Safe, Affordable & Supportive Housing: Will it Remain an Elusive Dream?

Residents of the greater New York metropolitan area and others who are familiar with the regional real estate market understand residential property costs have become prohibitively expensive for renters and owners alike in recent years. In March 2014, the Office of the State Comptroller released a report that confirmed and quantified these suspicions, and it portrayed a market that has become increasingly inaccessible to individuals and families of modest means. The past decade has delivered a marked increase in the percentage of New York State households with housing costs that exceed the affordability threshold as defined by the U.S. Department of Housing and Urban Development (HUD), and there is no indication this trend will abate any time soon. Data obtained via the U.S. Census Bureau’s decennial Census and the American Community Survey, another gauge of socioeconomic and demographic trends, suggest 50% of rental households had monthly housing costs that exceeded the affordability threshold in 2012, and a quarter of these households were “severely housing cost burdened” inasmuch as they incurred costs that exceeded 50% of their monthly income (Office of the State Comptroller, 2014).

Social and economic challenges that afflict the general public are frequently magnified among the population of individuals with significant behavioral health issues, and the increasing inaccessibility of the housing market is no exception to this phenomenon. Furthermore, the proverbial “safety net” that was established to protect this population from the vagaries of the housing market has failed to fulfill its mandate. A review of programs funded by the New York State Office of Mental Health (OMH) reveals a marked erosion in funding due to inflation for licensed residential programs and supported housing units between 1991 and 2014. Funding for supported housing, a model that replicates the federal Section 8 Housing Choice Voucher Program via its provision of rental subsidies to individuals with limited income, has effectively dwindled by 20% in New York City, Westchester and Long Island. Upstate regions have seen a 40% reduction during this same period, and despite aggressive advocacy by stakeholders to augment funding during recent budgetary negotiations the newly-enacted state budget for 2014-2015 failed to include any adjustment for upstate regions. Furthermore, those who are “lucky” enough to receive housing subsidies represent an increasingly smaller segment of the broader behavioral health population as demand for such assistance continually outpaces supply. Those who do not receive it, including many who languish on lengthy waitlists, are essentially barred from the housing market altogether. In 2012 in New York, SSI recipients paid, on average, 133% of their monthly income to rent one-bedroom housing units. This fact alone suggests the acquisition and retention of affordable housing is a virtual impossibility for individuals with behavioral health conditions and other disabilities who depend on Social Security benefits to meet their financial needs (Technical Assistance Collaborative, 2012).

All of these trends are especially problematic for individuals with behavioral health concerns, many of whom experience comorbid physical health conditions and other challenges that are exacerbated by chronic residential instability and its attendant ills. Public policy has clearly failed to account for the impact of this housing crisis on vulnerable populations. According to the state Health Commissioner, Dr. Nirav Shah, and his associates, “social determinants” of health such as safe housing, nutritious food, and educational and employment opportunities are frequently overlooked by our social service infrastructure in its singular preoccupation with the medical determinants of health (Doran, Misa & Shah, 2013). In a review of epidemiological and survey data, Dr. Robert Manderscheid (2009) describes a decline in the availability of housing and community support services for individuals with mental illness during a period in which these services should be significantly enhanced to compensate for a diminution of inpatient resources. Other authors (O’Hara, 2007; Mechanic, 2007; Newman & Goldman, 2009) repeatedly cite failed housing policy as a predominant factor in our national mental healthcare crisis, and they suggest chronic homelessness and residential instability pose significant barriers to the overall health and community integration of individuals with mental illness. It should therefore come as no surprise that the Organization for Economic Cooperation and Development (OECD) found the United States ranks first in healthcare spending but 25th in social services spending. Perhaps this fact, as much as any other, betrays our nation’s inefficient and misguided approach to the management of its social safety net. It is hardly surprising that an era of continuing deinstitutionalization without a commensurate enhancement of affordable housing or community support services should also produce a monumental increase in the population of individuals with serious mental illness entangled in our criminal justice system. Our nation’s jails and prisons have effectively become the new “homes” for many for whom there is no longer an institution or a community. And sadly, the enactment of the Patient Protection and Affordable Care Act (PPACA), a seemingly auspicious development for millions of Americans who have been unable to access comprehensive and affordable health insurance, may do little to address the fundamental needs of this population. Freshly-minted health insurance cards will likely fail to improve the overall wellbeing of those who lack access to safe and affordable housing and the basic necessities essential to sustain health.

Notwithstanding these significant deficiencies in the social safety net, we are privileged to bear witness to some promising changes within of our behavioral health system and the manner in which individuals with mental illness and substance abuse conditions are housed within their communities. A movement that began in the early 1960s with President Kennedy’s proclamation that institutions (specifically state-operated inpatient facilities for individuals with severe psychiatric or developmental disabilities) were essentially relics of an unenlightened past and should be dismantled and replaced by a more integrated and individualized continuum of services has acquired additional momentum in recent decades. In the past couple of years alone a confluence of events, including a proposal to close or consolidate several state-operated psychiatric centers, limit the placement of adults with mental illness in adult homes and nursing facilities, and curtail patients’ lengths of stay in private hospitals and acute care facilities has necessitated a robust expansion of residential support services for those who were formerly housed in institutional settings. Such continuing deinstitutionalization is undoubtedly consistent with a moral and ethical imperative to accommodate individuals in need in the most integrated and least restrictive settings possible. It is also a legal requirement as established by a decision of the United States Supreme Court in Olmstead v. L.C. This decision effectively mandated the community integration of vulnerable populations via judicial decree and lent additional urgency to the deinstitutionalization movement.

In theory, the needs of vulnerable individuals emerging from institutional care will be fulfilled through a reinvestment of savings accrued through facility closures and the redesign of the state Medicaid program. In 2013, the OMH released a proposal to close or consolidate several of its facilities and to establish “Regional Centers of Excellence” wherein remaining facilities would deliver specialized inpatient services and an array of outpatient supports through community-based service “hubs.” By some estimates, the state expends approximately $110,000 per bed annually in its inpatient facilities, so a significant reduction in service capacity presents a corresponding opportunity for reinvestment in housing and community support services (New York State Division of the Budget, 2014). In 2011, Governor Cuomo established a Medicaid Redesign Team (MRT) to conduct a comprehensive reevaluation of the nation’s most expensive Medicaid program, and it produced a host of recommendations to reduce program costs through improvements in organizational efficiency and investment in community-based support services that would divert recipients from more costly inpatient and emergency medical services. Some of these recommendations emerged from the MRT Affordable Housing Workgroup and led to a reinvestment in housing and community support services during fiscal year 2013-2014. Similar items were included in the budget that was just enacted on April 1st. All of these investments promise to deliver additional supported housing and service opportunities for individuals in their communities of choice.

Theory. Promise. Terms that evoke memories of a previous era of deinstitutionalization during which individuals were discharged en masse from state-operated facilities with the expectation they would receive supportive housing, vocational rehabilitation, outpatient treatment, care management and a host of other services that would promote their safe and successful integration into their communities of origin. As the foregoing suggests, however, only some of these services and supports were available, and often for the select and fortunate few. Others endured homelessness, incarceration, repeated episodes of hospitalization in acute care facilities (i.e., the “revolving door” syndrome), or reinstitutionalization in homes for adults, board and care facilities and similarly substandard residential accommodations. President Jimmy Carter condemned this as nothing less than the wholesale neglect of the mentally ill in his sweeping review of national mental health policy (Bloom, 2010). This begs an obvious question. Have we learned from our past or are we condemned to repeat it?

Initiatives currently underway give rise to a certain optimism that we might avoid some of these mistakes. These initiatives share a conceptual elegance and common lexicon that identify such themes as preventive care, person-centeredness, community integration and comprehensive care coordination as hallmarks of sound behavioral health policy. The advent of Medicaid-funded “Health Homes” and the evolution toward universal Managed Care for even the most vulnerable populations are expected to fulfill the “Triple Aim” of the PPACA to reduce cost, enhance quality and improve outcomes within the healthcare delivery system. It is not unreasonable, however, for one to suspect more prosaic motives underlying these initiatives.

Section 2703 of the PPACA authorizes states to develop Medicaid-funded Health Homes for the management of vulnerable populations, generally those with serious mental illness or chronic or comorbid physical health conditions. These populations have historically received few preventive care services or relied heavily on costly inpatient or emergency care to manage their conditions. Health Homes are designed to deliver a package of comprehensive services and supports to recipients whereby “care managers” develop and monitor care plans in consultation with other members of recipients’ support networks. In theory, improved communication and collaboration among service providers will promote recipients’ timely use of preventive services and enhance their access to other supports (e.g., housing, vocational services, etc.). Such an approach should have a salutary effect on the overall health and wellbeing of individuals who were previously disengaged from treatment or had failed to access the supports necessary to ensure their lasting stability. It must be noted, however, that the PPACA offered a seemingly irresistible incentive for states to adopt the Health Home option through a substantial enhancement in federal funding for this initiative, and this financial enticement likely provided the foundation on which programmatic rationales were subsequently erected. Many states, including New York, typically receive a federal contribution (i.e., “Federal Medical Assistance Percentage” or “FMAP”) of approximately 50% toward Medicaid-covered services. States and localities bear fiscal responsibility for the balance. The PPACA authorizes an enhanced FMAP of 90% for Health Home services for the first eight quarters (two years) following adoption of the Health Home option. In view of New York’s exorbitant Medicaid expenditures and the Cuomo Administration’s desire to contain its ever-increasing costs, anything less than the rapid and wholesale adoption of Health Homes in the face of such an incentive would have been unthinkable. Whether such an approach would prove superior to existing programs, such as Targeted Case Management (TCM), Managed Addiction Treatment Services (MATS), etc., for which no enhanced FMAP was available, was all but academic. Under the Health Home funding model, care management agencies receive a capitated monthly rate for the delivery of required services. These rates are established via an actuarial methodology that considers regional and case-specific acuity factors, and the fiscal viability of care management agencies now depends on a robust client enrollment that frequently alters the care manager-to-client ratio. Care managers that previously served 12 or 24 clients per month under the TCM model of care now serve several times as many, and their clientele includes individuals with an increasingly diverse constellation of psychiatric, substance use and physical health conditions. Can such a model achieve the Triple Aim? Will it be proven superior to the TCM model and its predecessors? It is undoubtedly too early to tell. But a preliminary report from the Assistant Secretary for Planning and Evaluation for the U.S. Department of Health and Human Services (ASPE) has cast some doubt on the efficacy of the Health Home model and exposed predictable shortcomings in its implementation that warrant additional scrutiny. In a survey of early adopters of the model the ASPE identified deficiencies in communication among recipients’ service providers, inefficient or inoperable information technologies and enduring challenges in recipient engagement as obstacles to successful implementation (U.S. Department of Health and Human Services, 2012). There is some reason to believe these challenges will be overcome in time but one should not assume as much. Moreover, there is nothing inherent in this new approach to service delivery that directly addresses the scarcity of affordable housing or its role in sustaining the health of its recipients.

In a similar vein, the widespread implementation of Medicaid Managed Care for populations that were previously “carved out” of it promises to reduce costs and improve healthcare outcomes. Medicaid recipients with serious mental illness, in particular, will soon have all of their services funded through private Managed Care plans authorized by OMH and the Department of Health (DOH). These plans establish capitated payment rates for contracted providers and effectively shift the financial risk for service provision from the state to providers and recipients. By some accounts the most vulnerable (i.e., the seriously and chronically ill) members of this population will bear the greatest risk should capitated payment rates limit their access to essential treatment and support services. Although such limitations will ostensibly be offset by plans’ promotion of preventive services and their integration of primary and behavioral healthcare, such claims warrant considerable skepticism. Indeed, it is not unreasonable to assume managed behavioral healthcare of the seriously mentally ill will encounter many of the same obstacles to successful implementation that afflict Health Homes, and it will likely do even less to directly address our affordable housing crisis or the other social determinants of health and stability for vulnerable populations.

One would hope the foregoing portrays both a cautionary tale and another opportunity for governmental and private stakeholders to “get it right,” and there is cause for tempered optimism. The OMH has recognized the potential repercussions of a poorly executed capitated payment system on the health and stability of its most vulnerable recipients, and it is in the process of calibrating payment rates accordingly. It recently issued a Request for Qualifications (RFQ) through which managed care plans may apply to deliver services to the “mainstream” behavioral health population or enhanced services to individuals with serious mental illness or more extensive behavioral health concerns. These specialized Health and Recovery Plans (HARPs) may award higher capitated payments for the delivery of a broad array of medical, behavioral health and social support services to this population. The OMH also continues to explore and incentivize the redesign of its existing residential support services and to develop new approaches to housing its recipients. These include an expansion of crisis respite services, hospital diversion and similar resources for which demand will likely increase in response to dwindling inpatient resources. These developments, however, are largely contingent on a continuing reinvestment of savings accrued through facility closures, Medicaid redesign and the effective replacement of a costly fee-for-service system with Managed Care. Care management agencies, many of which continue to navigate a tumultuous transition from a TCM to Health Home service modality, are uniquely positioned to identify pitfalls in this transition and the potential repercussions for service recipients. And it is incumbent on housing and residential service providers, healthcare professionals, recipients and their families to seize this opportunity to collaborate with their Health Home partners and other stakeholders in the governmental and private sectors. In the absence of such focused and coordinated advocacy, access to safe and supportive housing and the many other determinants of health and stability will likely remain an elusive dream.

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