By Stacy Collins
Associate Director, Health Systems Transformation
Of the many social determinants of health, housing stability is among the most basic and influential. Health care experts increasingly recognize the vital role that access to safe, stable, and affordable housing plays in ensuring good health for children and families. Unstable housing can contribute to the toxic stress many poor families experience and can impact an individual's entire health trajectory. Children experiencing housing instability are more likely than other children to have acute and chronic health problems and less access to medical and dental care. Conditions that require regular, uninterrupted care – such as a child's asthma or a pregnant woman's hypertension – are difficult to treat or control without stable, adequate housing. Families grappling with poverty and trauma, and living in urban areas with shrinking affordable housing stock, are particularly at risk for poor health outcomes. "Prevalence of homelessness among families" is a life course indicator, suggesting that the long-term physical and mental well-being of mothers and children can be compromised by housing instability.
Housing instability is loosely defined as experiencing difficulty paying rent, spending more than 50 percent of household income on housing, moving frequently and unpredictably, living in overcrowded conditions, or doubling up with friends and relatives. Homelessness is an extreme form of housing instability. A U.S. Department of Housing and Urban Development point-in-time measurement of homelessness in 2016 found that nearly 200,000 individuals in families with children met the definition of homeless. Millions more fit the broader definition of unstably housed.
Leveraging the power of Medicaid
As the largest single funding source for health care in the U.S., Medicaid can play a high-impact role in addressing the social determinants of health, including housing. Here are some of the ways:
Managed care contracts: States are increasingly incentivizing – and often requiring – Medicaid managed care organizations (MCOs) to address non-medical needs such as housing, which impact health care costs and outcomes. Many MCOs now provide housing support services to enrollees, including assistance with identifying short and long-term housing options, completing rental paperwork, and coordinating with local housing agencies.
Supportive housing programs: Medicaid dollars can now be used to support evidence-based interventions that combine affordable housing with comprehensive services to help people with significant health care needs maintain their housing and improve their health and well-being. In supportive housing programs, Medicaid covers the cost of case management; tenancy support; behavioral health care, including substance use treatment; primary care and other critical services. Supportive housing targets highly vulnerable populations – including mothers and children at risk for poor health outcomes – who need housing and service supports to remain stably housed and live healthy lives. Medicaid financing can promote the scaling up of evidenced-based supportive housing approaches.
The Affordable Care Act (ACA): The ACA Medicaid expansion increased the potential impact of Medicaid-housing collaborations by providing coverage to millions of uninsured low-income adults, many with supportive housing needs. Medicaid Accountable Care Organizations – created through the ACA – often partner with state public health departments, safety net providers, and housing authorities in helping homeless individuals and families secure and maintain safe and affordable housing.
More can be done to advance Medicaid solutions to housing instability for vulnerable populations. Loosening restrictions on the use of Medicaid funds for rental subsidies and affordable housing construction are two proposals. In many states, Medicaid financing for housing-related services is largely restricted to homeless adults with serious mental illness or other severe chronic conditions. Broadening eligibility to include other Medicaid populations, particularly women and families, is an additional opportunity to expand Medicaid's housing impact. Promoting Medicaid investment in promising maternal and child health(MCH) initiatives such as "Healthy Start in Housing" – a joint project of the Boston Public Health Commission and the Boston Housing Authority to help high-risk pregnant women secure and retain stable housing – is another approach worthy of exploration.
Despite the compelling business case, use of Medicaid funds to address housing instability for MCH populations has not been widely adopted. Title V professionals understand the indisputable relationship between housing and health and are well positioned to promote Medicaid investment in housing solutions to improve outcomes for women and families.