Health and housing gap for seniors is far larger and more expensive than we think

Conrado Solano, a retired Navy maintenance crewman, lost his health and then his house. He was 77 when bad luck hit in 2012. He had his hip replaced, started dialysis for kidney failure a year later, lost his house to foreclosure, lived briefly in a rented garage, and then moved into a long-term care facility in Daly City, Calif., just south of San Francisco.  

Solano’s luck took a turn for the better in 2015. As he recovered in a skilled nursing facility, his care team recognized that his return to the community hinged on obtaining affordable housing. Solano’s health plan, Health Plan of San Mateo, connected him with the Community Care Settings Program (CCSP) sponsored by the plan.

{mosads}The program manages medical care and finds housing for “dual eligibles” like Solano who are enrolled in both Medicare and Medicaid. Solano moved into a furnished apartment at a senior housing complex for low-income residents, where a care manager from HPSM began visiting weekly to coordinate his care, including transportation to his medical appointments.

The Community Care Settings Program reflects growing recognition by Medicaid health plans that health care doesn’t end at the clinic door. They are solving problems such as housing and transportation that influence their members’ ability to get and stay well. These “social determinants of health” — the conditions in which people are born, grow, live, work, and age — play a far larger role in health outcomes than medical factors. While federal policymakers have begun to awaken to the issue, health plans, local health and housing agencies, and other organizations are moving ahead with innovative programs like CCSP to bridge the health and housing gap — and generate substantial savings.

The health and housing gap — especially for seniors — is far larger and more expensive than most would care to admit. By 2035, more than 79 million Americans will be over the age of 65. The number of older adult households with a disability will top 31.2 million by then, and the number of older adults with dementia will reach 7.6 million.

An estimated 70 percent of these older adults will need long-term care. This unprecedented growth, combined with an acute shortage of affordable housing, has profound public health and housing implications. Now more than ever, it is imperative that housing and health authorities together create policies to improve the well-being of seniors holistically and cut the cost of long-term care.

The 62 health plans that make up the Association for Community Affiliated Plans (ACAP) are investing in innovations to address social determinants, even if they fall outside the traditional bounds of Medicaid health benefits. The traditional Medicaid program has a structural bias favoring institutional care because it is a mandatory covered benefit — even though community-based alternatives are far less expensive, and states can choose whether they are covered.

By law, Medicaid is prohibited from covering rent, but under certain waivers states can cover housing-related services. For example, under Medicaid’s Home and Community Based Waiver Program, housing transition and tenancy-sustaining services can be covered for people that meet institutional settings of care. These include help with searching for and securing housing, security deposits, establishment of utility accounts, and basic home furnishings.

It typically takes up to six months of intensive effort for the San Mateo program to transition a participant from a skilled nursing facility or long-term care facility back to the community. A case manager leads the transition and meets not only with the member, but with all people involved in the member’s care, including the member’s family, physicians and social workers. They connect individuals with services for food, transportation and medical care.  

The financial payoff is substantial. Data through December 2016 showed the cost of caring for participants fell 46 percent per member per month to $5,721 for the six months after discharge compared with the six months prior to discharge. In addition, surveys have indicated high levels of satisfaction with the services provided and the impact on their lives.

Today, 1.4 million Americans reside in nursing homes. Two-thirds of these people receive Medicaid coverage. However, one study found that up to 1 in 5 of these seniors— up to 280,000 in all — could live in less restrictive environments if they had affordable alternatives with wrap-around services. Because Medicaid covers nursing homes but often doesn’t cover community services, these individuals are often forced to stay in high-cost nursing homes when they could be living in the community at far lower cost.

Additionally, even if their Medicaid plans do cover home- and community-based services, they are in short supply. Many seniors in this situation find themselves forced into higher-cost, more-intensive settings owing to a nationwide shortage of affordable housing. U.S. taxpayers are on the hook for far higher costs as a result.

Addressing the problem will require policymakers — including the U.S. Departments of Housing and Urban Development and Health and Human Services — to stretch the traditional boundaries of health care to and include social determinants of health such as housing and transportation.  It’s a win-win for taxpayers and for patients. Just ask Conrado Solano.

Margaret A. Murray is the founding CEO of the Association for Community Affiliated Plans (ACAP), which works to strengthen not-for-profit Safety Net Health Plans in their work to improve the health of lower-income and vulnerable populations.