Government-funded supportive housing in New York State has a richly textured history that entails an amalgam of competing philosophies, political trends and economic imperatives. A complete survey of this history is beyond the scope of this article, and a comprehensive assessment of the “current state” of supportive housing cannot be rendered with concision. So how might one briefly characterize its current state? In the words of a good economist, “It depends.”
There are surely reasons to be hopeful about the current trajectory of supportive housing inasmuch as the New York State Office of Mental Health (OMH), the state agency charged with the financing, development and regulatory oversight of most housing units for adults with behavioral health conditions, has committed considerable resources to housing development in recent decades. Between 1983 and 2011 the supply of OMH-funded housing stock increased from 4,953 units to 33,615 units (New York State Office of Mental Health, 2013). This sixfold increase reveals a statewide commitment to provide community-based residential opportunities for vulnerable individuals, many of whom had histories of institutionalization in state-operated psychiatric centers and would remain at risk of continued institutionalization or similarly adverse outcomes in the absence of supportive housing. In addition, a vast array of other municipal agencies has promoted the development and operation of supportive housing. These include the Office of Alcoholism and Substance Abuse Services (OASAS), Office for People with Developmental Disabilities (OPWDD), Office of Temporary and Disability Assistance (OTDA) and Department of Housing and Urban Development (HUD), to name a few.
This movement toward community-based alternatives for vulnerable individuals was surely borne of noble intent and a progressive orientation, at least in part. It is also a byproduct of a longstanding economic imperative to reduce the capacity of costly state-operated psychiatric facilities. In fact, during the past three decades we have witnessed an inverse correlation between the overall stock of supportive housing and the census of state-operated psychiatric centers. The census of state-operated facilities decreased from 20,650 in 1983 to 3,069 in 2011 (New York State Office of Mental Health, 2013). Other factors have lent impetus to the movement toward community-based residential accommodations, not least of which was a landmark ruling of the U.S. Supreme Court in Olmstead v. L.C. that codified the rights of individuals with disabilities to reside in the least restrictive settings practicable (Olmstead v. L.C., 1999). New York State has applied an expansive interpretation of this ruling via an Olmstead Development and Implementation Cabinet that aims to reduce institutionalization in all its forms (Report and Recommendations of the Olmstead Cabinet, 2013). This has led to targeted supportive housing investments for specific subpopulations, including residents of adult homes and skilled nursing facilities and inmates of state and local correctional facilities. These investments assume the provision of supportive housing to vulnerable and previously institutionalized individuals will enable them to achieve greater autonomy and lasting community tenure, and there is considerable data to support this proposition (Culhane, et al., 2002; Gulcur, et al., 2003; NYC Department of Health and Mental Hygiene, 2013; Perlman & Parvensky, 2006.) In addition, the recovery movement has gained political currency in recent years, and key stakeholders now recognize the significance of this movement and its central tenets. Antiquated, provider-centric modes of service delivery have been largely (albeit not entirely) replaced by person-centered practices that accommodate recipients’ expressed needs and preferences. Within the realm of supportive housing these principles manifest as integrated, individualized residential accommodations with flexible support services. The foregoing trends, when viewed in the aggregate, suggest our state has adopted an exceedingly progressive orientation to community-based alternatives for vulnerable individuals that maximizes their opportunities to receive appropriate, individualized housing accommodations. But this is merely part of a larger and considerably more complex story.
Emerging data on social determinants of health suggest the conditions in which we live, work, learn and grow are more determinative of our health status than the quality or quantity of healthcare services available to us (Chaiyachati, et al., 2016). Quite simply, our zip code might be more important to our overall health and wellbeing than our genetic code. Decent, safe and appropriately supportive housing is arguably the most significant social determinant of health inasmuch as our success in other realms is contingent on residential stability. Prima facie evidence of this proposition will emerge through any encounter with a homeless individual who receives treatment for a serious health condition. Chronic conditions such as diabetes, cardiovascular disease or schizophrenia cannot be effectively managed without protection from the elements, adequate storage for food and medicine or the myriad other benefits that accrue to the domiciled. Nevertheless, the United States spends considerably less than other developed nations on essential social services (including housing supports), although it spends considerably more than its peers on healthcare (Butler, et al., 2017). This imbalance has worsened in recent years as state investments in social services have stagnated relative to inflation while expenditures on Medicaid (the primary public payer for healthcare services for disabled and economically disadvantaged individuals) have substantially increased (Gais, et al., 2009). This trend belies our nation’s collective misunderstanding of the role of healthcare (as it is traditionally defined) in the health equation. Sadly, New York is not insulated from national trends as evidenced by its overreliance on Medicaid to address the needs of its vulnerable citizens. Until recently, our state had the highest Medicaid expenditures of any in the nation and this largesse produced mediocre health outcomes at best. Moreover, federal regulations prohibit the use of Medicaid funds for housing, so our seemingly robust investment in healthcare did little to advance the most significant social determinant of health. It is therefore not surprising that our state’s sizeable investment in Medicaid yielded a paltry return on investment.
Policy makers and other key stakeholders have awakened to these realities and enacted certain reforms that are now coming to fruition. In 2011 a Medicaid Redesign Team (MRT) was appointed to overhaul a dysfunctional program and it produced numerous recommendations in its report to the Governor’s Office (New York State Department of Health, 2011). Significantly, the MRT included a Supportive Housing Workgroup that recommended targeted investments in supportive housing for exceptionally vulnerable individuals (i.e., those with chronic and comorbid health conditions who rely heavily on inpatient hospital and emergency department services). This workgroup presumed the provision of supportive housing to these individuals would effectively achieve the “Triple Aim” of healthcare reform, if only for a select subpopulation. In other words, it would reduce the cost of care, improve the experience of care (from the recipient’s perspective) and produce better outcomes. A preliminary evaluation of MRT investments in supportive housing was recently published by the Department of Health and it confirmed the assumptions of the workgroup. This evaluation examined 11,000 “high need” individuals who received supportive housing as a result of targeted MRT investments. Following the provision of supportive housing and related services this population enjoyed a 40% reduction in inpatient hospital days, a 26% reduction in emergency department encounters and a 15% reduction in overall Medicaid-funded health expenditures (New York State Department of Health, 2017). In an economy that measures progress by single percentage points and incremental changes these results are nothing short of epic, and they have significant implications for future investment in housing and other social support services.
The results of this evaluation coupled with our increasing awareness of the relevance of social determinants of health to the healthcare equation suggest significant investments in supportive housing are forthcoming. This is certainly true in some respects. Mayor de Blasio and Governor Cuomo have pledged their support for the development of thousands of new housing units in coming years, and our state legislature has begun to authorize some expenditures necessary for this development. The fulfillment of these commitments, however, is contingent on continuing budgetary appropriations (and the caprice of the legislative process) and other fiscal mechanisms of great complexity and questionable reliability. For instance, a movement to commit all state Medicaid dollars to the stewardship of privately-operated Managed Care Organizations is bound to upend existing service systems through which these resources flow. In other words, a seismic disruption within a Medicaid program on which numerous social service providers depend might limit their capacity to provide a broad variety of services, including supportive housing. Other initiatives presently underway, including DSRIP and the emergence of Value-Based Payment models of service delivery and reimbursement, will also substantially alter the allocation of public dollars in coming years. Supportive housing faces a dubious future in the absence of well-defined, actuarially sound and politically viable funding mechanisms. Our policymakers and key stakeholders should take heed lest our pursuit of the Triple Aim falter for lack of investment in one of the most essential social determinants of health.
The author may be reached at (914) 428-5600 (x9228) and at firstname.lastname@example.org.