Even before passage of the Affordable Care Act (ACA), interest had been growing in developing ways to integrate affordable housing and health care for seniors, people experiencing homelessness, people with disabilities, and other vulnerable populations whose living conditions could harm their health, lead to inappropriate use of emergency department and hospital care, and increase health care spending.
To understand how health care and housing collaborations have been developed and sustained, the Urban Institute studied existing health and housing partnerships and how various delivery and payment system reforms, including several ACA provisions, may have supported them.
Our scan of housing and health care collaborations initiated between 2010 and 2015 allowed us to examine the context in which they occurred and the ways the two service areas can be integrated. Several key themes emerged in our analysis:
- States are often essential actors in developing and supporting housing and health care collaborations. State authorities and policies bridge housing assistance and health care, the latter through Medicaid program design and public health investments. Moreover, although some collaborations occur at the county, city, or provider level, most are supported by state policies or funding.
- Collaboration-provided health care services fall into one of two categories: (1) care coordination and management services only, or (2) care coordination and management services plus primary care and behavioral or mental health care.
- With few exceptions, health care entities are not making direct investments in affordable housing development or rental subsidies for participants. Rather than financing capital investments or paying rent, most collaborations provide preferential access to existing housing units, and some use Medicaid to pay for specific housing related-services the program can cover for certain beneficiaries.
- Flexible payment arrangements that encourage savings are often critical for funding housing-related services. Several programs have used accountable care organizations along with global budgets and either one-sided or two-sided risk, which may help lower costs while maintaining care quality. Others involve Medicaid managed care organizations and capitated payments that can help reimburse housing-related or other social services that can support the effectiveness of health care.
- Few of the identified collaborations had undergone an independent evaluation, but some show promising early results. Most evidence on impacts comes from self-evaluation studies. Findings available to date are encouraging, showing improvements in quality of life and reductions in health care use and costs for program participants.
- Integrating housing and health care is hard work. Challenges include reluctance of health care payers to invest in nonmedical services, obstacles to data sharing, and uncertainty about how to design benefits and budgets for care coordination and housing-related services.
Our scan suggests that most states are still in the early stages of using the ACA’s delivery system reforms to integrate housing and health care for vulnerable populations. But we also found substantial interest in health and housing collaborations, and several states and localities are close to making significant steps toward this goal.
A few collaborations described in this report were directly brought about by ACA provisions, creating incentives for states, local governments, health and housing providers, and payers to work together. But most collaborations we examined emerged out of preexisting authorities and a broad trend toward whole-person approaches to care that more effectively improve outcomes for vulnerable populations than conventional health care. That said, evidence of effectiveness of the health and housing collaborations we examined is sparse because many collaborations have not had time to demonstrate long-term outcomes.
Work remains to learn how health and housing collaborations come together, what barriers prevent other jurisdictions from adopting them, what is needed to sustain them, and how they affect individuals’ health and well-being.Through examining key features of selected collaborations, this report is a first step in identifying the mechanisms that made them successful. It also highlights opportunities to develop and sustain housing and health collaborations at different government levels and among various service providers, as well as serving various vulnerable populations.