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Volume 8, Number 2
Reduce Medicaid Expenditures with Stable and Healthy Housing
Jeanette Manning, NAGTRI Program Counsel
In our culture we have accepted as a universal truth that we are what we eat. We also know that living a healthy lifestyle, exercising vigorously at least three to four times a week and consuming nutritious foods daily, like fruits, whole grains, and vegetables, make us healthier and less prone to disease and illness. However, living a healthy lifestyle, eating, and exercising alone are not enough. Actually, where we live has been shown to be one of the most significant factors in determining one’s health and health inequalities.
Medicaid costs for states are quite substantial, even with funding contributions from the federal government. The entitlement program covers short- and long-term care coverage for over 66 million low-income Americans.
This article will not focus on whether a state should expand its Medicaid program under the ACA. This issue, although relevant, is not the central question here. Public officials within states have assessed and continue to weigh the myriad reasons why expansion may or may not be best for their state. What is critical is that all states currently have a Medicaid program for which a considerable amount of state and federal monies are devoted to its operation. For this reason alone, every state should be thinking about developing mechanisms that make the program more cost-effective and beneficial for its recipients. Since a strong correlation exists between housing and improved health, state promotion of stable and healthy housing may be one creative link to decrease Medicaid expenditures.
Why Housing Matters
Recently, NAAG hosted a public health law fellowship supported by the Robert Wood Johnson Foundation, during which assistant attorneys general met with public health and law experts to explore how public health issues may be remedied at the attorney general level. As a fellowship organizer and former attorney in the Office of the Attorney General for the District of Columbia (OAG) who worked on some public health issues, I found the topics and panelists to be invaluable. Fellows discussed a variety of public health and legal issues, received a general overview on public health and its relevance to attorneys general, and visited with the acting U.S. surgeon general. However, the theme that resonated with me most involved comments that the number one indicator to quality health is a person’s housing.
The commentators discussed how the public health field is evolving where medical treatment is no longer just a “doctor-patient” only relationship but becoming an all-encompassing “doctor-patient-community” holistic, treatment model. They shared how research has shown that poor people who lived with precarious housing situations – substandard units, homelessness, and crime-ridden neighborhoods – had the worst medical histories. Although the concept of inadequate housing and one’s health status seemingly is not farfetched from my own experience working on public health and community issues at OAG, I became intrigued and wanted to explore what states are doing and how they might alleviate this phenomena.
After reviewing available research, it became evidently clear that housing conditions (internally and externally) certainly matter and plainly impact one’s quality of health.
The poor living in substandard housing also experience higher rates of morbidity, are exposed to more hazards, and tend to have a poorer quality of life, suffering from medical conditions like chronic respiratory illnesses, infectious disease, asthma, lead-based paint poisoning, stress and anxiety, obesity, and high-blood pressure.
Poor Housing Impacting Children and Increasing Medicaid Expenditures
Although numerous medical conditions contributing to health disparities are linked to substandard housing and affect people of all ages
Even though lead-based paint was banned since 1978, many older homes continue to have lead paint that poses a significant health hazard to children, chiefly those younger than six. Children are easily poisoned when paint deteriorates or chips, or a property is renovated and contaminated dust or soil is mishandled or not removed using lead-safe practices; however, lead in homes is not just limited solely to paint but can also be found commonly in lead water pipes and solder used in plumbing, all of which are found in older homes.
Significant progress has been made to reduce the number of children living in lead-based paint homes due to changes in the law and enforcement, awareness campaigns and research studies, and concerted government efforts at intervention. According to a 1998 Boston Medical Center report, an estimated 14 million children younger than age six were living in lead-based paint homes, and the majority at-risk group was white children.
According to a U.S. surgeon general report on promoting healthy homes, there were approximately 15 million asthma-related visits to physicians and outpatient hospital centers and nearly 2 million emergency department visits in 2004.
Cockroaches, in particular, are almost synonymous with living in public housing and other forms of low-income or subsidized housing. Low-income and poor minority children are far more likely to have asthma, have higher hospitalization rates, and have higher mortality rates than any other group.
Concerted national efforts have been made to lessen asthma’s impact, particularly for children. These efforts have included attempts to partner with public health professionals and low-income families, decrease the number of emergency department visits, hospitalizations and associated costs, and reduce the number of missed school days. Asthma Community Network (ACN), a free online network, serves as a national model with members from throughout the country involved in asthma management programs.
Local health entities in states such as Massachusetts, Michigan, Ohio, New York, Pennsylvania, Washington, and California, have partnered with other public health officials in creating “Healthy Homes” initiatives as a means to reduce home health hazards that exacerbate asthma. These partners conduct training for medical personnel, assess hazards within homes and work with families to improve their living conditions, in addition to attempting remediation at the properties.
Models Seeking Savings from Healthy and Stable Housing
Some states are brainstorming the most innovative ways to promote public health and safety for high-risk populations, while simultaneously hoping to contain health care costs. This idea is not nascent in any respect. However, what is an emerging tactic is how some states are changing the landscape in how they define health care. Instead of viewing health care as purely the receipt of medical treatment, some states are expanding the definition to include housing. In other words, housing is equally as important to medical services as doctors’ visits and hospitalizations. Given that high-risk groups tend to heavily rely upon Medicaid and also significantly and disproportionately drive up costs, some states have been promoting two models in recent years that use housing as the critical link to reducing health care expenses.
Stable Housing Model
The concept of states assisting people with securing permanent or long-term housing is not a new idea. In the past many states developed programs that offered affordable and permanent housing to its residents as a matter of general public policy to address homelessness or the limited housing inventory, especially in cities. Cities within states like New York, Washington, California, and Illinois have experimented, however, with implementing stable (or long-term, permanent) housing as a health care strategy to decrease Medicaid costs and other expenses associated with a small number of high-risk Medicaid patients (who disproportionately account for the majority of its expenditures). The states are beginning to focus more on social determinants that impact one’s health. Particularly, the states focusing primarily on high-risk groups of people are those living with HIV/AIDS, substance abusers, homeless, or those with chronic mental illness.
In one particular New York City study, researchers studied whether Medicaid spending could be reduced from fewer inpatient admissions involving the highest risk patients.
The stable housing model in Seattle, Wash., is the Housing First program, which was utilized in a study to determine its effectiveness at reducing medical costs.
Chicago, Ill., has also used the stable housing model as a means to reduce homelessness and treat housing as a health care need. Presently, Illinois Gov. Pat Quinn seeks to expand his state’s stable and supportive housing model with a new approach to use Medicaid dollars for housing directly because federal law does not permit states to utilize Medicaid funding for building or rental projects.
Healthy Homes Housing Model
The healthy homes housing model is more recognizable to states where instead of focusing on actually providing low-income and other high-risk groups with housing units, the focus of this model is to improve the existing unit that the family occupies. This model focuses directly on the environmental condition of the housing unit to ascertain whether it may be worsening a family’s physical health and subsequently driving up medical or Medicaid costs, particularly for children with asthma or lead-based paint poisoning. The healthy homes housing model focuses on factors that contribute to dilapidated housing and poor health, including studying air pollution, neighborhood instability, violence, and the surrounding environment outside of the housing unit.
The federal government – through collaboration with at least seven different agencies – established a Healthy Homes Work Group that focused on environmental health and safety risks to children in the home.
All of the Healthier Homes projects that are members of ACN are examples of healthy housing models. All of these programs provide supportive services to families and engage in collaborative efforts to make the home as safe as possible. For example, Seattle-King County in Washington has a program that focuses specifically on the housing units for children with asthma by reducing their exposure to allergens and irritants that exacerbate their symptoms.
A dangerous home is a trigger for many chronic illnesses, deaths, and injuries that naturally increase health care expenses. It is estimated that national health care costs associated with housing-related injuries and illness may amount to billions of dollars annually.
Possible State Responses
Undeniably, the health and social issues identified in this article are highly complex. The potential remedies are equally as challenging because of initial costs to implement programs, unpredictable social ills and crime, lack of education and lifestyle decisions among the disproportionately affected populations, unknown actual program costs or savings, and the need for more research on the financial viability of treating housing as a health care need. However, the current trend in many states is to explore alternative strategies to lessen the effect of increased health care costs from high-risk groups and accompanying social ills and illnesses.
Financial assistance has been offered from sources outside the federal government to research cost savings and program viability, including exploring the importance that housing has on people’s health and well-being. The MacArthur Foundation recently awarded nearly $3 million in grants to discover how housing matters and how it affects children, families, and communities.
Regardless of eventual research findings on cost savings or money spent to explore housing as a health care strategy, every state right now still has to contend with the best way to address issues that impact them. Low-income families and limited housing, high-risk groups utilizing Medicaid at disproportionately high rates, crime and public costs, injurious housing causing health problems or death for residents, and lead-based paint poisoning and asthma in children are inescapable issues for every state to varying degrees. State attorneys general throughout the nation already do and can continue playing a critical role in helping to alleviate some of the challenges raised in this article, given their enforcement authority or advisory role to state agencies. The attorney general’s office itself can be quite effective and has plenty of arsenal at its disposal to either raise awareness or directly address issues of public concern, including exploring ways to improve housing or reduce state Medicaid expenditures that offer a financial benefit to the state. Some suggestions include the following, which involve enforcement action and partnership development:
Lead-Based Paint Abatement
Given the number of existing lead-based paint hazards nationally, attorneys general can arrange for their attorneys to prosecute these cases. The prosecutions help to facilitate larger numbers of abatement, thereby making children safer. Prosecutions may involve criminal or civil prosecution against any party who is legally obligated to abate the problem or responsible for creating the problem. In most instances, these suits will be against property owners who fail to remove known hazards or against persons who stir up dust or soil when renovating homes known to have lead-based paint. In instances where remediation requires that families move temporarily until abatement is completed, AG offices should be prepared to deal with custodians of children who are aware of lead poisoning or the hazard but fail to remove their children from the dangerous environment. Often, custodians – fearful of the housing shortage – do not want to move during the remediation process for fear that they will be unable to return upon abatement. Such actions may border on being neglectful towards their children. Non-profit organizations and child protection and welfare agencies should be involved to work with the custodians when necessary. Assistant attorneys general (AAG) representing child protection and welfare agencies may need to be prepared to take action, if the children’s well-being and health continues to be compromised. AG offices may also want to work with state environmental and health departments to ensure that quality in-home assessments for lead-based paint are conducted and that community outreach campaigns are a priority.
Property Owner Engagement and Housing Code Enforcement
Attorneys general offices may want to open the lines of communication proactively (if necessary, in conjunction with client agencies) with property owners and engage them to abate housing code violations on their properties that render them unsafe. Prior to taking any legal action, AG offices could simply engage property owners in discussions and encourage them (or mandate) to fix their rental units according to code. When owners fail to address violations, rendering their properties unsafe, AG offices could enter into agreements with a delineated timeline when property owners must repair and rehabilitate their rental units in lieu of further legal action. Any failure on behalf of the property owner to act could result in AAGs taking legal action, or legal action could be the preferred option at outset to immediately address poor housing conditions.
With a group of recalcitrant property owners known to be slumlords, AG offices could use their office to reach a larger audience and file one large, comprehensive lawsuit against multiple property owners as opposed to individualized suits naming one owner at a time. Receivership actions are also potentially effective legal means to encourage or require property owners to repair their properties. AG offices may also want to consider working closely with client agencies responsible for enforcing housing code violations and advising them on available legal remedies and the importance of conducting thorough inspections, properly citing violations, and preparing airtight cases.
Zoning and Cross-Sectoral Planning and Engagement
When public finance projects are negotiated, there generally is a government lawyer involved in the process to review contracts and ensure legal compliance. Commonly, when locales are considering revitalizing neighborhoods or upgrading the current housing stock, there typically is an open comment period for community input and plenty of cross-sector collaboration and planning. AG offices should have a seat at the table for these projects at the initial planning stages and throughout the discussions until it is completed. AG offices may also play a pivotal role in helping to facilitate the collaboration of essential players, provide advice to their clients when they make decisions that affect the community, or provide the legal perspective and related implications of group decisions. Multiple sectors are almost always part of the discussions related to zoning, building projects, or revising housing codes. In these instances, AG offices can also engage advocacy or tenant groups and public health experts to work with architects, builders, local, state, and federal officials, property owners, urban planners, law enforcement, and the like, to ensure that best practices are implemented.
Exploring Housing as a Health Care Strategy
AG offices interested in exploring whether Medicaid expenditures may be decreased to put more money in state coffers may want to consider exploring housing as a health care strategy. Attorneys general offices may contact states directly where housing is viewed as a health care strategy to decrease costs. Attorneys general also could collaborate with state agencies to address the needs of low-income families and other high-risk groups using the stable housing or healthy housing models. Attorneys working in policy sections for AG offices could apply for grant funds to study whether high-risk populations are disproportionately increasing medical costs and costs for the public within a particular state (or use allotted grant money to provide services to these groups via partnerships with nonprofits or government entities). AG offices could also develop task forces and engage public health officials at hospitals, nonprofits, and academic institutions to explore areas of concern and guarantee community involvement. Any initiatives being considered in states that involve affordable housing deals should also include AG office input, even if limited, because social determinants and environmental concerns could ultimately impact their office and the public’s overall health.
In my own experience at the DC Attorney General’s Office, I regularly used the office in my official capacity to bring about fruitful change in the community. I supervised a section where we preemptively forced property owners to take action when they contributed to community blight and affected the public health or sued them when they failed to correct the harm. We closed brothels; prosecuted property owners and drug dealers who created dangerous nuisances and increased crime in communities; compelled property and business owners to speak with us and negotiated agreements with them to minimize violent crime at their illegal businesses or subsidized low-income housing units (using collaborative efforts with law enforcement and other government agency officials, when appropriate); abated lead-based paint hazards when children were poisoned; filed a comprehensive lawsuit against 23 recalcitrant property owners who failed to abate housing code violations in substandard housing; and advised agency clients on an array of related issues. From this work I know firsthand how an attorney general’s office can think and act creatively and use the office to make a difference in people’s lives while promoting the public interest.
I also worked directly with high-risk groups and understand discreetly from my many visits to poor neighborhoods littered with crime and witnessing their substandard housing conditions how low-income children and adults are disadvantaged socially and medically for myriad reasons. Of course, providing housing and making it healthier will not eradicate all of the medical conditions or social ills associated with the poor, high-risk, or low-income communities. It is also questionable how much of an interest attorneys general offices should take on these issues. Moreover, the verdict may still be out on the extent to which Medicaid expenses could be reduced from improving or providing housing to these groups. Nevertheless, every state has evidence of spending considerable amounts of money on law enforcement in high-crime neighborhoods, on correctional staff who man the prisons, on poor children who are chronically ill and use Medicaid, or on mental health services for those with severe diagnoses. Perfectly reasonable minds can differ about how much money should be spent on government services or entitlements, including Medicaid. There is plenty of room for debate on that issue. Instead, the focus here is simply to lay out some items for consideration on whether there are potential cost-saving measures available for exploration and implementation. I am pretty confident that we all can agree on the importance of money to make sure that we know whether it could be saved, or at the very least, that it is being spent wisely.
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