-urban areas. Baldwin said that the U.S. Department of Transportation has been doing work on this issue, as has the Association of Programs for Rural Independent Living.9 The biggest problem, she said, is the pathway of travel. “In rural areas, you rarely have a sidewalk, and people are using their wheelchairs and walkers in the middle of the street or dirt road,” she said. Street lighting is also an issue in rural communities. Community-based ride sharing, where faith-based and other local organizations make their vans accessible and provide an Uber-like service, offers one solution. With regard to health, Baldwin said that telehealth is making inroads in rural areas, and in some places doctors and practical nurses are starting to make house calls.
Carol Star from HUD said that financing the new production of affordable housing that will meet the needs of older adults and people with disabilities will remain a challenge. She noted that HUD has requested a large increase in rental assistance funds, but even if the agency is fortunate enough to get all of the funds it requested, those dollars will still be chasing a diminishing supply of housing that is accessible. In that regard, she challenged the workshop participants to think creatively about what makes sense to propose in the new environment for financing the kind of housing discussed during the workshop. Parekh suggested the possibility of combining funds from the Section 202 Supportive Housing for the
Elderly program10 with other funding streams, similar to the way the Section 811 Project Rental Assistance Program has done. Stone said that LeadingAge has a few providers who are mixing market rate and subsidized housing. Developers have shown an interest in this idea, though most of their efforts in many cities have been in building units for wealthier clientele. “But I do think the potential is there in terms of the sheer numbers of elderly who are going to be coming through the pipeline over the next 25 years,” she said. The challenge, she added, is to identify a model that combines market rate units with more modest units and uses tax incentives to move it forward. “This might happen more at the state or local level than at the federal level,” she said. “I think we are going to have to look more at private sector models with public sector investment.” Lisa Sloane added that her organization has a report on how state housing agencies in Illinois, North Carolina, and Pennsylvania have pioneered new approaches to funding expansions of permanent supportive housing for extremely low-income households (O’Hara and Yates, 2015). These financing strategies, she noted, could be adapted to use funding from the Housing Trust Fund11 program, which is targeted to this population.
Daniela Koci asked the panelists if they had seen any instances where regulators have shut down group homes that were not in full compliance with the new CMS rule regarding the settings for home- and community-based services. She also asked if they were seeing growth in different models that are more successful and more compliant. This new rule, Rosenoff said, describes the characteristics of the places that can provide Medicaid home- and community-based services, and it stresses that beneficiaries must have a choice of settings, not that they have to receive such services in their own home or in their own bedroom. She said that states are still submitting their plans to CMS with details about how they intend to comply with the rule.
A related issue, Rosenoff said, is what the U.S. Department of Justice and the states have been doing to make sure that states are complying with the Supreme Court’s Olmstead decision. “Clearly, states have been making some progress in complying,” she said, “and there have been large institutions that have shut down, some under court consent decrees, some voluntarily.” In many instances, the individuals in those institutions have been moved into supportive housing and other housing models in the community. Rosenoff characterized this effort as one that is still evolving, and
10 For more information, see https://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/mfh/progdesc/eld202 (accessed March 15, 2017).
11 The Housing Trust Fund is an affordable housing program at HUD. Funding under this program can be used for construction or preservation of affordable housing. For more information, see https://www.hudexchange.info/programs/htf (accessed March 15, 2017).
she said that a state will be complying if it is providing person-centered care and has a range of options for Medicaid beneficiaries and the places that can serve them. Baldwin added that the number one goal is not to close institutions but to ensure that those who live in them are not abused or neglected. She added that the concern she has heard about most from people who have moved out of institutions and into the community is that of loneliness once they leave the social environment of an institution.
Teresa Lee, providing the final comments of the day, said that she thinks that the new administration’s interest in reducing regulations may provide an opportunity to break down the silos between health care and housing, both of which are heavily regulated. “To me, as I am thinking about it, we have our work cut out for us regardless of administration,” Lee said. “We have our work cut out for us from a budget standpoint, and it is more important than ever to try to come together, to reframe, and to try to find common language. I encourage all of you to continue to seek out those partnerships and to engage with one another.”