February 25, 2014

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View Ms. Miller's slides View Dr. Doran's slides

The discussion expanded on an article published in the New England Journal of Medicine entitled, “Housing as Health Care: New York’s Boundary-Crossing Experiment,” authored by New York State Commissioner of Health Nirav R. Shah, Kelly M. Doran, and Elizabeth J. Misa. In the article, the authors advocated for the incorporation of social determinants into policy to improve population health outcomes, while outlining New York’s Medicaid investment in supportive housing and the crucial role it plays in meeting the health needs of New York’s high-cost Medicaid members. The authors concluded with an argument in favor of a Medicaid system in which spending on social determinants of health, such as housing, should not only be allowed, but be recognized as a best practice.

Three panelists discussed this timely issue:

Elizabeth J. Misa, M.P.A., Deputy Medicaid Director, Office of Health Insurance Programs, New York State Department of Health; coauthor of “Housing as Health Care: New York’s Boundary-Crossing Experiment,” New England Journal of Medicine

Kelly M. Doran, M.D., M.H.S., Instructor, Departments of Emergency Medicine and Population Health, NYU School of Medicine/Bellevue Hospital Center; coauthor of “Housing as Health Care: New York’s Boundary-Crossing Experiment,” New England Journal of Medicine

Kristin Miller, Director, Corporation for Supportive Housing; Member, Medicaid Redesign Team Affordable Housing Workgroup

Ms. Miller opened the session with an overview of supportive housing, which is affordable, independent living, with voluntary social support services, for vulnerable populations. Numerous studies have found that supportive housing models have resulted in positive health outcomes, have decreased emergency room admissions, and have produced cost savings. The strong evidence base of improved outcomes in supportive housing models has demonstrated the importance of social determinants of health in addressing disparities; however, the affordability of improving the housing system has remained a central question.

Dr. Doran framed the issue as one that the health care system can no longer ignore. “Actually, the most appropriate question might not be how we can afford to pay for social determinants of health as a health intervention, but whether we can afford not to pay for social determinants of health as a health intervention,” said Dr. Doran. The United States spends much more on health care than other countries and much less on social services. Ms. Doran pointed out that this different ratio might not be a problem if the United States was achieving good outcomes; however it does not, and the current strategy is not working.

Ms. Misa discussed New York State’s innovative approach to addressing social determinants of health by investing State Medicaid dollars into supportive housing. The proposed budget for 2014-2015 invests $260 million over two years to provide capital for the creation of new housing units, as well as to provide rent subsidies and support services. Ms. Misa noted that matching the high-cost, high-user, chronically homeless Medicaid population “into a better setting and providing wraparound services and a rental subsidy not only greatly improves the care of those individuals, but it saves a ton of money.”

The ultimate goal, added Ms. Misa, is to continue to encourage participation from the federal government. “We have had discussions with the federal government, and they have a view that you don’t use a Medicaid dollar to pay for capital or to pay for rent, and we think that it is more cost effective if you do.” The New York State Medicaid Redesign Team Affordable Housing Workgroup has extensive tracking and evaluation plans in place to gauge the success of the program and to present the findings to the public, as well as the federal government. The workgroup hopes this data can be used to promote policy change for allowing federal Medicaid dollars to pay for interventions that address social determinants of health.

Attendees included representatives from supportive and affordable housing; academic researchers; health care providers; City and State officials; and funders. Closing comments reminded the audience that addressing social determinants of health is a timely opportunity, as health reform explores new and innovative payment systems to align payment with quality and, eventually, population health outcomes.

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