Evidence Matters Transforming Knowledge

Into Housing and Community

Development Policy

FALL 2010

WINTER 2016

Safe, stable, and affordable housing can be a platform for better health outcomes. Station Center Family Housing in Union City, Bruce Damonte/David Baker Architects

California, offers 157 affordable units, green design, walkability, and onsite recreational opportunities and services for residents.

In This Issue

Leveraging the Health-Housing Nexus

1Leveraging the

Health-Housing Nexus

Awell-established and growing body to housing.2 Housing that is expen-

of research shows that social and

sive, overcrowded, in poor physical

economic factors substantially influ-

condition, or located in a hazardous

ence individual health. According to

neighborhood environment can lead to

Smoke-Free Public Housing:

one estimate, these nonmedical factors

negative health outcomes. Conversely,

13Research and Implementation can account for up to 40 percent of safe, stable, and affordable housing all health outcomes.1 Defined by the

in an opportunity-rich neighborhood

World Health Organization as “the

with access to health services can serve

Financing Effective Housing

circumstances in which people are

as a platform for improved health

19Interventions With Pay for born, grow up, live, work, and age, and outcomes. Housing with supportive Success

the systems put in place to deal with ill-

services and home and community-

ness,” many of the social determinants

based services (HCBS) can be especially

of health relate directly or indirectly

effective for improving health and

CONTINUED ON PAGE 3

Message from the

Assistant Secretary

The federal government’s recognition of the connection between housing and health pre-

dates HUD’s existence as an agency. The United States Housing Act of 1937 created the

United States Housing Authority within the U.S. Department of Interior with a mission “to

remedy the unsafe and insanitary housing conditions and the acute shortage of decent,

safe, and sanitary dwellings for families of low income, in rural or urban communities, that

are injurious to the health, safety, and morals of the citizens of the Nation.”

When HUD became a cabinet-level agency in 1965, improving health and sanitary

housing conditions was part of its mission. Over the past five decades, the agency has

made great progress in reducing the number of Americans living in substandard housing,

and HUD’s Office of Healthy Homes and Lead Hazard Control supports a wide range of

research and grantmaking to promote health and reduce lead-based paint and other household hazards — the office’s great work can be seen throughout this issue.

In the Office of Policy Development and Research (PD&R), our evaluation of the Moving to Opportunity for Fair Housing (MTO) demonstration has been a landmark case in using research to better understand the links connecting housing and neighborhoods with health. MTO was a random assignment study designed to help very low-income families with children in public housing or Section 8 project-based housing in neighborhoods with extremely high poverty rates relocate to “opportunity neighborhoods” with vouchers and additional housing counseling services. Researchers found that 10 to 15 years after moving, adult MTO participants in the treatment group generally lived in better neighborhoods, had a lower prevalence of extreme obesity and diabetes, and had fewer self-reported physical limitations than did those in the control groups, although youth in the treatment group did not show significantly different outcomes in physical health measures. Compared with the control groups, adults in the treatment group had significantly lower levels of psychological distress, anxiety, and depression, and girls in the treatment group experienced significant positive effects on a range of mental health measures. Boys, however, fared worse on several mental health measures, including a higher prevalence of posttraumatic stress disorder.

The MTO demonstration not only taught us critical information about neighborhood mobility that informs HUD’s policies, but it also set a precedent that we should consider health outcomes whenever we do research. In the years following the report’s release, PD&R has integrated health measures into a wide range of projects and datasets.

To expand our ability to integrate health measures into housing work, HUD has pursued several data matching projects.

A particularly fruitful partnership is our recently announced linked data product with the National Center for Health Statistics (NCHS) at the U.S. Department of Health and Human Services. This NCHS-HUD data matching analysis connects data from the National Health Interview Survey and the National Health and Nutrition Examination Survey to HUD’s administrative records from its three largest housing assistance programs, which will help researchers explore interactions between housing and health and better understand the social determinants that affect health outcomes. This collaboration took a great deal of staff time and skill and will serve as a model for future efforts to integrate HUD’s data with other sources to allow more comprehensive evaluation.

Matched administrative data will be used as part of PD&R’s evaluation of the Supportive Services Demonstration for Elderly Households in HUD-Assisted Multifamily Housing Program, a recently announced and very timely topic. These grants make funding available for supportive services in Section 202 multifamily (and other federally assisted) senior housing to examine how a supportive services model can affect the ability to age in place, the transition to institutional care, and the health outcomes and health care utilization of assisted seniors. The supportive services model that will be tested in the demonstration includes a full-time enhanced service coordinator and a part-time, onsite wellness nurse. The evaluation of this demonstration will further our understanding of best practices for assisting the aging at a time when the proportion of senior Americans is growing rapidly.

These are just a few examples of the body of work that PD&R, and HUD as a whole, is building to show the critical connection between housing and health.

— Katherine M. O’Regan, Assistant Secretary for Policy Development and Research

2

Editor’s Note

Evidence Matters has always been especially interested in the intersection between housing and critical outcomes such as education, public safety, and economic opportunity. As research from the How Housing Matters initiative has shown, one of the most important of these intersections is with health; stable, safe housing is essential to the health outcomes of all people, and its absence can be particularly damaging to children, the elderly, low-income families, and other vulnerable populations.

This issue addresses some of the ways in which the links between health and housing are driving policymakers at all levels to develop new strategies to better serve Americans.

The lead article, “Leveraging the Health-Housing Nexus,” discusses the many connections between housing and health proven by research as well as how federal policy is aligning programs and funding in both areas to improve health outcomes. The Research Spotlight piece, “Smoke-Free Public Housing: Research and Implementation,” looks at the research basis underpinning a proposed HUD rule to eliminate smoking in all public housing units. Finally, the In Practice article,

“Financing Effective Housing Interventions With Pay for Success,” discusses several examples of interventions that aim to improve housing stability and health using the Pay for Success model, in which the organization providing services is paid only if it achieves positive outcomes.

We hope this edition of Evidence Matters provides a helpful overview of this important topic. Our next issue will focus on housing finance and credit. Please provide feedback on any of our issues at www.huduser.gov/forums.

— Rachelle Levitt, Director of Research Utilization Division CONTINUED FROM PAGE 1

for low-income children and adoles-

Highlights

cents, and poor conditions such as

the presence of lead, mold, pests, and

n Housing aspects, ranging from physical quality to neighborhood

inadequate heating or cooling adversely

conditions, affect health in multiple ways, and research has established

affect physical health.4 Environmental

links between housing and a range of health outcomes.

conditions such as clutter, loose rugs,

n Targeted interventions at the nexus of health and housing, such as

electrical cords, and the absence of

addressing asthma triggers and providing supportive housing to those

railings and grab bars can increase the

experiencing homelessness, can improve health outcomes while

risk of falls, especially for older people.5

reducing long-term healthcare expenditures.

Although the physical quality of the

nation’s housing stock has improved

n The Patient Protection and Affordable Care Act has created new

substantially over the past several

opportunities to combine housing and health funds and test new coordinated

decades, a small but significant stock of

models of care.

severely inadequate housing remains,

affecting approximately a half-million

households.6 Physically inadequate

reducing the number of high-cost visits

The Housing Determinants housing disproportionately affects poor

to emergency departments for health

of Health

and minority children.7

services as well as reducing the need for

Various aspects of housing, ranging

institutional care among seniors and

from the physical quality of a home

A lack of affordable housing stock contrib-

people with disabilities, including those

to the conditions of the surrounding

utes to overcrowding, housing instability,

experiencing chronic homelessness.

neighborhood, affect residents’ health.

and homelessness.8 A lack of privacy

Recent changes in healthcare policy,

Among the social determinants of

and control, noise, overstimulation, and

many of them associated with the

health, housing is a key lever.3 A robust

other conditions related to overcrowding

Patient Protection and Affordable Care

body of research has established links

can cause psychological distress. In 2012,

Act (ACA), have opened up new oppor-

between health and housing. For ex-

14 percent of children lived in over-

tunities to use housing as a platform to

ample, Coley et al. find that the physical

crowded conditions. As with inadequate

achieve desirable health and fiscal out-

quality of housing is a strong predictor

physical conditions, poor and minority

comes, although some challenges remain.

of emotional and behavioral problems

children are disproportionately affected

3

Brian Rose

Lower housing cost burdens can give families greater flexibility to spend on healthy food and health services. Armstrong Townhomes, developed by BRIDGE Housing, offers 124

housing units in the high-cost housing market of San Francisco.

by overcrowded housing.9 Increased

The relationship between housing

preventive, and low-cost care inter-

stress and a lack of adequate sleep can

affordability and health outcomes is

ventions at the nexus of health and

negatively affect mental and behavioral

complex. On one hand, high housing

housing. Home modifications such

health.10 Overcrowded housing may also costs may reduce the amount of money

as installing grab bars in a shower,

increase the transmission of infectious

available for residents to spend on food

for example, can prevent falls, and

diseases.11 An insufficient supply of af-

or health services. On the other hand,

interventions such as mold remedia-

fordable housing limits residents’ ability higher-priced housing in an area with

tion reduce asthma. Evidence shows

to live in neighborhoods with beneficial

beneficial neighborhood effects can

that these and similar investments that

health effects and limits the stock available

improve residents’ health.14 Research

target housing-related social deter-

for conversion to permanent supportive

shows that high-quality neighborhoods

minants of health not only improve

housing. The lack of affordable hous-

reduce residents’ exposure to envi-

health outcomes but also reduce

ing that meets the needs of people with

ronmental toxins and stressors such as

health expenditures. The potential

disabilities in community settings, in

crime. High-quality neighborhoods

for gains is especially high for certain

particular, restricts fulfillment of the

can also offer better access to health-

subpopulations — children, seniors,

Olmstead mandate — a 1999 Supreme

related resources such as services,

low-income households, individuals

Court decision that requires public enti-

healthy food, medicine, and recreational

with disabilities, and individuals ex-

ties to provide the least restrictive care

opportunities.15

periencing homelessness — particularly

settings for persons with disabilities.12

those with complex health and social

Homelessness causes new physical and

The Housing-Health

issues who frequently use emergency

mental health problems and makes

Opportunity

departments and hospitals. This small,

existing problems worse. In addition to

Because the evidence supporting a

high-cost population has a dispropor-

stress, living on the street or in shelters

connection between housing-related

tionate impact on public spending.

can increase exposure to communicable

factors and resident health is so com-

For example, 5 percent of Medicaid-

diseases, malnutrition, and harmful

pelling, considerable potential exists

only enrollees accounted for nearly

weather conditions and make accessing

to both improve health and reduce

half of all spending for Medicaid-

or managing medicine difficult.13

healthcare costs through targeted,

only enrollees each year from 2009 to

4

2011.16 The opportunity to leverage

services and promote better health. In a

population to use an emergency depart-

strategic investments into public

groundbreaking 2002 study, Culhane et

ment at least once a year.24

savings is apparent. As Khadduri and

al. report that a supportive housing

Locke write, “[t]he combination

intervention in New York City between

For seniors and persons with disabilities

— and coordination — of housing,

1989 and 1997 reduced the utilization

in institutional long-term care, transi-

health care, and supportive services, if

of public services such as shelters,

tioning to home and community-based

effectively delivered and well targeted,

hospitals, and correctional facilities, with

settings not only satisfies the Olmstead

can help to achieve savings in health

a corresponding savings of $16,281 per

mandate but also is cost effective and

care expenditures, which are major

housing unit at $17,277 annually for a

the preference of many seniors. Re-

drivers in federal deficit projections.”17

net cost of $995.21 A more recent study

search shows evidence of cost savings

by Larimer et al. of a Housing First

from using HCBS rather than institutional

Within the literature connecting

intervention in Seattle for individuals

long-term care both on a per-person basis

housing and health, several studies

experiencing chronic homelessness

and, over the long term, at the state level.25

point to areas ripe for targeted inter-

and severe alcohol problems finds that

Environmental modifications can

ventions and investments to improve

the intervention, which offered partici-

reduce health risks for seniors aging in

health for various subpopulations.

pants housing and access to voluntary

their homes. Studies show that environ-

Research shows, for example, that

case management and onsite services,

mental assessments and modifications

multicomponent home interventions

reduced alcohol consumption as well

coupled with education and followup

aimed at addressing triggers such as

as total costs compared with control

reduces falls among older persons;

mold, rodents, cockroaches, and dust

groups after 6 months, with monthly

interventions that also add exercise and

mites are effective at reducing asthma

costs averaging $2,449 per person.22

vision management are particularly

symptoms among children and adoles-

Research has also found that case

effective.26 The Centers for Disease Con-

cents. In addition to improved health,

management, along with coordinated

trol and Prevention estimates that in

successful asthma interventions prom-

care, are effective in reducing hospi-

2013, falls caused $34 billion in direct

ise to decrease the estimated 500,000

talizations and emergency department

medical costs, indicating that reducing

hospitalizations, 1.8 million emergency

visits by chronically ill adults experiencing

falls could reap substantial savings.27

department visits, 12.3 million physi-

homelessness.23 Many individuals experi-

cian office visits, and 10.5 million

encing chronic homelessness are also

Finally, research has shown health ben-

school days missed each year, all of

high-cost, frequent users of health and

efits for low-income people who move

which amount to an estimated annual

emergency services for whom sup-

from high-poverty to low-poverty neigh-

cost of $56 billion in medical expenses

portive housing could be an important

borhoods. An evaluation of the Moving

and lost productivity.18 Lead abatement

health intervention. Individuals expe-

to Opportunity for Fair Housing Demon-

has also proven to be an effective

riencing homelessness are three times

stration Program, for example, finds that

investment with considerable impact;

more likely than those in the general

women who moved into lower-poverty

nationwide, the number of children with

lead poisoning dropped by approxi-

mately 75 percent from 1992 to 2012.19

Despite this remarkable progress, there

is still room for additional gains, par-

ticularly among low-income children.

The American Healthy Homes Survey

finds that an estimated 22 percent of

homes have one or more lead-based

paint hazards and that low-income

households have a higher prevalence

of such hazards.20

Research suggests that supportive

housing is an effective intervention

for individuals experiencing chronic

homelessness. Several studies find

evidence that Housing First and perma-

nent supportive housing interventions

Photo by Andre Chung

A GHHI hazard reduction worker paints a new lead-free window frame. Although much progress has been for people experiencing homelessness

made toward reducing instances of lead poisoning, an estimated 22 percent of homes have one or more reduce the use of expensive healthcare

lead-based paint hazards.

5

eligible to receive Medicaid, expand-

ing the number of opportunities to

fund supportive housing. Before ACA,

Medicaid eligibility included pregnant

women and children under 6 years of

age with household incomes below 138

percent of the federal poverty level,

children 6 to 18 years of age at or below

100 percent of the federal poverty level

through the Children’s Health Insur-

ance Program, and disabled adults 65

years of age and older. As interpreted

by the U.S. Supreme Court, ACA allows

states to voluntarily expand eligibil-

ity to all individuals under age 65

with household incomes at or below

133 percent of the federal poverty level.32

As of September 1, 2015, 30 states and

April Saul, courtesy of the Camden Coalition of Healthcare Providers

Kenneth, the first of 50 new residents, looks on as movers prepare his unit at the Heights of Collingswood the District of Columbia have opted to

apartments in Collingswood, New Jersey. Led by the Camden Coalition of Healthcare Providers, Heights of expand Medicaid eligibility and 20 have

Collingswood offers permanent housing and wraparound support services to individuals experiencing chronic homelessness with high-cost medical conditions.

not.33 Notably, this expansion opens

Medicaid eligibility to many of the

neighborhoods were less likely to be

social determinants of health builds on

approximately 83,000 individuals and

obese and have diabetes, and women

lessons learned from the Money Fol-

13,000 members of families with children

and girls who moved into lower-poverty lows the Person (MFP) Demonstration

experiencing chronic homelessness on

neighborhoods were less likely to have

program, Real Choice Systems Change

a given night nationwide.34

psychological distress and depression

Grants for Community Living program,

compared with the control group.28

and Section 1915(c) HCBS waivers.

Newly Eligible Providers. The Centers

Researchers find that under MFP, states

for Medicare & Medicaid Services

The Changing Health

that employed housing specialists were

(CMS) has also issued rule changes that

Policy Landscape

more successful at transitioning people

authorize Medicaid reimbursement

Recent changes in health policy have

from institutional to community-based

to nonmedical providers of services

created new avenues for capitalizing on

care than those that did not offer such

recommended by doctors or other

the housing-health opportunity. Signed

services.29 The Real Choice Systems

licensed practitioners (previously, only

into law in 2010, the Patient Protection

Change program helped states forge

the doctors or licensed practitioners

and Affordable Care Act (ACA) re-

and strengthen partnerships between

themselves could be reimbursed for

shaped the context for investments and

Medicaid agencies and housing orga-

providing services). The rule change is

interventions that leverage housing as a

nizations to leverage non-Medicaid

aimed at encouraging patients to use

platform for improved health and fiscal

funding sources for supportive housing;

preventive services. CMS character-

outcomes. ACA places renewed empha-

after all, having the ability to offer ad-

izes the change as “another tool for

sis on preventive, integrated, and holistic

ditional supportive services means little

states to leverage in ensuring robust

care and on the social determinants of

if the supply of housing to be coupled

provision of services designed to assist

health. More specifically, ACA opens

with these services is insufficient.30

beneficiaries in maintaining a healthy

new opportunities at the intersection

Finally, Section 1915(c) HCBS waivers

lifestyle and avoiding unnecessary

of health and housing by extending Med-

allowed states to experiment with of-

healthcare costs.”35 Janet Viveiros of the

icaid coverage to previously ineligible

fering medical and supportive services

National Housing Conference writes

individuals, expanding the types of

in home and community settings to

that although the rule change does not

providers eligible for Medicaid reimburse-

people needing institutional-level care.

authorize activities such as environmen-

ment, and authorizing new coordinated

Such waivers remain important for giv-

tal abatement, it does “[open] up more

models of care under Medicaid and

ing states the flexibility to experiment,

opportunity for activities that address

enhancing existing models.

but ACA has now designated several care hazards in homes through assessments

models that no longer require waivers.31

of asthma and lead poisoning risk in

ACA’s emphasis on facilitating com-

individual homes and the provision of ed-

munity integration and attention to

Expanded Coverage. ACA has dramatically

ucational materials to families about risks,

holistic approaches that address the

increased the number of individuals

treatments, and remediation options.”36

6

New Incentives and Requirements. ACA

regulations direct hospitals to “address

older adults who need long-term services

introduces incentives and penalties

social, behavioral, and environmental

and supports, and those experiencing

that encourage healthcare providers

factors that influence health in the

chronic homelessness. The authorized

to attend to the social determinants of

community.”40 Nonprofit hospitals are

activities fall into three general categories:

health. The Hospital Readmissions Re-

also required to conduct community

individual housing transition services

duction Program, for example, reduces

benefit activities. The Catholic Health

(tenant screening, support to address

payments to hospitals with excess read-

Association of the United States, the As-

tenancy barriers, assistance with hous-

missions of patients within 30 days of

sociation of American Medical Colleges,

ing searches and applications, move-in

discharge for designated conditions.37

and the American Hospital Association

assistance), individual housing and

Unstable housing is one of many factors

are pressing the Internal Revenue Service

tenancy-sustaining services (coaching,

that increase the risk of readmission,

to recognize housing as a community

training, support, and interventions to

which motivates hospitals to work with

benefit activity, arguing that “[i]t has

maintain tenancy), and state-level col-

supportive housing providers.38 Under

been demonstrated that providing

laborative activities related to housing

ACA, tax-exempt nonprofit hospitals

access to safe, quality and affordable

(state agencies partnering with and pro-

are required to conduct a community

housing can have a greater impact on

viding data to housing agencies to plan

health needs assessment every three

the health of a community than more

for housing opportunities for Medicaid

years and adopt an annually updated

traditional clinical modalities.”41

populations).42

implementation strategy that addresses

barriers to care and community health.

Newly Authorized Housing-Related Activities.

New Care Models and Initiatives. ACA

The regulations governing community

ACA has allowed Medicaid greater

endorses and encourages models of

health needs assessments encourage

flexibility to cover supportive services

care that emphasize holistic, preven-

collaboration between a community’s

that could be coupled with housing.

tive measures that address the social

hospitals and public health agencies,

CMS issued guidance to clarify which

determinants of health. Some of these

both in preparing the assessment and

housing-related services can be reim-

models have the potential to incorpo-

in planning its implementation.39 The

bursed for individuals with disabilities,

rate housing-related activities or provide

Domus Development

Garden Village in Sacramento, California, is the first property in the nation built under HUD’s Section 811 Project Rental Assistance Program. Section 811 provides funding to develop and subsidize rental housing with access to supportive services for very low- and extremely low-income adults with disabilities.

7

the services of a supportive housing

to social services. Health homes, however,

statewide. The 15 states that had health

unit or building. Among these new

are designed specifically for people

homes in place as of August 2014 vary in

or enhanced models and initiatives

with chronic illnesses, and states can

the populations they target and in their

are Accountable Care Organizations

choose to target specific subpopula-

payment systems, but their programs

(ACOs), health homes, community

tions. Target populations must meet at

have generally included people with

benefit requirements and community

least one of three eligibility require-

mental illness and have used a per-

health needs assessments for hospitals,

ments: having a serious mental illness,

member, per-month rate.48 As with other

the Community First Choice (CFC)

having two or more chronic conditions,

Medicaid programs, funding for health

Option, and the HCBS State Plan Op-

or having one chronic condition and

homes cannot be used directly for

tion.43 HUD’s Section 811 Project Rental

being at risk of a second. Wisconsin, for

housing, but the target populations are

Assistance Demonstration program,

example, chose to use health homes

likely to overlap with those served by

authorized by the Frank Melville Support-

in four counties to serve individuals

affordable housing programs. The oppor-

ive Housing Investment Act of 2010, also

with HIV/AIDS who either have one

tunity exists for health home providers

creates opportunities for collaboration to

other chronic condition or are at risk

to partner with other organizations for

expand the supply of supportive housing.

of another.47 CMS increased the Federal

activities such as enrollment outreach

Medical Assistance Percentages (the

and referrals to housing providers.49

The ACA recognized ACOs for Medi-

rates used to calculate matching funds)

States can decide what types of provid-

care patients and authorized a pediatric

for the first two years of the program to

ers can serve as a health home (such

ACO demonstration for patients partici-

encourage states to adopt the model.

as community mental health centers

pating in Medicaid and the Children’s

Health homes do not have to be offered

and physicians’ offices). The National

Health Insurance Program. Several

states have begun experimenting with

ACOs for Medicaid populations. ACOs

are voluntary networks of providers that

coordinate care from various providers

and share the risk and savings associ-

ated with the total cost of care for their

patient population. Coordination breaks

down silos of provider types and reduces

the duplication of services and expen-

ditures. ACOs use metrics to evaluate

the quality of patient care and receive

bonuses for meeting quality standards

or meeting savings benchmarks.44 The

12 states with Medicaid ACOs have used

a variety of payment systems. Although

all Medicaid ACO-model programs have

the same basic structure, they are known

by other names in some states; for ex-

ample, they are called Coordinated Care

Organizations in Oregon and Regional

Care Collaborative Organizations in

Colorado.45 Viveiros suggests that ACOs

have a strong incentive to partner with

organizations that can address the social

determinants of health such as housing

providers, which can offer nonmedical

services such as hospital discharge plan-

ning and can help residents enroll in

Medicaid or an ACO.46

Like ACOs, health homes involve one or

more healthcare providers or a managed

care organization that will coordinate

Photo by Andre Chung

care for an individual, including referrals

GHHI works to improve health by facilitating collaborative efforts to identify and remediate home health hazards.

8

Alliance to End Homelessness points

be placed in a Psychiatric Residential

10,000 members. The ACO is the

out that behavioral health agencies that

Treatment Facility, inpatient hospital,

default assignment for Medicaid enroll-

already fund supportive housing could

or therapeutic group home.54

ees in the county who do not select an

integrate health homes into their opera-

alternative health plan. Community

tions, leveraging their experience with

HUD’s Section 811 Project Rental

health workers coordinate care and

and connection to supportive housing

Assistance Demonstration program

services that address the social deter-

to benefit individuals with serious men-

likewise seeks to expand opportunities

minants of health. Services include job

tal illness or chronic conditions who are

for individuals to receive needed care

placement supports, case management,

experiencing homelessness.50

outside of costly institutional settings.

and housing navigation.58 Hennepin

The program leverages affordable

Health receives a per-member, per-

Five states to date have received approval

housing resources such as low-income

month payment regardless of the

to offer a Community First Choice (CFC)

housing tax credits to increase the sup-

services utilized by members as well as a

Option in their state plans. The CFC

ply of supportive housing units. HUD

share of any overall savings. As a result,

Option, authorized by ACA and added to awards funds to state housing agen-

the ACO has an incentive to avoid un-

the Social Security Act as Section 1915(k), cies that then collaborate with state

necessary and expensive care. Because

reimburses person-centered HCBS such

health agencies to create supportive

the housing situation of many Henne-

as assistance with activities of daily living

housing.55 The first property in the

pin Health members is precarious — 30

and health-related tasks. The option is

nation to implement Section 811

to 50 percent are homeless, living in

part of an effort to rebalance Medicaid

Project Rental Assistance was Garden

a shelter, or experiencing other hous-

spending on long-term services and

Village in Sacramento, California.

ing instability — Hennepin Health

supports. States can also reimburse costs

Through a collaborative effort among

uses existing contracts that the county’s

associated with transitioning out of insti-

the state’s Housing Finance Agency,

Human Services and Public Health De-

tutional care, including security deposits

Department of Housing and Com-

partment has with housing providers to

and first month’s rent. CFC Option plans munity Development, Department of

give Hennepin Health members priority

must be offered statewide.51 Oregon’s K

Health Care Services, Department of

admission to supportive housing. The ACO

Plan provides assistance with daily living

Developmental Services, and Tax Credit

also employs staff members to provide

activities through an agency-provider

Allocation Committee, along with local

housing counseling and navigation

model in which the state contracts with

partner Domus Development, Garden

services along with other social services

providers. Individuals eligible for

Village offers supportive housing units

that might affect members’ ability to

nursing facility services and needing

for 11 extremely low-income people

remain housed. Viveiros notes that not

an institutional level of care as well as

with disabilities.56 The residents were

enough affordable housing is available

those who have an income at or below

referred by California Community Transi-

to meet the needs of all Hennepin

150 percent of the federal poverty level

tion coordinators or the Department

Health members.59 The early results for

who need an institutional level of care

of Developmental Services Regional

Hennepin Health have been promising;

are eligible. In addition to personal

Center to transition out of an institu-

emergency department and inpatient

assistance, the plan allows expendi-

tional care setting.57

admissions decreased from the ACO’s

tures of up to $5,000 per modification

first to second years, and an overwhelm-

for environmental modifications that

Implementation

ing majority of enrollees indicated that

substitute for human assistance and

State health and housing agencies have

they were satisfied with the quality of

that are related to the person-centered

a growing number of options and oppor-

their care experience.60

plan; the plan will also allow expendi-

tunities to meet the needs of residents,

tures for transition costs, including first

and they have considerable flexibility

In New York, the state’s Medicaid

month’s rent and utilities.52

in choosing which programs to imple-

Redesign Team has identified invest-

ment. Building on Minnesota’s recent

ment in supportive housing as a critical

Under the 1915(i) HCBS State Plan

history of healthcare innovation, four

lever for improving housing and health

Option, states can choose to target a

Hennepin County organizations — the

outcomes as well as realizing Medicaid

specific population — a group with

county’s Human Services and Public

cost savings. The team recommended

either certain risk factors or a particu-

Health Department, the Hennepin

allocating funds for capital investment

lar disease.53 The state of Montana,

County Medical Center, Metropolitan

to create supportive housing units,

for example, opted to target HCBS

Health Plan, and NorthPoint Health

operating expenses, rent subsidies, and

benefits to youth with a serious emo-

and Wellness Center — participate

supportive services with the aim of tar-

tional disturbance who are also eligible

in an ACO called Hennepin Health.

geting patients with high and modifiable

for Medicaid. The program provides

Hennepin Health integrates physical

costs.61 The state requested authorization

mental health services in a community

and mental health, social, and claims

to reinvest a share of projected Medic-

setting for youth who might otherwise

processing services for approximately

aid cost savings into supportive housing

9

capital and operating costs, but CMS

paying for service coordination and

new opportunities. Even if Medicaid

rejected the proposal on the grounds

other activities that Medicaid covers.63

paid for all of the supportive services

that Medicaid is prohibited by law

HUD, for example, pays more than

for which it is permitted to pay, the

from paying for housing. New York has

$400 million per year for services for

limited supply of affordable housing

instead invested state funds to construct

individuals experiencing homelessness,

and the inadequacy of rental assistance

supportive housing units and subsidize

a large portion of which could be paid

will prevent stakeholders from provid-

rent. Jennifer Ho, HUD senior advisor

for by Medicaid.64 Managed care orga-

ing enough supportive housing to meet

for housing and services, says that the

nizations’ interest in addressing social

the need. Currently, only about one

state misdirected its energies by asking

determinants of health to improve

in four income-eligible households

CMS to do something it statutorily can-

members’ health outcomes, says Bailey, receives federal rental assistance because

not do. Instead, Ho argues, state plans

will motivate them to ensure that Medic-

of funding limitations, and similar

should focus on having Medicaid pay

aid covers more of those services so that

shortfalls exist for the other population

for all allowed services — a once-murky

housing providers can be free to invest

groups most likely to need housing

issue considerably clarified through the more in housing that ultimately will benefit with supports.67 For example, in 2011

CMS informational bulletin delineating

the care organization’s members.65

only 36 percent of income-eligible

households aged 62 and over without

children received rental assistance.68

Despite the evidence that permanent

supportive housing is a “proven,

cost-effective solution to chronic

homelessness,” the U.S. Interagency

Council on Homelessness says that

“[s]hortfalls in the most recent budget

passed by Congress have forced us to

move the national goal to end chronic

homelessness from 2015 to 2017.”69

The traditional separation of housing

and health policy presents a barrier to

coordination. Institutions and inter-

ests are entrenched, and the systems

are structured differently: Medicaid

is administered at the state level, and

housing is produced and administered

by developers and public housing

agencies, usually without coordina-

tion at the state level. Both systems are

complex, making it difficult for hous-

Corporation for Supportive Housing ing providers to navigate Medicaid and

A new supportive housing resident accesses her unit for the first time at an apartment building in New Jersey vice versa.70 Efforts to bridge these gaps,

designed to serve youth coming out of homelessness.

however, are emerging, as demonstrat-

which housing-related activities can

Challenges

ed by the Section 811 Project Rental

be covered — and maximizing federal

A growing research base and expand-

Assistance Demonstration program’s

Medicaid matching funds while also

ing policy options have created new

partnerships between state health and

investing in housing through other

opportunities to leverage health and fis-

housing agencies and collaboration and

funding streams.62 Peggy Bailey, director

cal benefits from the nexus of housing

communication among federal agencies.71

of health systems integration for the

and health, but significant challenges

National housing organizations and

Corporation for Supportive Housing,

remain. Foremost among them, as Ho

advocates face the added challenge of

says that the health sector does not

puts it, is that “[t]he budget environ-

adhering to different sets of policies

understand the extent to which hous-

ment is such that we’re not doing what

and rules for each state.72 For example,

ing providers fund services that could

we know works, and not doing anything

as the Corporation for Supportive Hous-

be paid for by Medicaid. Both state and

at [a] scale that matches the need.”66

ing helps housing providers determine

federal governments, she argues, could

Congress, state legislatures, and other

whether or not they can be reimbursed

stretch their non-Medicaid investments

stakeholders will need to commit more

for supportive services and, if so, become

in supportive housing if freed from

resources to fully capitalize on these

certified to bill Medicaid, it must make

10

sure it is complying with state-specific

supportive housing.76 And although

3 James Krieger and Donna L. Higgins. 2002. “Housing

and Health: Time Again for Public Health Action,”

regulations.

many high-cost services are avoidable,

American Journal of Public Health 92:5, 758.

the Medicaid and the rental assistance

4 Rebekah Levine Coley, Tama Leventhal, Alicia Doyle

Although ACA offers many new

populations include those groups and

Lynch, and Melissa Kull. 2013. “Relations between

Housing Characteristics and the Well-Being of Low-

opportunities, understanding and

individuals with the most persistent

Income Children and Adolescents,” Developmental

implementing it will be difficult, and

health disparities.77 Finally, although

Psychology 49:9, 1775–85.

5

the potential housing implications

most of the new models discussed

Mary E. Tinetti. 2003. “Preventing Falls in Elderly

Persons,” New England Journal of Medicine 348:1, 42.

are just one aspect. Despite the solid

above are available to states that do not

6 Barry L. Steffen, George R. Carter, Marge Martin,

evidence base showing that housing is

expand Medicaid eligibility, the reach

Danilo Pelletiere, David A. Vandenbroucke, and Yunn-

a key determinant of health, getting

of such programs will be limited com-

Gann David Yao. 2015. Worst Case Housing Needs: 2015

Report to Congress . Office of Policy Development and and maintaining supportive housing

pared with states that have expanded

Research, U.S. Department of Housing and Urban

as an administrative priority may prove

eligibility.

Development, 3.

7 U.S. Department of Housing and Urban Develop-

difficult. ACA is still in the early stages

ment. 2014. “Housing’s and Neighborhoods’ Role in

of implementation, and states are just

Conclusion

Shaping Children’s Future,” Evidence Matters (Fall), 1.

beginning to experiment with new

Investment in stable, affordable,

8 Nabihah Maqbool, Janet Viveiros, and Mindy Ault.

2015. “The Impacts of Affordable Housing on Health:

models of care delivery and authorized

healthy housing in safe neighborhoods

A Research Summary,” Center for Housing Policy, 1.

housing-related activities. Already,

with access to healthcare services and

9 Claudia D. Solari and Robert D. Mare. 2012. “Housing

however, major hurdles are apparent.

a variety of amenities promises im-

Crowding Effects on Children’s Wellbeing,” Social

Science Research 41:2, 464–76; Kids Count Data Center,

First, as discussed above, the limited

proved health for residents of all types.

Annie E. Casey Foundation. 2014. “Children Living

supplies of affordable housing and

Housing that adds supportive services

in Crowded Housing” (www.datacenter.kidscount.

org/data/tables/67-children-living-in-crowded-

rental assistance will restrict efforts to

for those who need them, particularly

housing#detailed/1/any/false/868,867,133,38,35/

use ACA programs to expand perma-

seniors and individuals with disabilities

any/368,369). Accessed 13 January 2016; Econo-metrica, Inc., Kevin S. Blake, Rebecca L. Kellerson,

nent supportive housing. Second, states

who are experiencing homelessness or

Aleksandra Simic, and ICF International. 2007. “Mea-

may face challenges in their attempts to

who need institutional levels of care,

suring Overcrowding in Housing,” U.S. Department of

target high-cost, high-need individuals

also promises to substantially improve

Housing and Urban Development.

10 Solari and Mare.

and enroll them in Medicaid. Adults

health outcomes. Addressing the social

11 Wilder Research. 2007. “Homeless and near-homeless

experiencing chronic homelessness, for

determinants of health that are related

people on northern Minnesota Indian reservations,” 3.

example, face barriers to enrollment

to housing — investing “upstream” to

12 “About Olmstead,” Americans with Disabilities Act

and may require targeted outreach.73

prevent and treat health issues before

website (www.ada.gov/olmstead/olmstead_about.

htm). Accessed 22 October 2015.

Housing agencies and other housing

they become more serious — may

13 Margot B. Kushel, Sharon Perry, David Bangsberg,

providers can assist through providing

substantially reduce public and private

Richard Clark, and Andrew R. Moss. 2002. “Emer-

gency Department Use Among the Homeless and

outreach, helping clients navigate the

healthcare costs. Through its expan-

Marginally Housed: Results From a Community-Based

enrollment process, or by becoming

sion of Medicaid eligibility and new

Study,” American Journal of Public Health 92:5, 778.

certified so that they can enroll clients

models of healthcare service delivery

14 Maqbool et al., 2; Tama Leventhal and Sandra

Newman. 2010. “Housing and Child Development,”

directly into Medicaid.74 It may also be

and payment, ACA, along with con-

Children and Youth Services Review 32:9, 1165–74.

difficult to identify high-cost individuals

current changes in healthcare policy,

15 Commission to Build a Healthier America. 2008.

before they incur substantial expenses

creates numerous opportunities and

“Where We Live Matters for Our Health: Neighbor-

hoods and Health, ” Robert Wood Johnson Foundation.

— people who have high costs one

incentives to pursue targeted invest-

16 U.S. Government Accountability Office. 2015.

year do not necessarily have similar

ments that leverage housing as a

“Medicaid: A Small Share of Enrollees Consistently

needs the next year, and most people

platform for improved health and

Accounted for a Large Share of Expenditures.”

17 Jill Khadduri and Gretchen Locke. 2012. “Making

who experience homelessness do so

fiscal outcomes. Capitalizing on this

Subsidized Rental Housing a Platform for Improved

only temporarily.75 Bailey notes that,

opportunity will require collaboration

Health for Vulnerable Populations,” Abt Associates.

although evidence exists that housing

among healthcare and housing providers, 18 Deidre D. Crocker, Stella Kinyota, Gema G. Dumi-

tru, Colin B. Ligon, Elizabeth J. Herman, Jill M.

stability reduces the use of health ser-

research to identify best practices, and a

Ferdinands, David P. Hopkins, Briana M. Lawrence,

vices, less is known about housing stability

commitment of the resources needed to

and Theresa A. Sipe. 2011. “Effectiveness of Home-

Based, Multi-Trigger, Multicomponent Interventions

and specific health outcomes, with

take proven models to scale.

with an Environmental Focus for Reducing Asthma

the exception of HIV/AIDS. In some

Morbidity: A Community Guide Systematic Review,”

cases, managed care providers have

1 Deborah Bachrach, Helen Pfister, Kier Wallis, and

American Journal of Preventative Medicine 41:2S1, S5–

Mindy Lipson. 2014. “Addressing Patients’ Social

S32; Jack Meyer, Gaylee Morgan, and Mike Nardone.

incentives based on particular health

2015. “Sustainable Funding and Business Case for

Needs: An Emerging Business Case for Provider

outcomes, and more research could

GHHI Home Interventions for Asthma Patients,”

Investment,” The Commonwealth Fund. See also:

Health Management Associates; Ruth Ann Norton

investigate the impact of supportive

Alvin R. Tarlov. 1999. “Public Policy Frameworks for

and Brendan Wade Brown. 2014. “Green & Healthy

Improving Population Health,” Annals of the New York

housing on specific conditions such as

Homes Initiative: Improving Health, Economic,

Academy of Sciences 896, 281–93.

and Social Outcomes Through Integrated Hous-

diabetes or heart disease. Such research

2 World Health Organization. “Social Determinants of

ing Interventions,” Environmental Justice 7:6, 151; could shed light on which individuals

Health: Key Concepts” (www.who.int/social_determi-

American College of Allergy, Asthma & Immunology.

nants/thecommission/finalreport/key_concepts/en).

2012. “Asthma Results in Missed Sleep, School Days

would be most likely to benefit from

Accessed 2 September 2015.

for Children” (acaai.org/news/asthma-results-missed-

11

sleep-school-days-children). Accessed 18 December

(kff.org/health-reform/state-indicator/state-activi-

long-term-services-and-supports/home-and-communi-

2015.

ty-around-expanding-medicaid-under-the-affordable-

ty-based-services/home-and-community-based-servic-

19 Peter Ashley. 2012. “HUD Working to Reduce Racial

care-act/). Accessed 19 October 2015.

es-1915-i.html). Accessed 30 September 2015.

and Ethnic Asthma Disparities Among our Children,”

34 Jack Tsai, Robert A. Rosenheck, Dennis P. Culhane,

54 Montana Department of Public Health and Human

The HUDdle, 4 June. Accessed 15 October 2015.

and Samantha Artiga. 2013. “Medicaid Expansion:

Services, Children’s Mental Health Bureau. 2014.

20 U.S. Department of Housing and Urban Develop-

Chronically Homeless Adults Will Need Targeted

“1915(i) Home and Community Based Services State

ment, Office of Healthy Homes and Lead Hazard

Enrollment and Access to a Broad Range of Services,”

Plan Program for Youth with Serious Emotional

Control. 2011. “American Healthy Homes Survey:

Health Affairs 32:9, 1553.

Disturbance (SED) Policy Manual, ” 5.

Lead and Arsenic Findings,” 4.

35 Cindy Mann. 2013. “Update on Preventative Services

55 U.S. Department of Housing and Urban Develop-

21 Dennis P. Culhane, Stephen Metraux, and Trevor

Initiatives,” CMCS Informational Bulletin (27 Novem-ment. 2015. “Section 811 Project Rental Assis-

Hadley. 2002. “Public Service Reductions Associated

ber) , 1–2.

tance (PRA) Program” (www.hudexchange.info/

with Placement of Homeless Persons with Severe

36 Viveiros 2015, 9.

programs/811-pra/). Accessed 1 October 2015.

Mental Illness in Supportive Housing,” Housing Policy

37 Centers for Medicare & Medicaid Services. “Readmis-

56 U.S. Department of Housing and Urban Develop-

Debate 13:1, 107.

sions Reduction Program” (www.cms.gov/medicare/

ment. 2015. “Deputy Assistant Secretary for the Office

22 Mary E. Larimer, Daniel K. Malone, Michelle D.

medicare-fee-for-service-payment/acuteinpatientpps/

of Multifamily Housing Programs Visits First 811 PRA

Garner, David C. Atkins, Bonnie Burlingham, Heather

readmissions-reduction-program.html). Accessed 23

Property” (www.hudexchange.info/news/deputy-as-

S. Lonczak, Kenneth Tanzer, Joshua Ginzler, Seema

October 2015.

sistant-secretary-for-the-office-of-multifamily-housing-

L. Clifasefi, William G. Hobson, and G. Alan Marlatt.

programs-visits-first-811-pra-property/). Accessed 1

38 Collaborative Healthcare Strategies, Amy Boutwell,

2009. “Health Care and Public Service Use and Costs

October 2015.

John Snow, James Maxwell, Angel Bourgoin, and

Before and After Provision of Housing for Chronically

Sarah Genetti. 2014. “Hospital Guide to Reducing

57 California Housing Finance Agency. 2015. “California

Homeless Persons With Severe Alcohol Problems,”

Medicaid Readmissions, ” Agency for Healthcare

First in Nation to House Disabled Residents through

Journal of the American Medical Association 301:13,

Research and Quality, U.S. Department of Health and

New HUD Funding: U.S. Department of Housing and

1355–6.

Human Services, 3.

Urban Development Official visited April 29,” press 23 Laura S. Sadowski, Romina A. Kee, Tyler J. Vander-release, 30 April.

39 Sara Rosenbaum. 2015. “Additional Requirements

Weele, and David Buchanan. 2009. “Effect of

for Charitable Hospitals: Final Rules on Community

58 Lynn A. Blewett and Ross A. Owen. “Accountable

a Housing and Case Management Program on

Health Needs Assessments and Financial Assistance, ”

Care for the Poor and Underserved: Minnesota’s Hen-

Emergency Department Visits and Hospitalizations

Health Affairs Blog (27 January). Accessed 20 October

nepin Health Model,” American Journal of Public Health

Among Chronically Ill Homeless Adults: A Random-

2015.

105:4, 622–3; Janet Viveiros. 2015. “Addressing Hous-

ized Trial, ” Journal of the American Medical Associa-ing as a Health Care Treatment,” Housing and Health:

40 Department of the Treasury, Internal Revenue

tion 301:17, 1771–8.

Innovations in the Field (June); Jennifer N. Edwards.

Service. “Additional Requirements for Charitable

24 Kushel et al., 778.

2013. “Health Care Payment and Delivery Reform in

Hospitals; Community Health Needs Assessments

Minnesota Medicaid,” Commonwealth Fund.

25 H. Stephen Kaye, Mitchell P. LaPlante, and Charlene

for Charitable Hospitals; Requirement of a Section

Harrington. 2009. “Do Noninstitutional Long-Term

4959 Excise Tax Return and Time for Filing Return,”

59 Viveiros 2015. “Addressing Housing as a Health Care

Care Services Reduce Medicaid Spending?” Health

Federal Register 79:250, 79002.

Treatment.”

Affairs 28:1; 263, 270.

41 Lisa Gilden, Janis M. Orlowski, and Melinda Reid

60 Blewett and Owen, 624.

26 Carla A. Chase, Kathryn Mann, Sarah Wasek, and Mar-

Hatton. Email to Sunita Lough and Tamara Ripperda,

61 Kelly M. Doran, Elizabeth J. Misa, and Nirav R.

ian Arbesman. 2012. “Systematic Review of the Effect

Internal Revenue Service, 14 July 2015.

Shah. 2013. “Housing as Health Care — New York’s

of Home Modification and Fall Prevention Programs

42 Vikki Wachino. 2015. “Coverage of Housing-Related

Boundary-Crossing Experiment,” New England Journal

on Falls and the Performance of Community-Dwelling

Activities and Services for Individuals with Disabili-

of Medicine 369:25, 2374–6.

Older Adults,” American Journal of Occupational Therapy

ties,” CMCS Informational Bulletin (26 June).

62 Interview with Jennifer Ho, 23 October 2015.

66:3, 284.

43 Viveiros 2015, 5–10.

63 Interview with Peggy Bailey, 26 October 2015.

27 Centers for Disease Control and Prevention. “Costs

44 Kaiser Commission on Medicaid and the Uninsured.

64 Jennifer Ho. 2015. Speech delivered at “The Intersec-

of Falls Among Older Adults” (www.cdc.gov/homean-

2012. “Emerging Medicaid Accountable Care Organi-

tion of Health and Housing: Opportunities and Chal-

drecreationalsafety/falls/fallcost.html). Accessed 18

zations: The Role of Managed Care, ” Henry J. Kaiser

lenges,” Centene and Alliance for Health Reform, December 2015.

Family Foundation, 1–3.

Washington, DC, 7 August.

28 Lisa Sanbonmatsu, Jens Ludwig, Lawrence F. Katz,

45 “Patient Centered Medical Homes (PCMH) and Ac-

65 Interview with Peggy Bailey.

Lisa A. Gennetian, Greg J. Duncan, Ronald C. Kessler,

countable Care Organizations (ACO),” The Henry J.

Emma Adam, Thomas W. McDade, and Stacy Tessler

66 Ho 2015.

Kaiser Family Foundation website (kff.org/medicaid/

Lindau. 2011. Moving to Opportunity for Fair Housing

67 Center on Budget and Policy Priorities. “Policy Basics:

state-indicator/patient-centered-medical-homes-pcmh-

Demonstration Program: Final Impacts Evaluation. U.S.

Federal Rental Assistance” (www.cbpp.org/research/

and-accountable-care-organizations-aco/). Accessed 8

Department of Housing and Urban Development,

housing/policy-basics-federal-rental-assistance). Ac-

October 2015.

Office of Policy Development and Research.

cessed 23 October 2015.

46 Viveiros 2015, 5.

29 Debra J. Lipson, Christal Stone Valenzano, and Susan

68 Joint Center for Housing Studies of Harvard Univer-

R. Williams. 2011. “What Determines Progress in

47 Julia Paradise and Mike Nardone. 2014. “Medicaid

sity. 2014. “Housing America’s Older Adults: Meeting

State MFP Transition Programs?” Mathematica Policy

Health Homes: A Profile of Newer Programs, ” Kaiser

the Needs of an Aging Population, ” 17.

Research, 7.

Commission on Medicaid and the Uninsured; 4, 15.

69 U.S. Interagency Council on Homelessness. 2015.

30 Matthew Kehn and Debra Lipson. 2014. “The Real

48 Paradise and Nardone, 4, 15; Viveiros 2015, 6.

“The President’s 2016 Budget: Fact Sheet on Home-

Choice Systems Change Grant: Building Sustainable

49 Viveiros 2015, 6.

lessness Assistance, ” 2.

Partnerships for Housing — Final Report,” Math-50 National Alliance to End Homelessness. 2012. “Medic-

70 Interview with Jennifer Ho.

ematica Policy Research.

aid Health Homes: Emerging Models and Implica-

71 Interview with Jennifer Ho; Ho 2015.

31 Janet Viveiros. 2015. “Affordable Housing’s Place in

tions for Solutions to Chronic Homelessness.”

72 Viveiros 2015. “Affordable Housing’s Place in Health

Health Care: Opportunities Created by the Affordable

51 Kathleen Sebelius. 2014. “Report to Congress: Com-

Care,” 13.

Care Act and Medicaid Reform, ” National Housing

munity First Choice, ” U.S. Department of Health and Conference, 3.

73 Tsai et al., 1557.

Human Services.

32 Viveiros 2015, 4–5; U.S. Interagency Council on

74 Council of Large Public Housing Authorities and

52 NORC. 2014. “Research Summary: ACA Section 2401,

Homelessness. “The Affordable Care Act’s Role in

Corporation for Supportive Housing. 2014. “Opportu-

Community First Choice Option (Section 1915(k) of

Preventing and Ending Homelessness” (www.usich.

nities for Health Partnerships through the Affordable

the Social Security Act; Oregon State Plan Amend-

gov/tools-for-action/aca-fact-sheet). Accessed 19

Care Act.”

ment Summary,” University of Chicago.

October 2015.

75 Doran et al., 2375–6.

53 Centers for Medicare & Medicaid Services. “Home &

33 Henry J. Kaiser Family Foundation. “Status of State

Community-Based Services 1915(i)” (www.medicaid.

76 Interview with Peggy Bailey.

Action on the Medicaid Expansion Decision”

gov/medicaid-chip-program-information/by-topics/

77 Interview with Jennifer Ho.

12

Research Spotlight

Highlights

n HUD’s proposed rule to ban smoking in all public housing properties aims

Smoke-Free

to reduce residents’ exposure to secondhand smoke while also reducing

Public Housing:

building maintenance costs and fire risks.

n There is consensus on the health dangers of secondhand smoke, espe-

Research and

cially to children. Because secondhand smoke moves between units in

Implementation

multifamily buildings, only the elimination of smoking in these buildings

fully protects nonsmokers.

O

n Researchers estimate that the proposed rule will reduce healthcare costs

n November 12, 2015, HUD Sec-

related to secondhand smoke among nonsmoking residents and generate

retary Julián Castro announced

other cost savings for public housing agencies. Although the proposed rule

a proposed rule to require all public

will have costs to smokers in time and inconvenience, it may also reduce

housing properties to become smoke-

the prevalence of tobacco use by smokers.

free indoors. “We have a responsibility

to protect public housing residents

n Evicting residents who repeatedly break nonsmoking rules is an action of last

from the harmful effects of secondhand

resort; public housing agencies with existing bans usually remedy offenses

smoke, especially the elderly and chil-

via warnings, referrals to smoking cessation programs, and other resources.

dren who suffer from asthma and other

respiratory diseases,” Secretary Castro

said at a press conference with U.S.

children under age 5 living in units

A Growing Response

Surgeon General Vivek Murthy.1 The

where someone smokes.5

to Evidence on Second-

proposed rule, when finalized, will re-

hand Smoke

quire public housing agencies (PHAs)

Considerable research on the dangers

HUD’s proposed indoor smoke-

to implement a policy within 18 months

of smoking and exposure to sec-

free public housing rule can best be

that bans lit smoking products “in all

ondhand smoke supports the need

thought of as a formalization and

living units, indoor common areas in

to protect residents from involuntary

extension of the precedent set by local

public housing, and in PHA administra-

exposure to tobacco smoke. The

smoke-free policies and smoking-

tive office buildings” as well as outdoor

proposed rule, however, will present

cessation programs. More than 600

areas within at least 25 feet of these

a complex set of potential costs and

of the nation’s approximately 3,300

buildings.2 The policy, which applies to

benefits for PHAs and their residents.

PHAs have already made at least one

all public housing units except those

This article examines the research

of their buildings smoke-free.6 These

in mixed-finance buildings, is intended

into the costs and benefits of elimi-

provisions have spread rapidly: in

to reduce PHA residents’ exposure to

nating smoking in public housing

2005, only 16 PHAs had smoke-free

secondhand smoke and lower mainte-

properties, considering the empirical

measures in place, but between 2005

nance costs and the risk of fire.

evidence in favor of indoor smoking

and 2011, 214 PHAs adopted them in

bans from the public health and policy

some form — for example, by pro-

More than 600 PHAs, with HUD’s

perspectives.

hibiting indoor smoking outright,

encouragement, have already imple-

mented smoke-free policies.3 Although

these PHAs represent between 200,000

and 300,000 public housing units, the

national smoke-free rule will reach

more than 700,000 additional units,

including more than 775,000 children

and “over 500,000 units inhabited by

elderly households or households with

a non-elderly person with disabilities.”4

A regulatory impact analysis performed

by HUD’s Office of Policy Development

and Research found that approximately

1.2 million nonsmoking public housing

residents are still exposed to second-

hand smoke, including roughly 60,000

More than 600 PHAs nationwide have adopted smoke-free policies for some or all of their buildings.

13

Sammy Mayo Jr.

U.S. Surgeon General Vivek Murthy and HUD Secretary Julián Castro participate in a White House convening on smoke-free public housing.

for new residents, or in certain build-

bans. The Centers for Disease Control

20 to 30 percent, and approximately

ings.7 Efforts to institute smoke-free

and Prevention (CDC) estimates that

7,300 nonsmokers in the United States

rules escalated after HUD’s Office

the number of U.S. households with

die each year of lung cancer caused by

of Public and Indian Housing is-

smoke-free rules “increased from 43

passive exposure to cigarette smoke.15

sued a notice in 2009 urging PHAs

percent in 1992–1993 to 83 percent

The cardiovascular effects of second-

“to institute non-smoking policies in

in 2010–2011, including an increase

hand smoke are even more far-reaching;

some or all of their public housing

among households with at least one

according to CDC estimates, second-

units,”8 a statement that was extended

adult smoker, implying that the smokers

hand smoke increases nonsmokers’ risk

to subsidized multifamily proper-

in these households agree to smoke

of heart disease by 25 to 30 percent and

ties in 2010 and renewed in 2012.

outside of the home.”12 HUD’s pro-

stroke risk by 20 to 30 percent, result-

HUD also published several guides

posed rule, then, aligns with formal and

ing in more than 34,000 premature

for both residents and administra-

informal measures to curtail smoking

deaths from heart disease and 8,000

tors of public housing that provided

in private and public spaces, building

deaths from stroke annually.16 These

resources and suggestions for suc-

on these existing efforts while expand-

are not just long-term risks — the CDC

cessful implementation.9 In addition

ing their reach to share best practices

explains that “even brief exposure to

to making information available,

and extend the benefits of smoke-free

secondhand smoke can damage the

HUD issued a notice in the Federal

homes to a larger group of residents.

lining of blood vessels and cause your

Register in 2012 soliciting feedback

blood vessels to become stickier. These

about adopting smoke-free policies

HUD’s efforts to first reduce and even-

changes can cause a deadly heart attack,”

in PHAs and multifamily housing.10

tually ban indoor smoking escalated in

especially in people who already have

Some of the responses HUD received

the wake of a 2006 Surgeon General’s

heart disease.17

are collected in “Change Is in the

report declaring that “there is no risk-

Air,” a comprehensive action guide

free level of exposure to secondhand

Infants and children are also vulner-

for implementing smoke-free housing

smoke.”13 Secondhand smoke itself con-

able to serious health issues caused

policies that was published in 2014.11

tains more than 7,000 chemicals; 250 of

by secondhand smoke. According to

them, including ammonia and carbon

the CDC, pre- or postnatal exposure

Attempts to curtail smoking in public

monoxide, are known to be harmful,

to secondhand smoke increases the

and subsidized housing are concurrent

and nearly 70 are carcinogens.14 Living

risk of sudden infant death syndrome

with the nationwide growth in volun-

with a smoker can increase a nonsmoker’s

because “chemicals in secondhand

tary, self-imposed in-home smoking

chances of developing lung cancer by

smoke appear to affect the brain in

14

ways that interfere with its regulation of

children.”26 As a result, thirdhand smoke,

are high. A 2014 study by King et al.

infants’ breathing.”18 In older children,

although less damaging than direct

estimates that prohibiting smoking in

passive inhalation of smoke impedes

exposure to tobacco smoke, still pro-

all subsidized or public housing nation-

lung growth and capacity, resulting

vides an important reason for indoor

wide “would yield annual cost savings

in frequent episodes of wheezing and

smoking bans.

of $496.82 million (range, $258.96–

coughing and instances of bronchitis

843.50 million), including $310.48

and pneumonia. Wilson et al. state

In multiunit housing, the effects of

million ($154.14–$552.34 million)

that “[e]ven brief exposure to ambi-

smoking extend beyond individual

in secondhand smoke-related health

ent tobacco smoke can decrease lung

apartments. A nationwide survey of

care, $133.77 million ($75.24–$209.01

function” and raise the risk of inflam-

multiunit housing units finds that, at

million) in renovation expenses, and

mation.19 Secondhand smoke can also

a given site, at least 26 percent and

$52.57 million ($29.57–$82.15 million)

prompt more frequent and more severe

up to 64 percent of residents report

in smoking-attributable fire losses.”32

asthma attacks.20 Wilson et al. say that

secondhand smoke “incursions into

HUD’s regulatory impact analysis of

“very low levels of tobacco-smoke expo-

their units from external sources (e.g.,

smoke-free public housing estimates an

sure have been associated with attenuated

hallways or adjacent apartments),”27

aggregate annualized benefit to nonsmok-

endothelial function,” or damage to the

a figure that does not take into ac-

er health ranging from $148 million to

arteries. Cognitive effects such as “de-

count the invisible accrual of thirdhand

$447 million at a lower discount rate of 3

creased scores on reading, math, and

smoke. A 2011 study measuring levels

percent and $70 million to $137 million

block-design tests of cognitive function” of cotinine, a biomarker used to indi-

at a higher discount rate of 7 percent.

and increased rates of conduct disorders

cate tobacco exposure, found that even

The analysis also predicts a further ben-

are also present.21

children who do not live with any smok-

efit to nonsmoker well-being ranging

ers display a “45 percent increase in

from $96 million to $275 million per

Although many people are aware of

cotinine levels if they live in apartments

year, a reduction in PHA maintenance

the dangers of secondhand smoke,

compared with detached homes.”28 As

costs of $16 million to $38 million per

fewer recognize the hazard created by

the Surgeon General’s report explains,

year, and a reduction in fire risk of $32

what is known as “thirdhand smoke.”

only “[e]liminating smoking in indoor

million, which translates into approxi-

Defined as “residual tobacco smoke

spaces fully protects nonsmokers

mately 150 fires averted and nearly 4

contamination that remains after the

from exposure to secondhand smoke.

lives saved annually.33

cigarette is extinguished,” it “take[s]

Separating smokers from nonsmokers,

the form of particulate matter depos-

cleaning the air, and ventilating build-

HUD’s analysis, like the cost estimates

ited in a layer onto every surface within

ings cannot eliminate exposures of

by King et al., does not quantify the

the home; in loose household dust; and

nonsmokers to secondhand smoke.”29

expected health benefit to smokers, as

as volatile toxic compounds that ‘off

In public housing, “tobacco smoke

the rule’s purpose is to prevent nonsmok-

gas’ into the air over days, weeks, and

exposure…is particularly troubling

ers from being exposed to secondhand

months.”22 The residue in thirdhand

because it afflicts disadvantaged and

smoke.34 However, one benefit to smok-

smoke contains lead, a substance that

vulnerable populations.”30 In 2014, 34

ers from the rule arises from research

has been declared unsafe for children

percent of households in public hous-

indicating that the commonality of

at any level of exposure. Research has

ing included elderly persons, 26 percent

smoking in a community is a significant

shown that the presence of a smoker in

included disabled persons, and 38 per-

risk factor that can increase the preva-

a household not only causes a statisti-

cent included children, groups who are

lence of tobacco use. For example,

cally significant increase in the lead

especially vulnerable to the effects of

a study of low-socioeconomic-status

level of floor dust 23 and an increase of

secondhand smoke exposure.31

black women in Chicago public hous-

more than 90 percent in the lead level

ing developments found that the most

of windowsill dust,24 but it also results in

Benefits and Costs

significant barriers to smoking cessa-

“significantly higher” blood lead levels

of Implementation

tion all “followed from social isolation

in children who reside in the home.25

Researchers have worked to quantify

and lack of support” in a highly stress-

the savings in healthcare costs that

ful environment.35 For many of the

Thirdhand smoke accrues despite

reducing secondhand smoke exposure

women surveyed, “the lack of expo-

protective measures such as opening

will generate as well as other savings

sure to those who ha[d] tried to quit

windows, turning on fans, smoking in

from smoke-free public housing — pri-

reinforced the belief that … those who

other rooms, or waiting for smoke to

marily reductions in renovation expenses

quit must exert Herculean efforts.”36

dissipate, meaning, as Winickoff et al.

and in the risk of catastrophic fires.

Studies have shown, however, that the

state, that “breathing air in a room

Although such analysis involves con-

inverse is also true; the contagion ef-

today where people smoked yesterday

siderable uncertainty, the anticipated

fect caused by more visible efforts to

can harm the health of infants and

cost savings to both residents and PHAs

reduce or curtail smoking can increase

15

HUD’s proposed implementation of smoke-free public housing stands to improve long-term health outcomes for young children.

success rates by shifting norms around

year. They estimate the costs to PHAs

and that people “are allowed to smoke,

smoking, providing social support, and

to comply with the proposed rule —

just not in the areas that have been

encouraging residents who struggle

including drafting their policies, holding

designated non-smoking.”40 Neverthe-

to quit to renew their efforts even if

public discussions, disseminating the poli-

less, Sheila Crowley, president and chief

they are not initially successful. Even

cies, training staff, updating leases, and

executive officer of the National Low

smokers who do not use these policies

monitoring — will average about $3.2

Income Housing Coalition, expressed

as an opportunity to quit are likely to

million per year in total, with higher costs frustration that neither homeowners

reduce the amount they smoke. A study

over the initial implementation period.38

nor recipients of other forms of hous-

in Portland, Oregon, found that within

ing assistance, such as vouchers or tax

a year of implementing a smoke-free

The most serious cost, and biggest

credits, are subject to these rules.41

policy, “almost half of ongoing smokers

challenge overall to smoke-free PHA

Although indoor smoke-free policies

reduced their cigarette consumption,”

policies, is the issue of enforcement and

are legal, attempt to avoid imposing an

and the quit rate increased from 2.6 to

punishment. Bans on indoor smoking

undue burden, and mirror policies in-

14.7 percent.37 Although the damaging

are legal; smokers are not a protected

creasingly adopted in market-rate rental

health consequences of secondhand

class under the Civil Rights Act of 1964,

housing, this equity issue remains.

smoke are especially pronounced in

and the courts have ruled that the due

multiunit housing, the opportunities

process clauses of the 5th and 14th

In addition, short of repeatedly knock-

for meaningful intervention at such

Amendments require only a reason-

ing on doors and inspecting apartments,

sites are enhanced as well.

able basis for restricting smoking.39

which agency staff may not have time to

PHAs, however, still face a number of

do, finding instances of indoor smok-

HUD’s proposed rule will also have

difficulties in enforcing these bans.

ing can be difficult. Many residents

costs — mostly in time and inconve-

Some residents believe that smoke-free

are reluctant to report their neigh-

nience for residents who smoke and in

policies violate their rights as paying

bors. In New York City, which has the

time for training and enforcement for

renters and refuse to comply. To coun-

nation’s largest PHA, some residents,

PHA staff. HUD’s regulatory impact

ter this, PHAs attempt to make clear

outside observers, and city officials are

analysis, in considering the opportunity

that “a resident’s status as a smoker or

concerned about the potential role of

cost of time smokers will spend going to

non-smoker is irrelevant,” that “smok-

police officers in enforcement, not-

and using outside smoking areas, values

ing status cannot be used to determine

ing that even if PHAs do not invite or

the lost time and inconvenience of

eligibility for applying for or residing in

encourage officers to assist in identify-

residents who smoke at $209 million per

public or assisted multifamily housing,” ing violations, “the presence of officers

16

acting as de facto hall monitors inside

from reaching areas where smoking is

stipulates that tenants’ leases include

housing developments differentiates

allowed.43 For some residents, the Reha-

the prohibition on lit tobacco, whether

the smoking ban being proposed for

bilitation Act of 1973 and the Americans

through an amendment process or

public housing from those instituted by

with Disabilities Act can provide relief

during the annual renewal period.46

privately owned apartment buildings,

in the form of a request for reason-

Residents who violate the policy receive

co-ops and condos.”42 Nevertheless,

able accommodation, which PHAs are

verbal or written warnings and, in many

HUD believes that the health, safety,

required to consider and grant when ap-

cases, also receive information about

and financial benefits of even an im-

propriate.44 PHAs have met these requests

smoking cessation resources and refer-

perfectly comprehensive reduction

by, for instance, transferring residents

rals to smoking cessation programs.

in indoor smoking make the rule

with mobility issues to units closer

HUD’s guidance, which is consistent

worth pursuing.

to elevators or doors so they can reach

with smoke-free policies already

outdoor smoking areas more easily.45

implemented at PHAs nationwide,

The eviction of repeat offenders is the

recommends “graduated enforcement

most serious potential cost of indoor

The proposed rule makes clear that

to assist residents with compliance and

tobacco bans. The HUD rule itself

eviction, although a necessary enforce-

prevent eviction.”47 Although enforce-

recognizes that “there may be costs to

ment option, is an action of last resort.

ment procedures vary among PHAs,

residents as a result of eviction, par-

To avoid evictions, PHAs ensure that

they all share the option to remedy

ticularly for persons with disabilities,

residents are aware of the smoke-free

noncompliance over a period of time.

and especially for those with mobility

policy and the consequences of re-

Rhode Island’s East Greenwich Hous-

impairments” that may prevent them

peat violations. HUD’s proposed rule

ing Authority, for example, counts each

Case Study: Housing Authority of the City of Austin

The experience of local PHAs illustrates the opportunities and challenges that indoor smoking bans present. For example, the smoke-free housing policy that the Housing Authority of the City of Austin (HACA) implemented on September 1, 2015, demonstrates how PHAs can respond to residents’ concerns and collaborate with public health agencies to reduce smoking and the harmful effects of secondhand smoke. HACA began by surveying residents in 2013. The results, which were consistent with other studies nationwide, indicated that most of the approximately 4,300 residents in its 1,800 housing units “are non-smokers but are bothered by tobacco smoke entering their home” and that “a majority of tenants prefer smoke-free housing,” including the “significant percentage” who face “asthma and/or other health conditions like lung disease and cancer.”1 Residents also “showed support for health programming and interest in smoking cessation assistance.”2 Unlike the proposed HUD rule, the policy that grew out of these concerns extends to electronic cigarettes as well.

HACA makes clear that its policy “is focused on the act of smoking, not the smoker.”3 This approach has two significant implications: first, the enforcement structure punishes violations at the household level rather than at the tenant level, and second, the policy takes steps to avoid stigmatizing smokers and to connect them to services that can help them remain in their homes. After signing a lease addendum that certifies that they understand the smoking ban and that violation may be grounds for eviction, residents receive a written warning after the first violation, a written letter of lease violation after the second, and probation after the third. Each of these notices comes with a referral for cessation services. The fourth violation triggers a 30-day notice of lease termination; however, the agency notes that it “may suspend [the] lease termination process if the family agrees to attend a HACA approved smoking cessation class and present HACA with a certificate of completion and a signed commitment to comply with HACA’s Smoke-free Housing Policy.”4

Reinforcing the fact that indoor smoking bans are a crucial step in a larger public health effort, HACA and many other PHAs not only provide resources for smoking cessation but do so in ways specifically targeted to the needs of public housing residents. In Austin, a partnership with an integrated care clinic has resulted in free weekly smoking cessation classes at several communities. Attendees receive information about creating a plan to quit smoking, using nicotine replacement therapy or other medications, and dealing with the urge to smoke, as well as other resources.5

1 Housing Authority of the City of Austin. 2015. “Austin Housing Authority Extinguishes Smoking in Public Housing Units” press release, 1 September.

2 Ibid.

3 Housing Authority of the City of Austin. 2015. “Smoke-Free Housing Policy” (www.hacanet.org/residents/smokefree.php). Accessed 16 December 2015.

4 Ibid.

5 Ibid.

17

violation only after a 20-day cure period

2 U.S. Department of Housing and Urban Develop-

Children to Residential Dust Lead, 1999–2004: I.

has passed.

ment. 2015. “Instituting Smoke-Free Public Housing:

Housing and Demographic Factors,” Environmental

48 “The mindset of the en-

Proposed Rule,” Docket No. FR 5597-P-02, 1.

Health Perspectives 117:3, 464.

forcement isn’t: ‘I’m going to catch you

3 For a list of these PHAs, see: Department of Housing

24 Ibid., 465.

smoking, I’m going to evict you,’” says

and Urban Development. “Smoke-Free Public Housing

25 Sherry L. Dixon, Joanna M. Gaitens, David E. Jacobs,

and Multifamily Properties” (portal.hud.gov/hud-

Rodger Moore, director of property

Warren Strauss, Jyothi Nagaraja, Tim Pivetz, Jonathan

portal/HUD?src=/program_offices/healthy_homes/

W. Wilson, and Peter J. Ashley. 2009. “Exposure of

management at Home Forward, the

smokefree). Accessed 31 January 2016.

U.S. Children to Residential Dust Lead, 1999–2004:

PHA of Portland, Oregon. “It is: ‘I’m go-

4 U.S. Department of Housing and Urban Development

II. The Contribution of Lead-Contaminated Dust to

2015. “Instituting Smoke-Free Public Housing,” 4, 15.

Children’s Blood Lead Levels,” Environmental Health

ing to work with you to give you as many

5 U.S. Department of Housing and Urban Development.

Perspectives 117:3, 470.

resources and as many chances as we pos-

2015. “Regulatory Impact Analysis: Instituting Smoke-

26 Winickoff et al. 2009, 74.

sibly can, without waiving our right for

Free Public Housing — Proposed Rule,” Docket No.

27 U.S. Department of Housing and Urban Development

FR-5597-P-02, 3–4.

eviction.’ We hold the resident’s hand as

2015. “Instituting Smoke-Free Public Housing,” 7.

6 U.S. Department of Housing and Urban Development

28 Wilson et al. 2009, 85.

long as we possibly can.”49 Between 2009

2015. “Instituting Smoke-Free Public Housing,” 12;

29 U.S. Department of Health and Human Services, 11.

and 2014, Portland issued 51 notices

U.S. Department of Housing and Urban Develop-

ment. “Public Housing” (portal.hud.gov/hudportal/

30 Jonathan P. Winickoff, Mark Gottlieb, and Michelle M.

to residents with an option to remedy

HUD?src=/program_offices/public_indian_housing/

Mello. 2010. “Regulation of Smoking in Public Hous-

ing,” New England Journal of Medicine 362, 2320.

and 9 notices with no option to remedy

programs/ph). Accessed 17 December 2015.

7

31 Center on Budget and Policy Priorities. 2015. “United

across 2,000 units.

U.S. Department of Housing and Urban Development,

50

Office of Healthy Homes and Lead Hazard Control.

States Fact Sheet: Federal Rental Assistance. ”

2011. “Smoke-Free Housing: A Toolkit for Residents of

32 Brian A. King, Richard M. Peck, and Stephen D. Babb.

These local PHA strategies exist along-

Federally Assisted Public and Multi-Family Housing,” 4.

2014. “National and State Cost Savings Associated

8 U.S. Department of Housing and Urban Develop-

With Prohibiting Smoking in Subsidized and Public

side HUD’s broader efforts to minimize

ment, Office of Public and Indian Housing and Office

Housing in the United States,” Preventing Chronic

the possibility of eviction. In addition

of Healthy Homes and Lead Hazard Control. 2009.

Disease 11:140222, 1.

33

to “develop[ing] guidance in reason-

“Non-Smoking Policies in Public Housing,” Notice U.S. Department of Housing and Urban Development

PIH-2009-21.

2015. “Instituting Smoke-Free Public Housing,” 5;

able accommodation,” HUD’s goal

9 See: U.S. Department of Housing and Urban Develop-

U.S. Department of Housing and Urban Development

for the public comment phase of the

ment, Office of Healthy Homes and Lead Hazard

2015. “Regulatory Impact Analysis,” 2, 33.

Control 2011; see also: U.S. Department of Housing

34 U.S. Department of Housing and Urban Development

rule’s implementation was to provide

and Urban Development, Office of Lead Hazard Con-

2015. “Regulatory Impact Analysis,” 36.

suggestions “on how to mitigate these

trol and Healthy Homes. 2014. “Change Is in the Air:

35 Loretta P. Lacey, Clara Manfredi, George Balch,

potential adverse impacts.”

An Action Guide for Establishing Smoke-Free Public

51 As a result,

Richard B. Warnecke, Karen Allen, and Constance

Housing and Multifamily Properties.”

Edwards. 1993. “Social Support in Smoking Cessation

nationwide, evictions are very rare.

10 U.S. Department of Housing and Urban Development.

Among Black Women in Chicago Public Housing,”

Although no comprehensive accounting

2012. “Request for Information on Adopting Smoke-

Public Health Reports 108:3, 389.

Free Policies in PHAs and Multifamily Housing, ”

of evictions due to smoking ban violations

36 Lacey et al., 391.

Federal Register 77:193 (4 October), 60712–4.

37

exists, at least three occurred between

Barbara A. Pizacani, Julie E. Maher, Kristen Rohde,

11 U.S. Department of Housing and Urban Develop-

Linda Drach, Michael J. Stark. 2012. “Implementation

2013 and 2015 — in Cincinnati, Ohio;

ment, Office of Lead Hazard Control and Healthy

of a Smoke-free Policy in Subsidized Multiunit Housing:

Homes 2014.

Fairhaven, Massachusetts; and Manches-

Effects on Smoking Cessation and Secondhand Smoke

12 U.S. Department of Housing and Urban Development

Exposure,” Nicotine & Tobacco Research 14:9, 1027.

ter, New Hampshire.52

2015. “Instituting Smoke-Free Public Housing,” 10.

38 U.S. Department of Housing and Urban Development

13 U.S. Department of Health and Human Services. 2006.

2015. “Regulatory Impact Analysis,” 71.

Conclusion

The Health Consequences of Involuntary Exposure to To-

39 Winickoff et al. 2010, 2319–25.

bacco Smoke: A Report of the Surgeon General. Atlanta, GA: 40

HUD’s proposed rule, which may still

U.S. Department of Health and Human Services, 11.

U.S. Department of Housing and Urban Development,

Office of Lead Hazard Control and Healthy Homes

evolve before it is finalized and imple-

14 National Cancer Institute. 2011. “Secondhand Smoke

2014, 17.

and Cancer” (www.cancer.gov/about-cancer/causes-

mented, builds on strong evidence

41

prevention/risk/tobacco/second-hand-smoke-fact-

Dylan Matthews. 2015. “Banning smoking in public

about the danger of secondhand smoke

sheet). Accessed 17 December 2015.

housing singles out the poor. But it also saves lives,”

Vox (15 November).

15

and on the experiences of PHAs who

Centers for Disease Control and Prevention. 2014.

42

“Health Effects of Secondhand Smoke” (www.cdc.

J. David Goodman and Mireya Navarro. 2015. “Smok-

have already instituted smoke-free

gov/tobacco/data_statistics/fact_sheets/secondhand_

ing Ban Proposal a Surprise to Some Public Housing

Tenants, ” The New York Times (12 November), A31.

policies. Although administrators will

smoke/health_effects/). Accessed 16 December 2015.

43

16

U.S. Department of Housing and Urban Development

need to clearly explain the new rule

Ibid.

2015. “Instituting Smoke-Free Public Housing,” 15.

17 Ibid.

to residents, promote smoking cessation

44 U.S. Department of Housing and Urban Development

18 Ibid.

programs, and consider residents’ input

2015. “Instituting Smoke-Free Public Housing,” 15.

19 Karen M. Wilson, Jonathan D. Klein, Aaron K. Blum-

45 U.S. Department of Housing and Urban Development, Of-

to ensure that the rule is fairly applied, the

kin, Mark Gottlieb, and Jonathan P. Winickoff. 2011.

fice of Lead Hazard Control and Healthy Homes 2014, 70.

rule stands to improve long-term health

“Tobacco-Smoke Exposure in Children Who Live in

46

Multiunit Housing,” Pediatrics 127:1, 86.

U.S. Department of Housing and Urban Development

outcomes, especially for vulnerable resi-

2015. “Instituting Smoke-Free Public Housing,” 4.

20 Centers for Disease Control and Prevention.

47

dents such as the young and elderly.

Ibid., 12.

21 Wilson et al., 86.

48 U.S. Department of Housing and Urban Development,

22 Jonathan P. Winickoff, Joan Friebely, Susanne E.

Office of Lead Hazard Control and Healthy Homes

— Keith Fudge, HUD Staff

Tanski, Cheryl Sherrod, Georg E. Matt, Melbourne F.

2014, 74.

Hovell, and Robert C. McMillen. 2009. “Beliefs About

49 Ibid., 62.

the Health Effects of ‘Thirdhand’ Smoke and Home

50 Ibid., 46.

1 U.S. Department of Housing and Urban Development.

Smoking Bans,” Pediatrics 123:1, 75.

2015. “HUD Secretary Castro Announces New Rule

23 Joanna M. Gaitens, Sherry L. Dixon, David E. Ja-

51 U.S. Department of Housing and Urban Development

Making Public Housing Smoke-Free, ” press release, 12

cobs, Jyothi Nagaraja, Warren Strauss, Jonathan W.

2015. “Instituting Smoke-Free Public Housing,” 48.

November.

Wilson, and Peter J. Ashley. 2009. “Exposure of U.S.

52 Matthews.

18

In Practice

Highlights

Financing Effective n The Pay for Success (PFS) model can help governments ensure that

their resources are spent on successful programs and has the potential

Housing Interven-

to encourage evidence-based policymaking. A variety of housing-related

PFS interventions are in progress.

tions With Pay for

n The Massachusetts Housing and Shelter Alliance and Santa Clara

Success

County, California, are using PFS interventions to expand and test

permanent supportive housing models in their communities.

In an era of tight public budgets,

n The Green & Healthy Homes Initiative, the Calvert Foundation, and the

private and philanthropic organiza-

Johns Hopkins Hospital and Healthcare System in Baltimore have part-

tions increasingly are underwriting

nered to develop a PFS contract to reduce asthma-related hospitalizations

public services through impact invest-

and emergency room visits in the city.

ments, which support a social good

while also generating a financial return.

In one form of impact investing, pay for

innovation of PFS is that payments are

financial risk for success are unlikely to

success (PFS), an organization (typi-

structured to reward results rather than

support programs that are not backed

cally a government) sets specific targets

reimburse providers for services ren-

by strong evidence because the possibility

that another organization, such as a

dered.2 One benefit of this approach is

of nonpayment would be too high.5

service provider or intermediary, must

that the cost of failure shifts from the

meet in return for payments. Private

government to private and nonprofit

Most PFS contracts have been imple-

and philanthropic investors supply

entities. Because payment for services is

mented in policy areas with the potential

the upfront capital that service provid-

for large savings from a new, more

ers use in exchange for a capped rate

effective program or preventive inter-

of return derived from the payments.

vention, such as in prisoner recidivism,

PFS has the poten-

The payments, however, are released

early childhood education, chronic

only if the desired targets are success-

homelessness, and workforce devel-

tial to encourage

fully met, which must be verified by an

opment.6 The very first PFS contract,

independent evaluator. An intermedi-

greater evidence-

the Social Impact Bond program at

ary organization with experience in PFS

Peterborough prison in the United

based policymaking

or the relevant policy area manages the

Kingdom, focused on reducing recidi-

contract and lines up investors. State

vism among ex-offenders who served

because rigorous

and local governments have begun

short prison terms. About 60 percent of

using PFS to implement interven-

evaluation is built

people in jail in the United Kingdom

tions to address education, asthma,

serve short sentences and cost the

into the contract.

homelessness, and prison recidivism.

Ministry of Justice about £40,000 (ap-

Housing-related PFS contracts designed

proximately US$60,000) per person per

to improve conditions for vulnerable

year. Launched in 2010, the Peterbor-

populations are currently underway

contingent on meeting specific targets,

ough project was projected to save £44

or under consideration in the state of

governments can ensure that their

million (approximately US$66 million)

Massachusetts; Santa Clara County, Cali-

resources are spent only on successful

and up to a possible £90 million (ap-

fornia; Cuyahoga County, Ohio; and

programs.3 This shift in risk gives pro-

proximately US$135 million) if returns

Baltimore, Maryland. Officials in these

viders an incentive to be innovative and

were better than expected.7 Social

communities expect to see not only

flexible in how they deliver services,

Finance, a nonprofit, served as the con-

better individual outcomes but also cost

swiftly adapting to changes and offering

tract’s intermediary organization, lined

savings in fields that housing quality af-

individually tailored services without

up funders, and helped assemble ONE

fects, such as criminal justice, childhood

fear of violating the terms of their con-

Service, the contract’s service provider.

welfare, and health care.1

tract.4 In addition, PFS has the potential

ONE Service did not use a fixed inter-

to encourage greater evidence-based

vention model or specific theory but

Innovations and Drawbacks policymaking because rigorous evalu- instead implemented a flexible contract Caroline Whistler, co-president of Third

ation is built into the contract; many

that deployed a combination of housing

Sector Capital Partners, a nonprofit

PFS contracts include randomized trials support, employment training, drug and

that helps construct PFS projects in

and control groups to measure success.

alcohol counseling, and mental health

the United States, says that the key

Also, private investors who bear the

services to keep ex-offenders out of jail.8

19

have an incentive to end programs that

are not on track to meet targets and

payout. John Cassidy, a senior manager

at Deloitte Consulting working with

the Centers for Disease Control and

Prevention (CDC) on PFS, says that

governments must design programs

that achieve outcomes without harming

the target population. Finally, interven-

tions that reach across agency boundaries

and levels of government face legal

and practical restrictions that make

aligning potential payers with effective

service providers difficult.15

Permanent Supportive

Housing

Permanent supportive housing programs

help families and individuals “break

the cycle of homelessness,” says Andy

McMahon, managing director of gov-

Massachusetts Housing & Shelter Alliance

Sherman (pictured above) found housing through MASH and has been able to turn his life around by improving ernment affairs and innovation at the

his health, volunteering, and reconnecting with his 15-year old son.

Corporation for Supportive Housing

(CSH), which improves the quality of

The potential for savings in excess of a

underway or in negotiation (four are

life for vulnerable populations, such

program’s cost and the fact that payments

discussed in this article), and only one,

as individuals experiencing chronic

are deferred until the project is success-

a prisoner recidivism contract with

homelessness, and decreases associated

ful have made PFS attractive to local

Riker’s Island, New York, has con-

service costs by reducing participants’

and state governments with constrained

cluded.11 More completed examples

use of expensive emergency services.16

budgets. In the Peterborough project,

are needed, says Yennie Tse, program

Unlike traditional models, which ad-

for example, interim results showed

manager in HUD’s Office for Interna-

dress the causes of homelessness before

that recidivism rates dropped com-

tional and Philanthropic Innovation, to

providing housing or as a precondition

pared with a control group, but that

understand the risk and reward of PFS

for remaining in housing, a permanent

drop was not enough to trigger the

and establish best practices, especially

supportive housing program provides

first round of payments. This example

those surrounding the structure of

individuals experiencing homeless-

highlights the appeal of PFS for govern-

contracts and negotiations.12 Without

ness with housing and voluntary

ments: the Ministry of Justice either got

an adequate understanding of risk

services first.17 McMahon argues that

the predetermined outcome or it did

versus reward, many investors remain

permanent supportive housing is well

not pay.9 Jeffrey Liebman of Harvard’s

philanthropic entities who can justify

adapted to PFS contracts because the

Social Impact Bond Laboratory

prioritizing social benefits. In cases

evidence base supports its effectiveness

observed that although constrained

where private investors have signed

and because it can significantly reduce

funding environments are forcing

on to PFS projects, such as the Riker’s

utilization costs in the healthcare and

programs to justify themselves, “it

Island initiative, their investments were

criminal justice systems. Permanent

remains the case that most government

partly guaranteed by a philanthropic

supportive housing, however, suffers

spending is not allocated based on the

organization.13

from the “wrong pocket problem,”

evidence or with a focus on innovation

which means that the savings from the

or performance.”10 PFS is one possible

PFS currently applies only to a limited

intervention accrue to an organization,

strategy to encourage greater innova-

number of policy areas. Programs that

agency, or government different from

tion and efficiency in the delivery

offer nonfinancial societal benefits or

the one paying for the intervention.18

of government services.

have difficult-to-measure outcomes may

not be suited to PFS.14 Many advocates

A 2014 review of permanent support-

Despite its promise, PFS remains largely

and researchers also note that PFS

ive housing studies found a “moderate”

untested, and a number of important

should not deliver essential government

amount of evidence supporting its

questions remain. In the United

services (such as fire and police protec-

benefits, adding that “[s]ubstantial

States, only a handful of contracts are

tion) because providers and investors

literature, including seven randomized

20

controlled trials, demonstrated that

model that sees significant savings in

The PFS initiative will allow MHSA to

components of the model reduced

health and criminal justice fields.22

expand its Home & Healthy for Good

homelessness, increased housing

program, a permanent supportive housing

tenure, and decreased emergency

Leveraging PFS To Combat Homeless-

program that has served 860 individuals

room visits and hospitalization.”19 A

ness in Massachusetts. The first PFS

experiencing chronic homelessness who

HUD study of families experiencing

contract for permanent supportive

are difficult to house and frequently use

homelessness in Washington, DC,

housing was awarded in 2014 in Mas-

high-cost services. Sixty-nine percent

found that permanent supportive

sachusetts, where state officials hope

of participants report having a mental

housing was 49 percent cheaper than

to house up to 800 individuals over the

health disability and 50 percent report

apartment-style shelter housing and

next 6 years and reduce the number

having a physical health disability, and

65 percent cheaper than congregate

of individuals in the state experienc-

tenants report being homeless for an

shelter housing.20 New York City found

ing chronic homelessness by half. The

average of 5 years before entering the

that for every unit of permanent sup-

Massachusetts Housing & Shelter Alli-

program. During the six months before

portive housing it provided, the city

ance (MHSA), a nonprofit dedicated

entering housing, the average tenant

saved $16,281 per year in medical and

to ending homelessness in Massachu-

spent more than four days in the hospi-

mental health care, and a 2008 study

setts, has partnered with CSH and the

tal, three days in detox, and five days in

of a Rhode Island permanent support-

United Way of Massachusetts Bay and

jail and made nearly three trips to the

ive housing project found the program

Merrimack Valley to provide 500 units

emergency room. By providing Home

reduced service costs by 25 percent

of supportive housing. CSH, United

& Healthy for Good participants with

pre- and post- entry into the program

Way, and Santander Bank N.A. are

housing, MHSA saved the state $12,101

by reducing the number of hospital

investing $2.5 million in the project.

per person per year, with most of those

stays, emergency room visits, and trips

If the project meets its target — all

savings coming from reductions in

to drug and alcohol treatment centers,

participants housed during the year

medical expenses.24

and encounters with the court system.21

remain stably housed for at least one

Uniting permanent supportive hous-

year — then the state of Massachusetts

The new PFS program, called the

ing and PFS has the potential to infuse

will make up to $6 million in success

Massachusetts Alliance for Supportive

new money into a housing intervention

payments.23

Housing (MASH), works with local

21

housing and service providers to place

providers to better understand differ-

which administers the state’s Med-

individuals who have been identified as

ent trends in different communities

icaid and Children’s Health Insurance

high-cost users of Medicaid in supportive

and make improvements to the housing

programs.27 MHSA, working through

housing. Using a mix of scattered- and

programs to ensure that they have a

MASH, helps local providers manage

single-site housing throughout Massa-

positive impact.25

their Medicaid billing and provides

chusetts, the program has placed 104

immediate financial support until pay-

individuals in supportive housing so far,

The PFS financing is a “highly lever-

ments are released. One strength of

with a goal of placing 250 participants

aged funding source,” explains Brigham,

this arrangement, says Brigham, is that

in its first year and 250 in its second

that brings in additional resources to

after the PFS contract ends, program

year. The supportive services are based

fund permanent supportive housing.

participants will retain most of their

on lessons learned from the Home &

The contract states that Massachusetts

supportive services because Medicaid

Healthy for Good program and link

will pay $3,000 per individual placed after

has no end date. The rental vouchers

paraprofessionals with tenants to help

a year of successful tenancy, but most

that are tied to MASH will also continue

them navigate local resources, find

of the costs of providing housing and

after the contract expires.28

employment opportunities, and medi-

services — about $17,000 per person

ate potential landlord-tenant disputes.

— are covered through other sources,

Incentivizing Housing Stability in

One of the innovations of this project,

such as $1 million in foundation grants,

Santa Clara County. Every night, more

says Tom Brigham, director of MHSA,

rental vouchers, Medicaid billing, and

than 6,500 people in California’s Santa

is a web-based data collection tool that

provider resources.26 Massachusetts has

Clara County do not sleep in their own

local providers and MHSA use to track

funded 145 project-based vouchers and

homes. Instead, they stay with friends,

individuals’ use of services and bouts

made them available to local housing

sleep in shelters, or live out on the

of homelessness. This tool, which will

providers, and the state is also setting

street. Of this group, approximately

be part of the eventual evaluation of

aside up to $11 million to fund health-

one-third has experienced chronic

the program, allows MHSA and local

related services through MassHealth,

homelessness, meaning that they

Alain McLaughlin

Permanent supportive housing programs help families achieve housing stability.

22

have a disabling condition, such as a

mental illness, and have been homeless

for a year or have had four periods of

homelessness in the past three years. In

addition to the human costs, homeless-

ness costs the county a lot of money; a

2015 study found that 104,206 county

residents who experienced homeless-

ness between 2007 and 2012 used more

than $3 billion in public services.29

Santa Clara County launched its first

PFS program in 2015, contracting with

Abode Services, a nonprofit committed

to ending homelessness, to provide 112

permanent supportive housing units

to individuals experiencing chronic

homelessness with comorbidities such

as a physical disability, a mental health

issue, or a substance abuse problem.

Project Welcome Home hopes to house

150 to 200 individuals over 6 years.

Abode Services will provide housing

and client-based supportive services,

and Third Sector Capital Partners will

help manage the contract. CSH and

Alain McLaughlin

Google, among others, are providing

Matt (pictured) was homeless for five years until he connected with an Abode Services worker who helped $6.9 million in investment capital and

him find a home in Oakland’s Lake Merritt neighborhood.

the University of California, San Fran-

cisco will evaluate the project.30

$6,831 after 12 months, up to a poten-

not overly concerned with enforcing

tial total of $12,420 per participant for

rules, focusing instead on keeping

The project’s overall goals are to im-

12 months of housing.33

people on track to meet their indi-

prove the quality of life of individuals

vidual goals.37

experiencing chronic homelessness

Individuals who utilize county services

and reduce participants’ reliance

frequently, particularly those experi-

Project Welcome Home is also being

on costly government services. The

encing chronic homelessness, place an

used as an opportunity to build the evi-

project’s official target is to have 80

inordinate financial strain on Santa

dence base for permanent supportive

percent of participants achieve 12

Clara County. The 2015 study also

housing.38 Although payment is linked

months of continuous, stable tenancy.

found that individuals experiencing

to the number of months of stable

After about a year of continuous

chronic homelessness cost the county

tenancy, a randomized control experi-

housing, says Louis Chicoine, chief

$83,000 annually in public services

ment is being run concurrently with the

executive officer of Abode Services,

per person.34 Abode’s various housing

project. Potential program participants

individuals experiencing chronic

options and supportive services allow it

are identified by the county and ran-

homelessness tend to stabilize and

to find the appropriate match for each

domly assigned to either the PFS group

become much less likely to lose their

participant’s needs, says Chicoine.35

or a group that receives normal county

home.31 The payment structure is

Individuals can live in master-leased,

services. According to Whistler, indi-

designed to reward long-term hous-

scattered-site units throughout the

viduals will be tracked when they come

ing, says Whistler, and “minimize

county or in single-site affordable

into contact with jails, shelters, and

having people drop out after a few

housing developments. For services,

emergency rooms, among other places,

months.”32 Payments are divided into

Abode has adopted the Assertive

to see whether stable housing reduces

three-month periods of stable, con-

Community Treatment (ACT) model,

their use of county services. The ability

tinuous tenancy and increase each

a multidisciplinary approach that uses

to introduce evidence-based evaluation

period. The contract pays $1,242 per

a team of professionals to deliver the

into county policymaking made PFS

participant for 3 months of stable hous-

specific mix of services a participant

an attractive prospect, says Whistler.

ing, then an additional $1,863 after 6

may need.36 According to Chicoine,

“When Pay for Success first came out,

months, $2,484 after 9 months, and

ACT is nonpunitive; the program is

there was this attachment to the idea

23

to help family caregivers struggling with

homelessness remain stably housed.

Under CTI, individuals receive different

levels of service, which Russell Spieth,

director of family services at FrontLine,

refers to as “dosages.” The first dose is

intensive, says Spieth. Case managers

work with program participants in their

new housing units three to four days

per week for approximately the first

three months. “We want to make sure

they are off to a good start,” explains

Spieth. “For example, we work with

landlords to help mediate disputes and

help individuals access services within

their community.” FrontLine gradu-

ally reduces the dosage as participants

establish relationships within their

community and require less direct

support, eventually ending CTI services

once families are stable. Funding CTI

services through PFS allows FrontLine

Alain McLaughlin

to offer a greater variety of services

Representatives from Santa Clara County, Abode Services, The Health Trust, the James Irvine Foundation, and Google.org celebrate the launch of Project Welcome Home.

than it would if it relied on Medicaid

reimbursement alone. Many of the

of cost savings by investing in interven-

connect to various community sup-

families served through the program

tions, but the primary interest for Santa

ports to reduce the number of days that

face unique, varied, and sometimes

Clara is to better spend the limited

children spend in foster care, called

nonmedical challenges that may not

resources they have.”39 Although results out-of-home placement days.41 Accord-

be covered by Medicaid. According

from the Project Welcome Home study

ing to David Merriman, administrator

to Spieth, it was important that “our

are not yet available, Abode reports that

of Cuyahoga County Job and Family

CTI workers feel free to do whatever

in fiscal year 2015, 90 percent of Abode

Services, “[W]e decided to explore Pay

need[s] to be done to successfully help

supportive housing residents either

for Success because it fit with what we

families reunify.”44

remained housed or exited to other

see as a new way of tackling home-

stable housing.40

lessness and improving childhood

The long-term success of the program

welfare as well as a strategy to effectively

will depend on the strength of the

Reuniting Families in

provide services at scale.”42 The county

relationship among the partner orga-

Cuyahoga County

expects savings in 3 service areas —

nizations, says Merriman.45 In addition

In January 2015, Cuyahoga County,

criminal justice, childhood welfare, and

to FrontLine Service and Enterprise

Ohio, launched a PFS initiative, Part-

homelessness — and will pay $75 per

Community Partners, numerous

nering for Family Success, to help 135

reduced foster care day based on the re-

nonprofit, philanthropic, and govern-

families struggling with homelessness

sults of a randomized control trial. The

ment agencies must work together

reunite with their children placed in

program’s overall target is a 25 percent

to achieve program objectives. The

foster care. Although children are

reduction in out-of-home placement

George Gund Foundation, for exam-

not placed in foster care specifically

days, at which point all funders will be

ple, was an early financial supporter

because of their parents’ homelessness,

paid back and the county would potentially of the initiative and funded an initial

problems such as substance abuse can

save $130,000. Reducing the placement

assessment performed by Third Sec-

create a lack of safe and stable housing

rate by up to 50 percent could save

tor Capital Partners. The Cuyahoga

that can cause children to be removed

Cuyahoga County $3.5 million.43

Metropolitan Housing Authority is

from their parents’ care. Through the

providing the bulk of the housing,

Partnering for Family Success initia-

FrontLine Service is using a Housing

creating a priority preference for

tive, FrontLine Service, a homelessness

First strategy and adapting Critical

caregivers enrolled in the program,

service provider, and Enterprise Com-

Time Intervention (CTI), a therapy

and Cuyahoga County’s Office of

munity Partners will help vulnerable

designed to help individuals transition

Homeless Services and the Children

families access supportive housing and

from an institution into housing,

and Family Services department will

24

manage referrals, with assistance from

provide residents with education on

attacks and subsequent hospitaliza-

the nonprofit Domestic Violence and

asthma triggers and low-cost items such

tions can translate into large savings

Child Advocacy Center.46

as allergen-impermeable covers for

for governments and public hospitals.52

beds and pillows. Moderate interventions

Asthma interventions, however, are

Remediating Asthma Triggers include multiple low-cost options, in-

affected by the previously mentioned

With PFS Financing

home training, or professional cleaning.

wrong pocket problem; despite their

Asthma affects millions of people in

Major interventions tackle structural

wide range of health benefits, they are

the United States, including 7 million

improvements such as changing ventila-

funded largely by housing programs

children, and, according to the CDC,

tion systems.50

such as HUD’s Healthy Homes Pro-

results in $50.1 billion in direct costs

gram.53 Using PFS to link housing to

and $5.9 billion in indirect costs such as

Asthma interventions are well suited to

health would allow more resources to

lost productivity.47 Although a number PFS because in-home changes can sub-

be spent on preventive interventions

of factors can trigger an asthma attack,

stantially reduce medical costs, benefit

instead of expensive emergency care.

many asthma triggers are environmen-

low-income individuals who frequently

tally based and can be reduced through

use public resources such as Medicaid,

The Green & Healthy Homes Initia-

housing remediation.48 The CDC’s

and have a long track record of success.

tive (GHHI), the Calvert Foundation,

Community Preventive Services Task

The U.S. Department of Health and

and Johns Hopkins Hospital and

Force recommends a home-based, mul-

Human Services has estimated that

Healthcare System in Baltimore have

titrigger, multicomponent approach for

every dollar invested in asthma interven-

partnered to develop a PFS contract to

children with poorly controlled asth-

tions saves between $5.30 and $14.00.51

reduce asthma-related hospitalizations

ma.49 Interventions and remediation

Poor, urban, and minority children are

and emergency room visits. GHHI, a

programs reduce dust mites, pollen,

more likely to be affected by asthma

nonprofit organization with a history of

mold, pet dander, cockroach drop-

and are more likely to depend on

reducing environmental hazards that

pings, and cigarette smoke and work on

publically funded healthcare options,

undermine the health of children and

a variety of scales. Minor interventions

meaning that a reduction in asthma

families, will remediate 1,800 homes.

Photo by Andre Chung

A GHHI environmental assessment technician documents home health hazards during a comprehensive home assessment.

25

Johns Hopkins will have access to the

medical usage database, Chesapeake

Regional Information System for Our

Patients, which will allow them identify

children going to the emergency room

for asthma-related issues and quickly

recommend in-home assessment and

remediation.58

Working with a health system as the

payer rather than a government entity

involves considerable upfront work, says

Norton, but doing so is essential to the

long-term scalability of the health-based

housing intervention. She explains

that changing financial incentives are

encouraging hospitals to emphasize

preventive care to “reduce hospitaliza-

tions and repetitive use of the emergency

room by addressing asthma triggers in

the home environment.” Demonstrat-

ing the business case and strong financial

returns of asthma remediation to

Photo Courtesy of Green & Healthy Homes Initiative

hospitals and state Medicaid programs

By providing remediation and energy-efficiency services, GHHI helps families like Lekquan and her son improve the quality of their housing.

should encourage other communities to

adopt remediation programs.59 GHHI

The Calvert Foundation, a community

in-home assessment and educational

recently received $1.011 million from

development financial institution, is the

session about asthma triggers followed

the Corporation for National and Com-

primary investor, and Johns Hopkins’

by the removal of known triggers. GHHI

munity Service to evaluate the feasibility

Medicaid managed care organization

follows up with families throughout

of asthma-related PFS contracts in five

will make success payments. Johns

the first year to ensure that GHHI’s

other locations: Buffalo, New York;

Hopkins will cover the cost of the con-

healthy home standards are being

Grand Rapids, Michigan; Memphis,

tract through decreases in emergency

maintained.56 The intervention model,

Tennessee; Salt Lake City, Utah; and

room visits and hospitalizations from

which was established with input from

Springfield, Massachusetts. GHHI, the

those with chronic asthma.54 Accord-

HUD and the U.S. Environmental

Calvert Foundation, Milliman, and

ing to Ruth Ann Norton, president and

Protection Agency, has been shown to

Health Management Associates are

CEO of GHHI, the goal is to make the

reduce asthma-related hospitalizations

working with service providers and

“health clinic to the home a seamless

by 66 percent and emergency room

health systems in these five cities and

connection. We are trying to make con-

visits by 28 percent.57

are adapting the lessons and models

tractors who do remediation the new

developed in the Baltimore program to

face of health care. How we repair our

GHHI, the Calvert Foundation, and

these remediation programs.60 HUD’s

homes and what we put into them have

Johns Hopkins are currently in the

Office of Healthy Homes and Lead

everything to do with health.”55

final stages of negotiation and are still

Hazard Control is also expanding PFS

developing the economic and actuarial

by supporting program development

GHHI takes a holistic approach to cre-

modeling necessary for the contract. The

that will provide new capital investment

ating healthy homes, improving energy

payment structure for the contract will

for home interventions in two pilot

efficiency as well as remediating toxins,

be tied to either a success metric, such

locations: the city of San Diego and

making home improvements to reduce

as the number of homes remediated, or

Alameda County, California.61

asthma triggers, and providing hous-

the reduction in emergency room visits

ing and health education. GHHI works

and hospitalizations. Norton reports

Other Potential Housing

to develop relationships with families

that a secondary goal is to examine

Interventions

and has found that home improve-

the effect of remediation programs on

As the body of research linking housing

ments coupled with asthma education

school and work attendance, but this

and neighborhood to health, wellness,

produce the best long-term results. The

examination has not been built into

education, crime, and childhood out-

remediation process begins with an

the economic modeling. GHHI and

comes grows, more housing programs

26

might benefit from PFS contracting.

the Fall 2014 issue of Evidence Matters). Affordable Care Act expands Medicaid Where a person lives can affect his or

Programs that improve the physical

in 31 states (including the District of

her risk of diabetes and obesity, level

dimensions of housing, move families

Columbia) to cover more high-risk indi-

of school achievement, and access to

to amenity-rich, low-poverty neigh-

viduals.62 Although Medicaid does not

economic opportunity. Poor-quality

borhoods, or improve high-poverty

currently cover direct housing costs,

housing (often found in high-poverty

neighborhoods could feasibly generate

evidence attesting to housing’s role in

neighborhoods) can also contribute to

savings for the government that exceed

health outcomes may change what is

childhood asthma and lead poisoning,

the cost of the program.

seen as a medical expense. Santa Clara

and other dimensions of housing, such

County and Massachusetts, as well as

as crowding, affordability, and stability,

Housing interventions shown to reduce

numerous other permanent support-

have been shown to affect childhood

medical costs may attract Medicaid

ive housing projects, all demonstrate

development and overall success (see

funding as the Patient Protection and

the value of linking Medicaid-funded

HUD Engages With Partners in Pay for Success Demonstrations

On October 15, 2015, HUD, in partnership with the U.S. Department of Justice (DOJ), announced $8.7 million in demonstration grants to use Pay for Success (PFS) financing to reduce homelessness and prisoner recidivism. Although policymakers have made significant progress toward the federal goal to end chronic homelessness, 84,291 individuals were identified in 2014 as experiencing chronic homelessness. Because of their housing instability, many of these individuals cycle in and out of emergency rooms, psychiatric centers, and jails. Ex-offenders are particularly susceptible to homelessness, which may affect recidivism rates. According to the National Alliance to End Homelessness, 10 percent of people recidivat-ing were homeless beforehand, and 20 percent of people leaving prison become homeless upon reentering the community.1

The DOJ/HUD PFS Permanent Supportive Housing Demonstration is an opportunity to test the effectiveness of using PFS to finance permanent supportive housing with a Housing First approach. The demonstration targets people experiencing homelessness who also have frequent contact with the criminal justice, homeless services, and healthcare systems. HUD will award a maximum of $1.3 million to each grantee organization to carry out one or more of the fol owing eligible activities:

n Feasibility analysis: Conducting an analysis to determine whether a PFS project implementing permanent supportive housing is feasible at a particular site.

n Transaction structuring: Structuring a contract between all stakeholders of the PFS project.

n Outcome evaluation: Evaluating and validating the outcomes of the PFS-financed permanent supportive housing intervention through a third-party evaluator.

n Success payments: Some grant funding is available to partially cover the costs of successful outcomes of the permanent supportive housing intervention.2

These grants will build capacity in the PFS field for using permanent supporting housing as an intervention to address homelessness and reduce recidivism among people who are frequently involved with the criminal justice system.

Achieving these dual objectives may help alleviate pressure on strained government budgets and meet the goal to end chronic homelessness.

Separately, HUD is designing another PFS demonstration, authorized through the Fixing America’s Surface Transporta-tion Act, that will increase the efficiency of energy and water systems in multifamily rental buildings receiving HUD

assistance. HUD will partner with Enterprise Community Partners, Inc., the Low Income Investment Fund, and Stewards of Affordable Housing for the Future for this demonstration, which is currently in development.3

1 U.S. Department of Housing and Urban Development. 2015. “Pay for Success Permanent Supportive Housing Demonstration,” 3–5.

2 Ibid.

3 Enterprise Community Partners. 2014. “Bipartisan Legislation to Increase Energy Efficiency in Multifamily Housing Introduced in Congress, ” press release (15 June).

27

Corporation for Supportive Housing

One of 60 apartments in Palo Verde, L.A. Family Housing’s first permanent supportive housing project for low-income adults formerly or currently experiencing chronic homelessness or who are living with mental illness.

supportive services to housing. According

mobility program, Rinzler et al. found

not mean that PFS is an easy solution or

to Brigham, Medicaid funding is a criti-

that reductions in adult diabetes and

appropriate for every type of interven-

cal component of the MASH program.63 extreme obesity could generate savings

tion. Governments and practitioners

In addition to permanent supportive

that more than cover the cost of a mobility

need to “dissect the data to understand

housing programs, PFS contracts could

program. Using data from HUD’s MTO

the problem’s prevalence, geographic

potentially cover interventions to reme-

experiment and a Baltimore mobility

scope, and target population” before

diate lead and reduce asthma triggers

program, Rinzler et al. found that the

embarking on a PFS contract, explains

in the home. According to Norton,

programs, which cost $2.2 million to

Cassidy. Beginning a PFS contract

in-home asthma and lead remediation run over a 10-year period, generated

requires a long-term commitment from a

are healthcare expenses because they

$3.8 million in medical savings.66 Pollack

number of dedicated organizations.69

are directly tied to the health of the

et al., however, write that researchers

The precontract assessment and analysis

individual.64

would need to answer several questions

of the target populations and financial

about the optimal way to obtain health-

modeling of possible interventions can

PFS contracts could also potentially

care savings before a housing mobility

take up to two years to complete on

link housing mobility programs to

PFS contract could move forward.67

top of months of contract negotiations

Medicaid because where people live

among governments, service providers,

affects their health. HUD’s Moving to

Conclusion

investors, and intermediary organizations.70

Opportunity for Fair Housing Demon-

Interest in PFS has grown quickly over

stration Program (MTO) found that

the past few years as more communities According to Tse, many investors look for

moving to lower-poverty neighborhoods

look for innovative ways to solve social-

strong local leadership and strong part-

correlated with better health outcomes,

sector problems, says Cassidy. “There

nerships with local actors before they

especially for women, who experienced

have been dozens of attempts to solve

will consider supporting a PFS-funded

lower rates of obesity and diabetes and

problems in a traditional way … and

intervention. Contracts are improved

fewer incidents of psychological distress

this model brings new people to the

by having good working relationships

and depression.65 In a study modeling

table who wouldn’t normally be here.”68 among all partners and by using service

the savings that result from a housing

This growing interest, however, does

providers with proven track records of

28

running successful programs.71 Using

Cassidy, by reducing hospitalizations,

Accountability Office. 2015. “Collaboration among

Federal Agencies Would Be Helpful as Governments

trusted service providers can help

the need for special education classes,

Explore New Financing Mechanisms,” 6–8.

assuage local government fears over the

and the number of youth interacting

2 Interview with Caroline Whistler, 10 October 2015;

loss of control that PFS requires. Abode,

with the juvenile justice system, but

U.S. Government Accountability Office, 6–8.

FrontLine, GHHI, and MHSA have

forecasting the exact dollar amount

3 Eileen Neely. 2014. “Unlocking Private Capital to

Invest in Human Capital,” Institutional Investor website

decades of experience with permanent

and to whom it will accrue is difficult,

(www.institutionalinvestor.com/blogarticle/3303554/

supportive housing or asthma remedia-

and any savings may only be realized

Blog/Unlocking-Private-Capital-to-Invest-in-Human-

Capital.html#.VplaNSorKUk). Accessed 15 January tion. Granting these organizations

years in the future.74 When savings ac-

2016.

flexibility allows them to individually

crue at different levels of government,

4 Overholser and Whistler, 5–6.

tailor their services to their clients

aligning all of the necessary players

5 Glahn and Whistler , 21; Hanna Azemati, Michael

and increases the likelihood of success. can be challenging. In Massachusetts,

Belinsky, Ryan Gillette, Jeffrey Liebman, Alina Sell-

man, and Angela Wyse. 2013. “Social Impact Bonds:

In permanent supportive housing, for

the MASH program operated at the

Lessons Learned So Far,” Community Development example, landlord-tenant management

state level and therefore was tied to

Investment Review 9:1, 30; U.S. Government Account-

ability Office, 52.

can be crucial to a participant’s success

Medicaid savings based on the state’s

6 Azemati et al., 7, 29.

in remaining stably housed but often is

contribution rather than the federal

7 Currency conversion is based on November 2015

not covered because it is not a medical

government’s contribution.

exchange rate.

expense. In Santa Clara County, Abode

8 U.K. Ministry of Justice. 2014. “Peterborough Social

Impact Bond HMP Doncaster: Payment by Results

is able to use PFS funding to cover this

Many PFS contracts focus primarily on

pilots — Final re-conviction results for cohorts 1,”

crucial service.72

cost savings, but encouraging more

Ministry of Justice Statistics Bulletin (7 August); Centre

for Social Impact Bonds. 2013. “Ministry of Justice:

governments to reimburse for results in

Offenders released from Peterborough Prison”

Governments need to decide on

all of their programming could “mea-

(data.gov.uk/sib_knowledge_box/ministry-justice-

offenders-released-peterborough-prison). Accessed 15

an appropriate evaluation system for

surably improve the lives of people

January 2016; U.K. Ministry of Justice. 2014. “Revision

the intervention that is derived from

in need,” says Whistler.75 Many of the

to: Phase 2 report from the Payment by Results Social

the goals of the contract. Santa Clara

organizations involved in these early ex-

Impact Bond Pilot at HMP Peterborough” (www.gov.

uk/government/uploads/system/uploads/attach-

County based payments on a success

amples see PFS as a means to increase

ment_data/file/325738/peterborough-phase-2-pilot-

metric — the duration of stable housing

evidence-based policymaking. “We are

report.pdf). Accessed 15 January 2016.

9 U.K. Ministry of Justice 2014. “Phase 2 report.”

for individuals experiencing chronic

looking to use pay for success and social

10 Jeffrey Liebman. 2013. “Building on Recent Advances

in Evidence-Based Policymaking,” Brookings Institution, 2–4.

11 “Pay for Success U.S. Activity,” Nonprofit Finance

PFS contracts could potentially cover

Fund website (www.payforsuccess.com/pay-success-

deals-united-states). Accessed 23 October 2015; Justin Milner, Erika C. Poethig, John Roman, and Kelly

interventions to remediate lead and reduce

Walsh. n.d. “Putting evidence first: Learning from the

Rikers Island social impact bond,” Urban Institute.

asthma triggers in the home.

12 Azemati et al., 29; Overholser and Whistler, 7.

13 Overholser and Whistler, 8; Azemati et al., 27.

14 Kohli, Besharov, and Costa; U.S. Government Ac-

countability Office, 35.

homelessness — because county officials

impact investing,” says McMahon, “as a

15 Interview with John Cassidy, 14 October 2015; Ian

felt that the evidence base for permanent

lever to change public policy in the way

Galloway. 2014. “Using Pay-for-Success to Increase

supportive housing was strong enough

government allocates money, focusing

Investment in the Nonmedical Determinants of

Health,” Health Affairs 33:11, 1901.

to do so. In Cuyahoga County, officials

more of it on solutions with proven effi-

16 Interview with Andy McMahon, 11 October 2015.

contracted with Case Western Reserve

cacy.”76 Numerous interventions that offer 17 U.S. Interagency Council on Homelessness. “Perma-

University to employ a randomized

significant quality of life improvements —

nent Supportive Housing” (www.usich.gov/solutions/

housing/permanent-supportive-housing). Accessed control trial to measure the impact of the

for example, those that link housing and

23 October 2015; U.S. Department of Housing and

intervention and serve as the basis for

neighborhoods to school improvements

Urban Development. n.d. “Housing First in Perma-

payments.

nent Supportive Housing” (www.hudexchange.info/

73

— could be enhanced by emphasizing the

resources/documents/Housing-First-Permanent-

success of the program rather than the

Supportive-Housing-Brief.pdf). Accessed 15 January The wrong pocket problem remains

program’s specific inputs.

2016.

18 Interview with Andy McMahon.

difficult to overcome. The intricacies of

19 Debra J. Rog, Tina Marshall, Richard H. Dougherty,

social policy, especially surrounding hous-

1 Jitinder Kohli, Douglas J. Besharov, and Kristina

Preethy George, Allen S. Daniels, Sushmita Shoma

Costa. 2012. “Social Impact Bonds 101: Defining an

ing and its impact on health, education,

Ghose, and Miriam E. Delphin-Rittmon. 2014. “Per-

Innovative New Financing Tool for Social Programs,”

manent Supportive Housing: Assessing the Evidence,”

and economic opportunity, are difficult

Center for American Progress, 2; Drew Von Glahn and

Psychiatry Services 65:3, 287–94.

to unwind in a way that can link savings

Caroline Whistler. 2011. “Pay for Success Programs:

20

An Introduction,” Policy and Practice (June) , 19–22; Brooke Spellman, Jill Khadduri, Brian Sokol, and

in one program to costs in another.

George Overholser and Caroline Whistler. 2013. “The

Josh Leopold. 2010. “Costs Associated With First-Time

Homelessness for Families and Individuals,” U.S. De-Asthma and lead remediation often

Real Revolution of Pay for Success: Ending 40 Years

of Stagnant Results for Communities,” Community partment of Housing and Urban Development.

more than pay for themselves, says

Development Investment Review 9:1, 7; U.S. Government

21 Dennis P. Culhane, Stephen Metraux, and Trevor

29

Hadley. 2002. “Public Service Reductions Associated

40 Email Correspondence with Katie Derrig, Grants and

“Lead Hazard Control and Healthy Homes: Lead

with Placement of Homeless Persons with Severe

Communications Manager with Abode Services, 14

Hazard Reduction — 2016 Summary Statement and

Mental Illness in Supportive Housing,” Housing Policy

October 2015.

Initiatives, ” 33-3; Kavita Patel, Steve Farmer, Meaghan Debate 13:1, 107–63; Eric Hirsch and Irene Glasser.

41 Cuyahoga County Office of the Executive. 2014.

George, Frank McStay, and Mark McClellan. 2014.

2008. “Rhode Island’s Housing First Program Evaluation,”

“Nation’s First County -Level Pay for Success Program

“Pediatric Asthma: An Opportunity In Payment

United Way of Rhode Island; “Permanent Supportive

Aims to Reconnect Foster Children with Caregiv-

Reform And Public Health,” Health Affairs Blog (18

Housing: A Cost-Effective Alternative in the District

ers in Stable, Affordable Housing, ” press release, 3

September).

of Columbia,” Coalition for Nonprofit Housing &

December.

54 Green and Healthy Homes Initiative and the Calvert

Economic Development website (www.cnhed.org/

42

Foundation. 2015. “RFP #2 for Pay for Success/Social

blog/2011/11/permanent-supportive-housing-a-cost-

Interview with David Merriman, 15 October 2015.

Impact Bonds Projects” (www.greenandhealthyhomes.

effective-alternative-in-the-district-of-columbia/).

43 “Fact Sheet: The Cuyahoga Partnering for Family

org/sites/default/files/GHHI-RFP-2.pdf). Accessed Accessed 15 January 2016.

Success Program” Pay for Success Learning Hub website (www.payforsuccess.org/sites/default/

16 January 2016.

22 Kohli, Besharov, and Costa, 3.

files/141204_cuyahoga_pfs_fact-sheet.pdf). Accessed 55 Interview with Ruth Ann Norton, 16 October 2016.

23 Corporation for National and Community Service,

15 January 2016.

56 Green and Healthy Homes Initiative. 2015. “Green

Office of Research and Evaluation. 2015. “State of

44 “Fact Sheet: The Cuyahoga Partnering for Family

& Healthy Homes Initiative Selects Service Providers

the Pay for Success Field: Opportunities, Trends, and

Success Program.”

to Participate in Asthma-Related Pay for Success

Recommendations, ” 26; Marcy Thompson, Keith Harris, and Richard Cho. 2015. “When Homelessness

45 Interview with David Merriman.

Projects,” press release, 19 May.

Becomes Rare, Brief, & Non-Recurring: Clarifying the

46 “Fact Sheet: The Cuyahoga Partnering for Family Suc-

57 Interview with Ruth Ann Norton.

Federal Criteria and Benchmarks,” U.S. Interagency

cess Program” ; Interview with David Merriman.

58 Ibid.

Council on Homelessness website (www.usich.gov/

47 U.S. Centers for Disease Control and Prevention.

59 Ibid.

news/clarifying-the-federal-criteria-benchmarks). Ac-

2011. “Vital Signs: Asthma in the U.S. ,” CDC Vital 60

cessed 23 December 2015.

Green and Healthy Homes Initiative.

Signs (May).

61

24 Massachusetts Housing and Shelter Alliance. 2015.

Alameda County Community Development Agency.

48 Green and Healthy Homes Initiative and the Child-

“Permanent Supportive Housing: A Solution-Driven

2015. “Accept Grant Award From the U.S. Depart-

hood Asthma Leadership Coalition. 2014. “Issue

Model — June 2015 Home & Healthy for Good

ment of Housing and Urban Development Via

Brief: Using Social Impact Financing to Improve

Progress Report.”

Quantech, Inc. for a Pay for Success Asthma Demon-

Asthma Outcomes.”

stration Project in Alameda County, ” correspondence 25 Interview with Tom Brigham, 16 October 2015.

49 U.S. Centers for Disease Control and Prevention.

with the Alameda County Board of Supervisors, 26

26 Interview with Tom Brigham.

2011. “Recommendations from the Task Force on

May.

27 Commonwealth of Massachusetts and Massachusetts

Community Preventive Services to Decrease Asthma

62 Janet Viveiros. 2015. “Affordable Housing’s Place in

Alliance for Supportive Housing. 2014. “Pay for

Morbidity Through Home-Based, Multi-Trigger,

Health Care,” National Housing Conference’s Center

Success Contract by and between the Commonwealth

Multicomponent Interventions,” American Journal of for Housing Policy, 2–8; Kaiser Family Foundation.

of Massachusetts and Massachusetts Alliance for Sup-

Preventive Medicine 41:2S1, S1.

“Current Status of State Medicaid Expansion Deci-

portive Housing, ” 7–8, appendix M.

50 U.S. Centers for Disease Control and Preven-

sions” (kff.org/health-reform/slide/current-status-

28 Interview with Tom Brigham.

tion. “Common Asthma Triggers” (www.cdc.gov/

of-the-medicaid-expansion-decision/). Accessed 26

asthma/triggers.html). Accessed 23 December 2015; 29 Economic Roundtable. 2015. “Home Not Found: The

October 2015.

Tursynbek A. Nurmagambetov, Sarah Beth L. Barnett,

Cost of Homelessness In Silicon Valley, ” County of 63

Verughese Jacob, Sajal K. Chattopadhyay, David P.

Interview with Tom Brigham.

Santa Clara, 14.

Hopkins, Deidre D. Crocker, Gema G. Dumitru, and

64 Interview with Ruth Ann Norton.

30 County of Santa Clara, Office of Public Affairs. 2015.

Stella Kinyota. 2011. “Economic Value of Home-

65 Lisa Sanbonmatsu, Jens Ludwig, Lawrence F. Katz,

“County of Santa Clara Launches California’s First

Based, Multi-Trigger, Mulicomponent Interventions

Lisa A. Gennetian, Greg J. Duncan, Ronald C. Kessler,

‘Pay for Success’ Project,” press release, 13 August;

with an Environmental Focus for Reducing Asthma

Emma Adam, Thomas W. McDade, and Stacy Tessler

County of Santa Clara. 2015. “Project Welcome Home

Morbidity: A Community Guide Systematic Review,”

Lindau. 2011. Moving to Opportunity for Fair Housing

Fact Sheet” (www.payforsuccess.org/sites/default/

American Journal of Preventive Medicine 41:2, S39.

Demonstration Program: Final Impacts Evaluation, U.S.

files/final_-_150811_scc_ch_pfs_fact_sheet_vfinal_0.

51 Deidre D. Crocker, Stella Kinyota, Gema G. Dumitru,

Department of Housing and Urban Development, Of-

pdf). Accessed 23 December 2015.

Colin B. Ligon, Elizabeth J. Herman, Jill M. Ferdi-

fice of Policy Development and Research, foreword.

31 Interview with Louis Chicoine, 5 October 2015.

nands, David P. Hopkins, Briana M. Lawrence, and

66 Dan Rinzler, Philip Tegeler, Mary Cunningham, and

32 Interview with Caroline Whistler.

Theresa A. Sipe. 2011. “Effectiveness of Home-Based,

Craig Pollack. 2015. “Leveraging the Power of Place:

33 County of Santa Clara.

Multi-Trigger, Multicomponent Interventions with an

Using Pay for Success to Support Housing Mobility,”

Environmental Focus for Reducing Asthma Morbid-

34 Economic Roundtable, 2.

Federal Reserve Bank of San Francisco, 2–13.

ity: A Community Guide Systematic Review,” American

67

35 Interview with Louis Chicoine.

Journal of Preventive Medicine 41:2S1, S5–S32.

Craig Evan Pollack, Rachel L. Johnson Thornton, and

Stefanie DeLuca. 2014. “Housing for Health: Target-

36 Susan D. Phillips, Barbara J. Burns, Elizabeth R.

52 T. Bryant-Stephens and Y. Li. 2008. “Outcomes of a

ing housing mobility vouchers to help families with

Edgar, Kim T. Mueser, Karen W. Linkins, Robert

home-based environmental remediation for urban

children,” Journal of the American Medical Association A. Rosenheck, Robert E. Drake, and Elizabeth C.

children with asthma,” Journal of the National Medical Pediatrics 168:8, 695–6.

McDonel Herr. 2001. “Moving Assertive Community

Association 100:3, 306–16; G. Flores, C. Snowden-

Treatment Into Standard Practice,” Psychiatric Services Bridon, S. Torres, R. Perez, T. Walter, J. Brotanek,

68 Interview with John Cassidy.

52:6, 771–9.

H. Lin, S. Tomany-Korman 2009. “Urban minority

69 Ibid.

children with asthma: substantial morbidity, com-

37 Interview with Louis Chicoine.

70 Interview with Yennie Tse, 19 October 2015.

promised quality and access to specialists, and the

38 University of California, San Francisco. 2015. “Evalu-

importance of poverty and specialty care,” Journal of 71 Ibid.

ation of Provision of Permanent Supportive Housing

Asthma 46:4, 392–8.

72 Interview with Louis Chicoine.

for Chronically Homeless Individuals Through Pay

53 U.S. Department of Housing and Urban Develop-

73 Interview with Yennie Tse.

for Success,” ClinicalTrials.gov website (clinicaltrials.

ment. “The Healthy Homes Program” (portal.hud.

gov/ct2/show/NCT02440360). Accessed 15 January 74 Interview with John Cassidy.

gov/hudportal/HUD?src=/program_offices/healthy_

2016.

75

homes/hhi). Accessed 23 December 2015; U.S.

Interview with Caroline Whistler.

39 Interview with Caroline Whistler.

Department of Housing and Urban Development.

76 Interview with Andy McMahon.

30

Additional Resources

n “A State Policy Framework for Integrating

n “Housing and Health: New Opportunities

Force, describes the looming demographic

Health and Social Services” (2014), by

for Dialogue and Action” (2014), by Jeffrey

challenges and potential opportunities re-

Tricia McGinnis, Maia Crawford, and Ste-

Lubell, Rebecca Morley, Marice Ashe, Linda

lated to America’s growing senior population.

phen A. Somers, offers a five-step policy

Merola, and Jeff Levi, documents various

bipartisanpolicy.org/wp-content/up-

framework that states can use to establish

ways in which housing affects health and

loads/2015/09/BPC-Housing-Health-

infrastructure for integrating health and

outlines steps that the public health and

Senior-Population.pdf.

social services, especially as they relate

housing policy communities can take to

to Medicaid beneficiaries.

strengthen collaboration and promote mu-

n “Medicaid and Permanent Supportive

www.commonwealthfund.org/publica-

tual goals. changelabsolutions.org/sites/

Housing for Chronically Homeless Individu-

tions/issue-briefs/2014/jul/state-policy-

default/files/Health%20%20Housing%20

als: Emerging Practices From the Field”

framework-health-social-services.

New%20Opportunities_final.pdf.

(2014), from the U.S. Department of Health

and Human Services, explains how federal

n “The Connection between Health and

n “Housing and Health Care: A Toolkit for

government resources have expanded per-

Housing: The Evidence and Policy Land-

Building Partnerships” (2014), by Leading

manent supportive housing and innovations

scape” (2015), by Beeta Rasouli and

Age, provides a variety of practical re-

in healthcare that will affect Medicaid and

Joshua Okrent, reviews specific federal,

sources related to housing and health care

housing programs. aspe.hhs.gov/sites/

state, and local housing initiatives aimed at

partnerships, including guides on how to

default/files/pdf/77116/EmergPrac.pdf.

improving the health of children and fami-

identify partners and structure relationships,

lies and examines their cost implications.

insights from healthcare practitioners, and

n “The Payoff of Pay-for-Success” (2015),

allhealth.org/publications/Disparities_

a return-on-investment calculator.

by V. Kasturi Rangan and Lisa A. Chase,

in_health_care/Health-and-Housing-

leadingage.org/housinghealth/.

argues that adapting pay-for-success

Toolkit_168.pdf.

contracts outside a narrow band of social

n The Power of Impact Investing: Putting

policy will be difficult and that philanthro-

n “Leveraging the Social Determinants of

Markets to Work for Profit and Global Good

pies, not private investors, will remain the

Health: What Works?” (2015), by Lauren

(2014), by Judith Rodin and Margot Bran-

major source of funding. ssir.org/up_for_

A. Taylor, Caitlin E. Coyle, Chima Ndumele,

denburg, explores the evolving role of impact

debate/article/the_payoff_of_pay_for_

Erika Rogan, Maureen Canavan, Leslie

investing and its relationship with traditional

success.

Curry, and Elizabeth H. Bradley, evaluates

philanthropic strategies and investment

and summarizes the evidence underlying in-

tools.   wdp.wharton.upenn.edu/book/

n “Hospitals as Hubs to Create Healthy

terventions that address social determinants

the-power-of-impact-investing/?utm_

Communities: Lessons from Washington

of health and focuses on innovative models

source=rfblogpost&utm_medium=

Adventist Hospital” (2015), by Stuart M. But-

in Massachusetts that improve health and

web&utm_campaign=impactinvesting.

ler, Jonathan Grabinsky, and Domitilla Masi,

reduce costs. bluecrossfoundation.org/

examines the potential of hospitals to serve

sites/default/files/download/publication/

n The “Dimensions of Quality” toolkit, by

as an “upstream” factor positively affecting

Social_Equity_Report_Final.pdf.

the Corporation for Supportive Housing,

health care. www.brookings.edu/re-

provides resources on implementing per-

search/papers/2015/09/28-hospitals-as-

n “Reconnecting Health and Housing: Philan-

manent supportive housing programs for

hubs-to-create-health-communities-but-

thropy’s New Opportunity” (2015), by David

housing developers, government officials,

ler-grabinsky-masi.

D. Fukuzawa and Fred Karnas, explores

tenants, and healthcare organizations.

how philanthropy can play a vital role in

www.csh.org/quality.

connecting the housing and health sectors

For additional resources archive, go to

by building an evidence basis, fostering

n “America’s Growing Senior Population:

www.huduser.gov/portal/periodicals/

discourse and policy change, and promoting

Assessing the Dimensions of the Demo-

em/additional_resources_2016.html.

innovation. online.liebertpub.com/doi/

graphic Challenge” (2015), by the Bipartisan

pdfplus/10.1089/env.2015.0006.

Policy Center’s Health and Housing Task

Evidence Matters

Discuss this issue on the

Evidence Matters Forum at

Rachelle Levitt: Editor

www.huduser.gov/forums.

Keith Fudge: Managing Editor

You can subscribe to

Evidence Matters at

Authors: Keith Fudge (HUD) and

Sage Computing staff

www.huduser.gov/

portal/evidence.html.

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