Public housing in lower Manhattan in New York City. Spencer Platt/Getty Images

The Intersection of Housing and Medicaid: A Policy Brief

Policies and Programs Addressing Housing Instability and Quality Issues through Medicaid

Executive Summary

The U.S. health system has evolved around the idea of episodic, or reactive, care. In this format, people get sick and then receive care after it may be too late to affect their disease progression. Shifting the health system from reactive to proactive is a major goal of health policymakers and those attempting to improve the population well-being of people in the U.S. Working to prevent and mitigate upstream factors associated with disease development and progression is crucial to preventing disease and managing existing conditions (Daniel-Robinson & Moore, 2019). Of particular interest are factors that precede the formation of chronic illness. In the U.S. healthcare system, chronic conditions are responsible for the majority of illnesses and healthcare utilization resulting in 75% of total health expenditures (Milani & Lavie, 2015). Medicaid populations are socio-clinically complex and likely to include members with multiple complex medical conditions (Kronick, Bella, & Gilmer, 2009). It is necessary for Medicaid programs to address these problems through payment and delivery reform due to growing expenditures and the goal of improving societal health.

There is a well-established link between housing insecurity and chronic disease that results in higher rates of chronic illness and increased health expenditures. Previously, the housing-health connection has been thought of and associated with physical environment-related issues and dangerous housing; however, recent studies suggest that adverse health outcomes are also linked to housing rental assistance status, housing stability, housing affordability, and neighborhood characteristics (Parreñas, Thai, & Silvey, 2016). Substandard, unaffordable housing can create public health challenges for a large number of Americans and creates an important policy issue for the healthcare industry (Parreñas et al., 2016).

In this policy brief, policy mechanisms and operational strategies that have been implemented to address the intersection between health outcomes and housing-related issues will be presented as models for innovation, and, collectively, will be distilled into their most important features.

Several state Medicaid agencies and large healthcare organizations (HCOs)have been active in this area. The innovative models developed by these “early movers” can provide a roadmap for other Medicaid agencies and companies to develop their own programs aimed at addressing housing insecurity and quality through the health delivery system. The following programs will be explored as potential models for policymakers in State Medicaid Agencies:

1. North Carolina Department of Health and Human Services

2. United Health Group (UHG) Housing Initiatives

3. Arizona Mercy Maricopa Integrated Care

The Cost and Prevalence of Chronic Conditions in Medicaid

Medicaid populations are demographically diverse and individuals experiencing complex medical conditions are highly common(Kronick et al., 2009). In Medicaid, disabilities are also very common with disabled Medicaid enrollees experiencing an even higher incidence of chronic disease and accounting for a major percentage of overall spending (Kronick et al., 2009).

In recent years, cost inflation in Medicaid programs has become a key issue of concern for policymakers at both the state and federal levels. Generally, high-risk and high-cost enrollees only account for 1–10% of the population, but are linked to between 24% and 68% of total spending (Wammes, van der Wees, Tanke, Westert, & Jeurissen, 2018). Medicaid agencies must address this key driver of cost through adequate management of patients having already developed a condition and through the mitigation of upstream factors of chronic disease formation.

Many of the recent health reform efforts have been centered on the perceived cost and quality improvement benefits of improved care coordination to address high-risk members that contribute heavily to expenditures. Care coordination involves many activities but is intended to help patients navigate their healthcare needs and facilitate connection to social services and other community supports.

Chronic conditions result from a wide variety of social risk factors and health behaviors. Risk factors can be behavioral or physiological such as obesity, smoking, a sedentary lifestyle, a diet lacking fruits and vegetables, obesity, and substance abuse (Adams, Grandpre, Katz, & Shenson, 2019).

Risk factors can also be socio-economic in nature. Socially-derived determinants such as low income, low educational attainment, lack of access to healthcare, housing insecurity, food insecurity, interpersonal violence, previous incarceration, presence of discrimination, and other social factors also contribute to chronic disease formation (Adams, Grandpre, Katz, & Shenson, 2017; Cockerham, Hamby, & Oates, 2017; Daniel-Robinson &Moore, 2019).

The WHO defines the social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the set of forces and systems shaping the conditions of daily life (Cockerham et al., 2017).”

According to the National Association of Community Health Centers, 40% of life expectancy and health outcomes can be attributed to socio-economic factors (NACHC, 2012). Shifting system orientation to effectively manage and prevent chronic diseases requires the mitigation of social factors such as housing instability and quality. State Medicaid programs and organizations operating within them must prioritize the development of programs that can support individuals with high social needs.

Associations Between Housing Issues and Health

Theory

In 1943, Abraham Maslow published his “hierarchy of needs” with each level need be met before the next higher level can be attained (Figure 1). The most basic level of the well-known pyramid structure is physiological needs including breathing, food, shelter, water, clothing, and sleep. The next level, once those basic needs are met, is labeled safety and security and includes health, employment, property, family, and social stability. Under this theory, it follows that if shelter, or housing, in this case, is not stable then the level above such as health is not attainable to a sufficient degree.

Figure 1: Maslow’s Hierarchy of Needs

Theoretically, then, it is imperative to address the physiological needs level first before attempting to address higher-order needs such as health. Medicaid programs looking to be more proactive in the prevention of chronic conditions should look to address the upstream risk factors of disease that are well-known. As it relates to housing, consistent shelter, according to Maslow, is necessary to maintain health, promote economic stability, and obtain employment.

It is then necessary for Medicaid agencies, in support of their health goals, to ensure this basic level of need for enrollees.

Housing Instability and Insecurity

Housing instability is a situation where a low-income renter is unable to make rent payments, or is paying a large percentage (>30%) of their monthly income on rent. In the US, 47% of renters are cost-burdened where they pay 30% or more of their income on housing (Harvard JCHS, 2018). High housing costs make it difficult for a household to afford other necessary goods such as healthy foods, health-related expenses, and other physiological and health necessities. Housing instability issues contribute to other social determinants such as food insecurity.

Housing instability is linked to chronic disease through the association it has with negative health behaviors and other social risk factors that are causally linked to the formation of chronic illness.

In a study of Washington State BRFSS data, housing instability was associated with several key negative health behaviors that are known to increase the risk for chronic disease (Stahre, VanEenwyk, Siegel, & Njai, 2015). Among people reporting housing insecurity, 33% reported delaying physician visits, 26.9% smoked, and 26% had poor self-reported health (Stahre et al., 2015). Housing insecure individuals were more likely to be smokers and six times more likely to delay a physician’s visit due to cost than individuals not experiencing housing insecurity (Stahre et al., 2015). Similarly, in a study by Raven et al, high-risk patients with chronic illness were identified during a hospitalization where interviews were conducted to understand patient socioeconomic conditions (Raven, Billings, Goldfrank, Manheimer, & Gourevitch, 2009). In the study, researchers found that of the patients in the study 60% were homeless or “precariously housed” and 68% had more than one chronic condition. These patients frequented the ER as their primary point of care and cost the system $39,000 to $84,040 annually on average (Raven et al., 2009).

There exists a clear pathway leading from housing instability to increased expenditures for Medicaid programs, thus it is imperative that agencies develop programs designed to address these important factors that lead to chronic disease and higher health expenditures.

Housing Condition and Environment

In addition to housing insecurity, evidence suggests that housing quality and the physical environment also affect the health status of an individual. In particular, Asthma is a chronic condition where the environment has a great deal of bearing on patient outcomes (Northridge, Ramirez, Stingone, & Claudio, 2010). Asthma has high prevalence throughout the United States and contributes to high healthcare spending. Due to the large proportion of children in Medicaid, who are particularly susceptible to environmental asthmatic irritants, asthma is an excellent example of a condition that would benefit from housing-related interventions(Northridge et al., 2010). In a study by Northridge and colleagues looking at asthma and housing quality in New York, the highest prevalence of asthma was found in public housing (2010). The presence of rats, cockroaches, and water leaks leading to mold were all independently associated with higher rates of asthma (Northridge et al., 2010). 68.7% of public housing residents reported at least one of these factors (Northridge et al., 2010). This study, and many others like it, indicate the link between housing quality and asthma. Due to the high cost of inpatient and emergency services, both of which asthmatic patients seek out after exacerbation of their condition, it is important that Medicaid agencies recognize the role that housing quality plays in conditions like asthma. Successful programs have been created to improve housing quality through the use of Medicaid funding, such as in North Carolina.

Medicaid Program Regulations and Waiver Authority

Under traditional Federal Medicaid regulations, the inclusion of housing as a clinical intervention is prohibited i.e. the direct use of funds to provide housing is not currently allowed. The use of federal match funds to pay for or to subsidize an individual’s housing is not legal (Paradise & Cohen, 2017).

The Center for Medicare and Medicaid Services (CMS) allows the incorporation of housing-related interventions into Medicaid through several types of programs that are specific to activities related to individual care and state-level development (Paradise & Cohen, 2017). The use of Medicaid funds is permitted for programs designed to help individuals identify barriers to housing stability, creating a housing plan, and the payment of one-time move-in fees. Funds can also be incorporated into programs that help individuals remain in housing, resolve landlord disputes, and that provide general tenant education services (Paradise & Cohen, 2017).

At the state level, traditional Medicaid program regulations allow for the development of relationships with community partners and for shared planning and collaboration (Paradise & Cohen, 2017). While traditional Medicaid payment regulations are inhibitory to more direct and robust housing intervention programs, there exist several options to utilize waiver authority and new alternative payment models (APMs) to develop innovative programs that address housing insecurity and quality issues for enrollees.

The following are available policy mechanisms to build such programs:

Section 1915 Waiver Authority

The Medicaid Home and Community-based Services (HCBS) program under the 1915 waiver allows programs to address patients with specialized health care needs at the location of their home. The HCBS program is designed for specific diagnoses that contribute to high healthcare utilization and cost, such as high prevalence chronic conditions like diabetes and congestive heart failure. The program components provide a model for integrating the social determinants of health through the required person-centered plans of care while also ensuring the protection of health and welfare of those covered by the waiver.

Program requirements include support for medical as well as a range of non-medical services such as providing meals, or housing-related interventions (Daniel-Robinson & Moore, 2019). The major functional benefit from this program is the direct access health providers have to the individual in their place of living to perform assessments and services. Access to patients outside of the controlled environment of the health system is a major advantage when it comes to addressing social and behavioral factors (Daniel-Robinson & Moore, 2019). Due to the frequency of the provision of services in the home, there is an opportunity to address housing-environment issues as well as other social determinants. Under the waiver, states may cover housing, tenancy support, and employment-related services for those with certain disabilities or medical conditions (Lipson, 2017). These waivers utilized by states to implement home and community-based services have demonstrated savings to the Medicaid program by reductions in readmissions, emergency department visits, and nursing home care (Centers for Medicare and Medicaid Services, 2019). Section 1915 waiver authority is often utilized for programs taking care of disabled and homebound individuals that contribute to a large percentage of healthcare spending. Incorporating housing-related programs into a 1915 waiver program is permissible and allows for flexibility unafforded by traditional Medicaid program requirements.

Section 1115 Waiver Authority

The Section 1115 waiver authority is a federal Medicaid waiver allowing states to experiment with different payment and delivery models with the flexibility to conduct pilots and demonstration projects tailored to optimize the delivery of care within the state (Hinton, Musumeci, Rudowitz, Antonisse, & Hall, 2019). The 1115 waiver is a very flexible program waiver that requires federal budget neutrality (Hinton et al., 2019). Delivery System Reform Incentive Payment programs, authorized under Section 1115 authority, provide a policy lever for state Medicaid agencies to innovate care delivery and payment linking improvements in health outcomes to the structural program changes. These program changes can include interventions for housing instability and quality. States have used the 1115 waiver to implement a wide variety of programs. The Section 1115 waivers in states such as Kansas, Massachusetts, New Jersey, Oregon, New York, and Texas funded programs that enhance coordination between the health system and social services (such as housing authorities), including support services and housing (Guyer, Shine, Rudowitz, & Gates, n.d.). 1115 waiver programs in states such as Minnesota, Vermont, and Oregon have been used to transform the delivery and payment systems to encourage care coordination and facilitate incentives that encourage HCO’s to work with community-based organizations and social supports (Longyear, 2019). These new payment incentives help incentivize health systems to take a more proactive approach to their service lines (Longyear, 2019).

Alternative Payment Models and AHCs

The Accountable Health Community (AHC) model was designed by the Center for Medicare and Medicaid Innovation (CMMI) to help integrate community resources into the health system while promoting accountability in the health system (Center for Medicare and Medicaid Services, 2017). As Medicaid agencies seek to increase the value of care, accountable care communities were promoted by the Centers for Medicare and Medicaid Services (CMS) as an approach to address the gap in coverage and services between social/community resources and clinical care (Alley, Asomugha, Conway, & Sanghavi, 2016). A five-year investment allowed for the scaling of new all-payer delivery system reform efforts that incorporated community-based interventions that demonstrated promise in health care cost and quality outcomes. To support the implementation of the AHC program, CMMI developed the Accountable Health Communities Core Health-Related Social Needs (AHC-HRSN) screening tool to collect information on SDOH — transportation, housing instability, utility assistance, food insecurity, and interpersonal violence-related questions (Center for Medicare and Medicaid Services, 2017). The collection of data surrounding SDOH is a crucial first step to begin systematically addressing the various factors affecting health status. Screening tools such as AHC-HRSN are excellent methods for incorporating SDOH into electronic-health record systems to develop both aggregate and individual level SDOH-related information (Center for Medicare and Medicaid Services, 2017).

Information Collection and Exchange

The first key step to begin addressing the social determinants of health, from a health system perspective, is information collection. Information is crucial to both understand the prevalence of the disparities and to identify patients for intervention once it is implemented (Longyear, 2019; Longyear, Adams, Moore 2020). Data collection, during program implementation, is also necessary to facilitate the intervention into housing insecurity through the health system due to the need for program evaluation to determine savings and quality outcomes. The health system has three primary methods to begin a robust collection of social data, such as housing insecurity and quality issues.

At the individual provider level, there exist surveys and screening tools that can identify an individual with housing needs. The Accountable Health Communities Health-related Social Needs Screening Tool (AHC HRSN) is one such tool that can be utilized to understand patient social needs such as housing (Center for Medicare and Medicaid Services, 2017). The survey asks questions about both housing security and housing conditions. This tool can be used to identify patients that may benefit from housing interventions. Incorporating this survey into electronic health records (EHRs) would allow for the aggregative study of a system’s housing-related problems as well as entering the clinically relevant patient information into a patient’s medical history. Once this is tracked, housing-related programs and community-based partnerships can easily identify the patient for inclusion in the program.

Not only is it necessary for individual providers and health organizations to identify individual patients, but the aggregate population-based data is required to develop long-term housing planning and community-based programs. For the calculation of alternative payment models, expenditure data, and program evaluations, it is necessary to enter the housing-related diagnosis information into the administrative claims data. There exist ICD-10 Z-codes that can be used to identify patients in the administrative claims data as having a condition related to housing insecurity (Daniel-Robinson & Moore, 2019). Once in the claims data, the social factors can be linked to utilization and cost as well as to diagnosis-related groupings. These codes can be utilized by larger health organizations and health insurers to develop partnerships, identify patients who may require case management, and inform program development as well as to enable program evaluations looking at savings and outcomes as both clinical and payment data is interoperable once entered into claims.

For early-stage programs looking to address housing-related social determinants of health, data collection and measurement are crucial early steps. The utilization of ICD-10 Z codes, evidence-based screening tools, and integrated data sets can provide a basis to develop programs designed to address housing-related issues that contribute to significant chronic health problems.

Policy and Program Solution Examples

1. North Carolina Department of Health and Human Services

The North Carolina Department of Health and Human Services is implementing a major health system transformation that supports chronic disease management through the movement from Medicaid fee-for-service to managed care as well as through innovative programs looking to address the upstream factors of health. One such feature is enhanced care management that will provide Medicaid enrollees with access to programs and services that address their social needs (North Carolina Department of Health and Human Services, 2018b). To reach that goal, MCOs are required to adopt standardized social needs screening as part of their care management programs (North Carolina Department of Health and Human Services, 2018b). Standardized universal screenings will be required to occur within 90 days of enrollment and will assess food, housing instability and quality, transportation, and interpersonal safety (North Carolina Department of Health and Human Services, 2018b, 2018a). This information will be shared with enrollees’ primary care providers or PHPs. Once the data is collected and individuals are identified they can be referred to additional programs under development. Health insurers or managed-care organizations (MCOs) will be required to provide home-based assistance to enrollees requiring connection to community social resources like tenant services and legal assistance with housing issues (North Carolina Department of Health and Human Services, 2018a). To support efforts to utilize enrollee social information, North Carolina is developing a centralized information system that will be available to both the health system and outside community-based organizations (Daniel-Robinson & Moore, 2019). This data system and intentional screening for SDOH factors is essential to programs looking to develop their capabilities in addressing upstream factors of disease.

North Carolina is also looking to directly address housing quality issues with respect to asthma. The clinical case presented by North Carolina is summarized as follows: A child on Medicaid with asthma is identified as repeatedly visiting the emergency department (ED) because of asthma attacks brought on by an apartment’s moldy carpet or broken air conditioner. Once identified in the ED, the child can then be enrolled in the North Carolina Healthy Opportunities Pilot. Pilot funds can be used to replace carpets or fix an air conditioner, thus removing environmental factors leading to the formation and exacerbation of the condition (North Carolina Department of Health and Human Services, 2018a).

Program Outcome Evaluation

This program is currently being implemented and has not generated any outcomes evaluations at this time.

Analysis

North Carolina is utilizing several policy mechanisms to accomplish their large system reform goals. The centerpiece of the program is the shift from traditional Medicaid fee-for-service payment mechanisms to the use of a managed care-based reform where MCOs are at risk for care management and must comply with NC program requirements. In this, the state utilizes managed care regulatory authority to design system reform. The state also pursued an 1115 waiver to implement programs like the Healthy Opportunities Pilot, to help implement their data system requirements, and to help with the transition to a managed care-based capitated payment system. North Carolina is taking the data collection steps necessary to implement its early programs as well as those necessary to continue to build additional functionality in the future. As well as developing a program to address housing quality issues.

2. United Health Group

Beginning in 2011, United Health Group (UHG) began working with leading affordable housing advocates to invest in developments in healthcare and social services (United Health Group, 2019). The collaboration lead to programs that help connect low-income enrollees with social supports in their communities. As the program developed, UHG began studying their own Medicaid enrollee data across the country and found that enrollees with stable housing experience more effective care management and health outcomes (2019). Since 2011, UHG has invested ~$400 million in 80 affordable communities resulting over 4500 new homes for Medicaid enrollees (UHG, 2019). Specifically, UHG has prioritized investment into new communities that include on-site services such as clinical healthcare, social counseling, job training, and childcare (UHG, 2019). The housing is specifically aimed at high-risk populations such as homeless individuals, persons experiencing housing instability, military veterans, seniors, and those with SMI (UHG, 2019). This integrated and direct investment approach has yielded significant savings for UHG and has improve health outcomes.

Program Outcome Evaluation

UHG reports outcomes from one state program where individuals with housing support saw 60% fewer emergency department visits and a 50% reduction in the total cost of care (UHG, 2019).

Analysis

Due to UHG’s status as a corporation, they have more flexibility in the allocation of funds directly to housing. This case study provides an example of the benefits derived from direct investment into housing and the effect on healthcare outcomes. Under 1115 waiver authority, it is possible to develop programs that make similar direct investments into affordable housing for high-risk Medicaid enrollees, but the process is not as simple as those available to private and public corporations. UHG not only directly provides affordable housing options, but also works to help coordinate the care of high-risk individuals to help them find social support and housing if they are ineligible for a direct housing option. UHG was able to determine the return on investment for such a direct investment program which resulted in a 50% reduction to the total cost of care for select individuals enrolled in a housing program. This return on investment is crucial to encourage private sector health organizations to invest in housing-related interventions.

One of the key benefits of the direct investment program is the mitigation of a key barrier to effective case management in Medicaid, communication. The most common challenge cited by Medicaid case managers is the inability to contact and follow-up with enrollees (Koch, Wakefield, & Wakefield, 2014). A stable address allows contact to be consistent and helps facilitate improved care management. UHG has recognized the significant barrier that housing instability plays in effective care management and the role it plays in health outcomes. Through this understanding, the company has developed programs to generate significant outcomes improvements and savings.

3. Arizona Mercy Maricopa Integrated Care

Mercy Maricopa is a non-profit health plan that operates in Phoenix, AZ. The plan manages the care of behavioral health patients for Medicaid-eligible individuals. The plan has a supportive housing program that is targeted at adults with serious mental illness (SMI). This population makes up 5–10 percent of their plan membership (Paradise & Cohen, 2017). Maricopa formed a program through a partnership with the City of Phoenix Housing Department and the Valley of the Sun United Way organization to form a program looking to support patients with SMI (Paradise & Cohen, 2017).

The program operates supportive housing services in 3,400 housing units. Of those units, 907 are “scattered site” units funded by Mckinney Vento Homeless Assistance grants in a partnership with HUD and 707 are subsidized by the state. Individuals are identified as eligible for the program by diagnosis with SMI, homeless status, and medical vulnerability (Paradise & Cohen, 2017). Expanding on the success seen by their SMI housing program, Maricopa created a new program, called the Comprehensive Community Health Program (CCHP), for adult plan members who do not qualify for SMI-related housing but have been identified as having a substance abuse disorder or other mental health diagnoses. CCHP, unlike the SMI program, is built on an integrated health home that provides education and support for patients (Paradise & Cohen, 2017). The program assists individuals with support for obtaining a housing voucher through the Housing Choice Voucher Program, also known as Section 8. These vouchers are contributed by the Phoenix Housing Department (275 Vouchers), United Way contributes items and services, and the Medicaid-plan itself program provides supportive housing services and employment support education (Paradise & Cohen, 2017).

Program Outcome Evaluation

The CCHP program does not have a completed program evaluation, but the SMI-based housing program shows that admissions to inpatient psychiatric facilities decreased 46% and utilization of crisis-related services decreased by a third (Paradise & Cohen, 2017). Housing-related outcomes for the program include housing retention increasing by 3% and the percent of members contributing to their rent increased by 4.2% (Paradise & Cohen, 2017).

Analysis

The CCHP and SMI programs are excellent examples of how Medicaid agencies can operate within traditional Medicaid authority to address housing-related issues. By forging partnerships at the state and community levels, Maricopa is able to address the housing instability issues of its most vulnerable and costly members. The Medicaid plan itself provides services at a value necessary to obtain HUD vouchers (Paradise & Cohen, 2017). On a smaller scale and with specific state-derived Medicaid funds, the health plan also pays directly for housing (Paradise & Cohen, 2017). The bulk of the program operates through innovative partnerships, but it does use a direct payment method with funds that are not subject to the federal match exclusion.

Key Program Requirements and Conclusion

At the most basic level, there are two major steps necessary to begin a program looking to address housing insecurity through the health system. First, data collection must precede program development and design in order to successfully measure and understand the bounds of the issue. Screening patients for clinical data inclusion and entering ICD-10 Z codes into the administrative data are the two immediate steps. Programs like North Carolina are requiring screening for all Medicaid enrollees upon enrollment (North Carolina Department of Health and Human Services, 2018b). Once identified as a major problem, identification is necessary to target patients who require the most housing support and who are most likely to benefit i.e. finding clinically high-risk enrollees who also have an associated housing issue.

Second, a program must be developed, and funding must be secured. Choosing the appropriate funding mechanism for the program’s characteristics is necessary. Some programs can work within the traditional Medicaid program requirements, while others will need to utilize a waiver or model program to source the funding for the program interventions. These are the two major conceptual steps that are necessary to begin to address housing-related issues.

There are three primary groups of housing-related interventions that can help improve enrollee housing status. First, there is the facilitation of community-based partnerships and social support wherein the health system connects patients to existing programs in their communities. Second, there is the direct facilitation of housing to individuals that experience housing instability. Third, programs also can address housing quality issues such as the asthma program utilized by North Carolina. These three primary groups of activities require different funding mechanisms due to the existing regulatory environment under the Federal Medicaid program. Fortunately, there are flexible policy vehicles that exist to develop programs such as the 1115 waiver and the 1915 waiver.

Further research is required to better understand the potential return on investment and savings derived from interventions that either connect patients to housing resources in their communities or provide a direct allocation of funds to housing as a medical intervention. Developing a strong return on the investment case for investment in housing as a medical intervention will make program development and widespread adoption of the practice more feasible. For both Medicaid agencies and HCOs that operate within a state program, it is necessary for researchers and program evaluators to make the case for the ROI that exists from programs that help Medicaid enrollees find stable housing. However, the cases presented in this policy brief have indicated significant clinical and financial outcomes and so the case for housing-related interventions through state Medicaid programs is strong.

Recommendations

Based on the current body of research and program evaluations, the following recommendations can be made to Medicaid Agencies looking to address the role that housing insecurity and quality play in the development of chronic conditions that, consequently, contribute to increased healthcare expenditures:

Early Priorities

1. Standardize screening for SDOH in state Medicaid Programs using AHC HRSN or a similar screening tool.

2. Require MCO data collection for housing insecurity and the encouragement of the use of ICD-10 Z Codes to enter the housing and SDOH data into administrative claims data.

3. Integrate housing and health data sets to improve risk scoring and program evaluation capabilities. Facilitating the interoperability of housing authority data sets with clinical sets can help facilitate program development and improve patient identification.

4. Leverage the collection of patient-specific social needs on the Medicaid enrollment form.

National Recommendations

1. Implement Alternative Payment Mechanisms for providers to connect patients to housing resources. By providing direct and bundled APMs for housing-related issues Medicaid enrollees can have funding needs met quickly.

2. Implement state-wide programs that facilitate the provision of housing through largescale and direct investment.

3. Encourage and incentivize the development of partnerships with community-based organizations addressing housing issues at all levels of health delivery.

4. Encourage change to federal law barring the match of Medicaid funds used to pay for housing support. HHS has issued statements looking to accomplish this in the near future.

5. Invest heavily in information systems that bring patient information directly to providers of care and housing supports to ensure that case managers and providers of healthcare can refer patients to programs.

Future Research

1. Develop an evidence base for the potential health care savings derived from programs providing housing support.

2. Continue to research programs to make the business case by indicating specific ROI for housing-related investment programs.

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VP Digital Health and Innovation @ Wanderly | Author of “Innovating for Wellness” | Healthcare Management and Policy @ GeorgetownU

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Robert L. Longyear III

Robert L. Longyear III

VP Digital Health and Innovation @ Wanderly | Author of “Innovating for Wellness” | Healthcare Management and Policy @ GeorgetownU

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