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Housing and Health Partners Can Work Together to Close the Housing Affordability Gap

January 17, 2020

Access to safe, affordable housing supports people’s physical and mental health, research shows. The health care system has an important role in connecting patients to housing, but housing programs themselves need substantial additional resources to make a meaningful dent in the number of households that struggle to afford housing. Over 17 million households eligible for federal rental assistance do not receive it due to limited funding.[1] This contributes to over 47 percent of renter households spending more than 30 percent of their income on housing costs, and almost 25 percent spending more than 50 percent of their income on housing.[2],[3]

"The health care system has an important role in connecting patients to housing, but housing programs themselves need substantial additional resources to make a meaningful dent in the number of households that struggle to afford housing. "

When households struggle to pay the rent, they not only face financial and housing instability, but they are also at heightened risk for a host of negative health outcomes. When people experience homelessness, they struggle to eat nutritious food, get regular preventative care, and manage chronic health conditions. More generally, high housing costs worsen the adversity that low-income families experience, forcing them to face a persistent threat of eviction and make difficult choices between paying the rent and paying for medicine, food, heating, transportation, and other essentials. Housing costs may also compel families to live in housing or neighborhoods that are rife with health and safety risks. These consequences can contribute to “toxic stress” and other mental health conditions that alone can be devastating but can also exacerbate physical health conditions for adults and children.[4]

Health stakeholders can make modest but important programmatic contributions to directly expanding access to affordable housing. On the direct access front, state Medicaid programs and managed care organizations can pay for housing-related support services such as housing location services, eviction prevention (such as negotiating with landlords and assistance with personal budgeting), and tenant rights and responsibilities training — efforts that can help prevent a loss of housing or assist families in finding more suitable housing quickly. Hospitals can use their various assets, including land, investment portfolios, community benefit resources, and data capacity to make strategic financial investments in housing.[5] Managed care and hospital systems are also finding ways to make strategic financial investments to develop affordable housing — investments that can yield a small return for the health entity investor and add needed housing stock. Finally, community-based services providers (such as behavioral health clinics and social services agencies) and local public health departments can partner with housing providers to improve the condition of public and affordable housing properties, deliver individualized home-based support services, and target community health programs to low-income residents.

While these and other initiatives can reduce health care costs for targeted individuals and improve people’s health, resolving unmet housing needs requires larger scale policy efforts, including far broader availability of basic rental assistance for struggling households and increasing the supply of affordable housing, especially for those experiencing or at risk of homelessness. Because health care stakeholders see face-to-face the difference affordable, quality, stable housing can make in health outcomes and have data that underscore the broader implications of a lack of affordable housing, they have an essential role to play in the housing policy debate.

Housing and Health Status Are Linked, Evidence Shows

Growing evidence shows that housing stability and location can significantly affect health care costs, access, and outcomes.[6] Supportive housing — affordable housing combined with intensive coordinated services — can lower participants’ health care costs. Research has shown that for those participants who incurred high health care costs before being housed in a supportive housing program, these health care cost reductions can pay for (sometimes more than pay for) the cost of the supportive housing. Interventions to help families improve the condition of their housing or move to healthier neighborhoods also show promise to improve people’s health status. Understanding and properly applying the evidence of how and when housing access saves money, when housing interventions improve health outcomes, or when both are accomplished is important to ensuring that housing investments are well-targeted to achieve the desired outcome.

Lack of Housing Can Lead to Higher Health Costs

Health care spending is often higher for people experiencing homelessness, who often use expensive emergency room care as their primary source of health care.[7] Homelessness can cause serious infections, increase the likelihood of contracting the flu or colds due to exposure, or spur a health crisis due to untreated chronic conditions such as diabetes, high blood pressure, or heart disease. The insecurity and chaos of living without a home can also exacerbate mental health and substance use conditions because people aren’t safe or able to adhere to treatment plans. These disruptions to care for physical and behavioral health conditions can increase anxiety, depression, and paranoia, which can lead to avoidable incarceration, institutionalization, and inpatient hospitalizations.

The inability to afford housing can also lead to longer-than-necessary stays in institutional care if people have lost their housing due to inability to work while in a nursing home, mental health facility, or other institution like jail. These health care costs are unnecessary and preventable. People can be at risk of homelessness when length-of-stay limitations force people out of institutions without a stable housing alternative, which can also lead to increased health care costs due to avoidable emergency crisis care.[8] Community-based services, such as in-home care, outpatient mental health care, or medication-assisted substance use treatment, are often available, but they aren’t enough to keep people out of institutional care if they can’t afford a place to live.

Housing Conditions and Neighborhood Factors Can Lead to
Avoidable Health Costs and Bad Outcomes

Poor-quality housing or housing located in neighborhoods in which policymakers and businesses have underinvested can lead to health conditions that worsen not only individual health outcomes but also the public’s health in preventable ways that sometimes are inexpensive in the short term but costly to both people and the health system over time.

Contaminants such as lead paint and mold, unkempt or unsanitary living conditions, and deteriorating buildings can lead to chronic health conditions such as childhood or adult asthma, brain injuries or developmental disabilities, preventable infections, or trips and falls that can result in injuries or premature deaths. In 2014, 20 to 30 percent of asthma cases were linked to home environmental conditions, 21,000 lung cancer deaths were the result of radon in homes, over 24 million homes had lead-based paint hazards, and home injuries led to over 6 million seniors being hospitalized or in nursing homes due to preventable falls, the American Public Health Association and the National Center for Healthy Housing estimated.[9] Neighborhood conditions can also lead to poor health of residents. People need to be able to find grocery stores with fresh, inexpensive produce, clean water, walkable amenities for exercise, and conditions that lower stress such as access to jobs and low crime.[10]

Poor housing conditions, chaotic and violent neighborhoods, and worry about housing stability can also cause toxic stress or exacerbate mental health and substance use conditions. This stress can negatively affect both children’s and adults’ well-being. Parental depression and other stress-related problems are associated with poor social development and poor physical, psychological, behavioral, and mental health for children, particularly young children, studies find.[11]

Housing Interventions Boost Health

Supportive Housing Evidence

Supportive housing has been shown to reduce health care costs for high-need, high-cost users of the health care system who are experiencing chronic homelessness or are living in institutional care. Most people who experience homelessness simply need financial assistance to help them afford rent, but for those who need the extra help, supportive housing can end their homelessness and stabilize their health and health care costs.

Supportive housing couples affordable housing — usually a voucher that covers the gap between the rent and what tenants can afford to pay — with health care services and case management for people with complex needs. People live independently and are assigned a case manager who helps residents coordinate their medical appointments, access social services such as employment assistance or parenting classes and behavioral health services, and work through crises to avoid eviction. Supportive housing providers focus on keeping the person housed, engaged with the services they choose, and out of expensive health and social systems of care.

When targeted to high-cost users of the health care system who have histories of homelessness, supportive housing reduces health system costs by keeping people out of hospitals, emergency rooms, and nursing homes, studies show. In Chicago, for example, supportive housing reduced costs for high-need, high-cost users of hospitals who also were homeless by over $6,000 per person per year.[12]

Housing Location Evidence

Providing housing vouchers can also improve health outcomes by reducing residents’ exposure to detrimental environmental conditions. Housing vouchers can help people live in communities of their choice including high-opportunity neighborhoods, which can have strong positive effects on adults’ and children’s mental and physical health.

HUD’s Moving to Opportunity (MTO) program has demonstrated these effects.[13] MTO was a ten-year (1993-2003) research project in which low-income families received rental assistance vouchers, along with intensive housing search and counseling services, to help them move from high-poverty to low-poverty neighborhoods. Several MTO studies comparing families that received MTO vouchers to similarly situated families that didn’t receive an MTO voucher found that using rental assistance to move to high-opportunity neighborhoods improved families’ immediate outcomes, including health-related conditions.

Adults in families that used an MTO voucher to move to lower-poverty neighborhoods reported 33 percent fewer instances of major depression than those without MTO vouchers. Adults who moved with MTO vouchers also had much lower rates of extreme obesity and diabetes. Children’s outcomes also improved, broadly. Children in families that used MTO vouchers were 32 percent more likely to attend college and earned 31 percent more as young adults than similar children who didn’t have access to MTO vouchers. And girls were 30 percent less likely to become single parents.

Housing Programs Are Underfunded

Unlike major health programs like Medicaid and the Affordable Care Act’s marketplace subsidies, affordable housing programs aren’t entitlement programs that serve everyone who meets the eligibility requirements and applies for assistance. Instead, Congress sets funding allotments for housing programs annually at levels that limit the number of families that can receive assistance.[14] Once funding runs out, everyone else must wait. That results in 75 percent of households eligible for federal rental assistance not receiving it.[15] (See Figure 1.) Families may wait for years to receive housing assistance, and overwhelming demand has prompted most housing agencies to stop taking applications entirely.[16]

The unmet housing need is large among vulnerable groups like low-income families with children, seniors, and people with disabilities. Some states and localities use their own resources to make additional rental assistance available, usually for targeted populations such as people experiencing homelessness, people with chronic health conditions, or people with disabilities, but these programs are small and don’t cover the gap left by inadequate federal resources.[17] In addition, they leave behind people who are on the margins of eligibility, such as those who are healthier, younger, or have experienced shorter periods of homelessness. In 2017, almost 11 million low-income renter households paid over half their income for housing.[18] Such renters face a far greater risk than other households of eviction, homelessness, and other hardship.

Figure 1
 

Medicaid, by contrast, is available to everyone who meets its eligibility requirements.[19] Medicaid expansion, in the states that have implemented it, extends coverage to people based on income and provides coverage to everyone who meets the income and other eligibility criteria in the program. Funding responds to demand and no person eligible for Medicaid can be turned away.

The differences in the programs’ funding structure and adequacy can lead to frustration by health providers who serve vulnerable populations whose housing concerns are causing or exacerbating health conditions. These providers are accustomed to being able to draw on public programs like Medicaid for all eligible patients, but the severe funding limitations in housing programs mean that although health providers may identify housing as a key need to treating a patient’s health, they likely cannot secure appropriate housing assistance and supports for them.

New Buildings Alone Won’t Fix the Affordable Housing Crisis

Upon learning of the shortage in affordable housing, many people’s first instinct is to call for building more units. While some communities need additional units, in most communities, adding to housing supply isn’t the main solution. People need help affording the housing in which they already live, which calls for more rental assistance resources.

Most people who struggle to afford housing have a place to live — but the gap between their income and housing costs is too great, so they can’t always meet other basic needs or they teeter on the brink of eviction.a Indeed, even most housing units created using the Low Income Housing Tax Credit (LIHTC) program — the nation’s largest subsidy for the development of affordable rental housing — aren’t affordable for people with extremely low incomes unless they also have a voucher or other rental assistance.

LIHTC is an effective subsidy for developing housing that’s affordable to families with incomes at 60 percent of the local median income.b But it’s hard for states or developers to make LIHTC rents affordable to extremely low-income families (those with incomes at or below 30 percent of the local median income).c LIHTC generally subsidizes only construction and renovation costs. Because most extremely low-income families can’t afford the rent to cover the day-to-day costs of operating rental housing (such as maintenance, security, and utilities), most of them can’t afford unsubsidized rents, even in LIHTC buildings.d Therefore, rental assistance is still needed to help extremely low-income families afford housing.

In contrast to development projects, rental assistance can be expanded quickly to provide affordable housing to certain populations, such as those experiencing homelessness or high-cost users of the health care system. In addition, affordable housing development subsidies are usually less cost-effective at reducing low-income families’ rents than rental assistance, studies show.e Finally, many people currently in unsubsidized housing can barely afford their apartment or make difficult choices about food, medicine, or clothing in order to pay their rent. In these circumstances, rental assistance is the better solution to making housing affordable and easing the burden on families because they don’t need to move to a new building; they need help paying to stay where they currently live.

a Alicia Mazzara, “Census: Income-Rent Gap Grew in 2018,” Center on Budget and Policy Priorities, September 27, 2019, https://www.cbpp.org/blog/census-income-rent-gap-grew-in-2018.

b NYU Furman Center, “The Effects of the Low-Income Housing Tax Credit (LIHTC),” May 2017, http://furmancenter.org/research/publication/the-effects-of-the-low-income-housing-tax-credit-lihtc.

c Low-income = household income not exceeding 60 percent of local median income. For a family of four in the United States, 60 percent of the local median is equivalent to about $45,300.

d Megan Bolton, Elina Bravve, and Sheila Crowley, “Aligning Federal Low Income Housing Programs with Housing Need,” National Low Income Housing Coalition, December 2014, https://nlihc.org/sites/default/files/Alignment_Report_1214_1.pdf.

e Edgar O. Olsen, The Cost-Effectiveness of Alternative Methods of Delivering Housing Solutions,” University of Virginia, 2009, http://economics.virginia.edu/sites/economics.virginia.edu/files/papers/CESurvey2009.pdf; U.S. General Accounting Office, “Federal Housing Assistance: Comparing the Characteristics and Costs of Housing Programs, January 2002, https://www.gao.gov/assets/240/233652.pdf.

Health System’s Housing Initiatives

The scarcity of affordable housing coupled with the urgency to reduce health costs has put pressure on the health system to fill in gaps. Managed care organizations, hospitals, and state Medicaid programs have started to invest in targeted, small-scale affordable housing initiatives.[20] Typically, these health care entities partner with established local affordable housing developers or housing authorities that administer rental assistance. These initiatives, while providing important lessons, have limited reach and fall far short of meeting the demand for affordable housing, even for the identified target populations.

Managed Care Investment

Managed care organizations are finding it increasingly difficult to control health care costs — their primary goal — without making non-health care investments. They are increasingly investing in programs aimed at addressing non-health factors, otherwise known as social determinants of health, that have been proven to have an impact on health outcomes, including housing.[21]

Some managed care organizations have invested in affordable housing development. Kaiser Permanente and Enterprise Community Partners, an organization that brings together affordable housing development investors, have partnered in Oakland, California, on a $50 million fund that will help create and preserve affordable housing to help people with chronic illnesses. They also have created a $250 million housing equity fund directed at preserving and improving affordable housing that supports healthy communities. These investments enable Kaiser Permanente to advance its goal to increase access to housing because they recognize that more housing improves its members’ health, along with that of the broader community; reduces health expenditures; and allows Kaiser Permanente to potentially realize a return through tax savings (although these savings will likely be smaller than it may have otherwise earned through private investments).[22]

Rental assistance is needed to ensure that housing is accessible for those with extremely low incomes, and it helps in areas where there’s enough housing but it’s not affordable for people with low incomes. (See box, “New Buildings Alone Won’t Solve the Affordable Housing Crisis.”) Some Medicaid managed care organizations have recognized this need and are testing ways to provide rental assistance. For example, Health Plan of San Mateo in California pairs health care services with ongoing housing assistance for over 120 people to avoid nursing home care costs. As of 2017, the plan’s costs for these members had fallen by 50 percent.[23]

Hospital and Health Systems

To maintain their tax-exempt status, non-profit hospitals must contribute resources that improve the communities they serve.[24] These hospitals conduct community needs assessments every three years to determine how to direct these resources. Projects must fit into one of four categories: improving access to care, enhancing health of the community, advancing medical or health knowledge, or reducing the burden of government or other community health programs.

A growing number of hospitals are making financial investments in housing capital costs with the intended purpose of addressing the housing needs of people who are homeless or at risk of homelessness and either currently or potentially high-cost users of health care, with the expectation that increasing available affordable housing will help stabilize the person and reduce the need for high-cost hospital or health system use. These investments also often generate direct, usually small, financial returns in either the short or long term for the hospital system.[25] Sometimes, hospital systems will use community benefit resources in the same neighborhood as their housing investment properties so that both the housing and services needs are met for the target population. Examples of hospital and health systems working to address housing include: Denver Health in Denver, Colorado; AdventHealth in Orlando, Florida; Bon Secours hospital in Baltimore, Maryland; Dignity Health System in several locations; Nationwide Children’s Hospital in Columbus, Ohio; and five hospital partners in Portland, Oregon.[26]

Medicaid

There is significant eligibility overlap between people who are eligible for federal rental assistance and those who qualify for Medicaid. However, the Medicaid statute prohibits federal Medicaid funding of “room and board,” which has been interpreted to mean rent and building costs. Medicaid can reimburse costs for health care services that enable people to live independently at home and maintain their housing. Seniors and people with disabilities may need health providers to visit them in their home to help them with personal care services. And people with long histories of homelessness or institutional care may need housing-related support services such as negotiating with landlords to avoid eviction, housing search, and tenants’ rights and responsibilities training, for certain populations based on medical needs.[27]

The Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicaid, has approved demonstration projects in several states to deliver housing-related services such as in-home personal care services, behavioral health care services, and intensive case management, and housing-specific supports like help searching for housing and working with landlords, if Medicaid beneficiaries need these services to maintain their health and keep them out of expensive institutional care (see Appendix for more details). These are often pilot programs with narrowly defined target populations, but they are helping to test Medicaid’s role in stabilizing people in housing. Illinois, for example, includes housing status as a criterion for eligibility in its planned pilot project, relying on HUD regulations that define homelessness.[28] This recognizes that homelessness exacerbates poor health and indicates that people with chronic or disabling health conditions who are experiencing homelessness should receive non-traditional Medicaid services, such as housing search and stabilization services, to improve their health.

Medicaid programs have also connected people to housing through CMS’ Money Follows the Person (MFP) demonstration program, which helps people transition from nursing home or mental health facility care to living independently in the community.[29] Because this program is a temporary demonstration, and therefore not part of the regular Medicaid program, states can use MFP funding for non-Medicaid services, such as direct housing costs.

Several states have used MFP to pay for short-term rental assistance, utility fees, and housing modifications to help people leave institutional care and receive in-home services.[30] This is less costly than a nursing home stay and achieves better client satisfaction because people prefer living at home.[31] Original funding for this program expired in September 2016, but Congress added about $140 million in additional funds in fiscal year 2019 to help states continue their MFP programs through the program’s September 2020 expiration date. Congress and the President must act to extend or reauthorize the program beyond 2020.

Federal Housing and Health Grant Programs

Federal grant programs, such as the Community Mental Health Block Grant, the Community Services Block Grant, the Housing Opportunities for People with AIDS program (HOPWA), and the Community Development Block Grant, can fill in the gaps between what Medicaid can pay for and what people with complex health conditions need to remain housed and avoid expensive health services. Government entities should incentivize partnerships across health and housing government agencies and community-based programs by strategically using these grants to fund investments in agency- and program-level data collaboration and sharing, promote integrated case management practices that ease the burden on families and streamline administrative requirements, and standardize service definitions and eligibility requirements across agencies and programs to increase efficiency and ease administrative burden.

At the federal level, for example, HUD and the Department of Health and Human Services (HHS) can identify ways for their grantees that serve similar (if not the same) populations to collaborate so that programs from both agencies, along with Medicaid, maximize their impact and people’s housing and health needs are met in a coordinated way. For instance, grantees in HHS’ Ryan White Program, which provides medical care and services to low-income people with HIV/AIDS, often overlap with HUD’s HOPWA grantees; HUD and HHS can coordinate grant programs by encouraging the HUD and HHS grantees to work together when their grant objectives are aligned. HUD and HHS can also identify opportunities to make joint grant awards to ease administrative burden and ensure that providers or localities can come closer to meeting clients’ comprehensive needs. HUD and HHS each have grant programs focused on several other populations, such as people experiencing homelessness, seniors, and people with disabilities.

The Health System Alone Can’t Solve the Affordable Housing Crisis

Health initiatives such as those described above can improve service delivery for some people with unstable housing or, through MFP, deliver temporary housing assistance, but the health care system isn’t well positioned to fill the large gap between those who receive federal housing assistance and those who are eligible. The health system isn’t equipped to manage housing stock, inspect units for safety, or pay people’s rent, and it shouldn’t recreate an existing affordable housing infrastructure.

Publicly funded health programs need more money to continue to improve access to health services. Expanding Medicaid’s scope to include housing, beyond immediate assistance to transition from institutional care or homelessness, would undermine the program’s primary purpose of helping people afford health care services. Many state Medicaid programs are stretched, with health services such as dental care, vision care, and behavioral health care too often inadequately available to Medicaid beneficiaries.[32] Medicaid investment in health-related activities shouldn’t be jeopardized by over-expanding into other areas.

Housing stability could be jeopardized if housing supports are linked to Medicaid eligibility. People often have better health outcomes once they are stably housed, but they may still need rental assistance after their health improves. They may also earn enough to make them ineligible for Medicaid but housing affordability may remain challenging. If states or managed care providers used Medicaid to pay for their housing, beneficiaries would likely lose their rental assistance if they were no longer eligible for Medicaid. While eligibility for housing assistance targeting people with extremely low incomes generally overlaps with eligibility for Medicaid, federal housing assistance can go to people with incomes of up to approximately 80 percent of the area median income — a much higher income level than the eligibility cutoff for Medicaid, even in expansion states.[33] But there aren’t enough federal housing resources to guarantee that someone losing Medicaid could immediately transition to other rental assistance programs. That means that despite earning higher income — and possibly receiving health insurance through their employer or in the marketplace — many such renters would still pay severely unaffordable rents and struggle to keep their housing.

Steps to Create More Affordable Housing, Broaden Access to Health Care

Partnerships across health and housing sectors are key to helping people with low incomes obtain and maintain housing that they can afford. Policymakers will have to make significantly larger investments in housing assistance to move successful interventions from small pilot projects to programs large enough to serve all who need integrated housing and health care services. The health care system has the data and experience needed to illustrate the impact that better access to affordable housing can have. The housing system has the expertise and many of the processes, such as inspecting units and paying people’s rent on time, needed to serve more people but it lacks the resources to do so. The housing and health sectors together can maximize their collective resources and expertise to call for increased federal affordable housing funding; increased Medicaid coverage for housing-related services; and effective coordination of Medicaid and other federal health funding with housing resources to comprehensively meet people’s physical, behavioral, and social support needs.

Strategies for Increasing the Availability of Affordable Housing

The following concrete policies can reduce the number of households that struggle to afford housing and improve the fact that 75 percent of households eligible for rental assistance don’t receive it due to funding scarcity:

Expand the Housing Choice Voucher program. A substantial increase in housing vouchers is needed to make housing affordable for people with low incomes. Federal vouchers, which currently serve 2.2 million households across the country, are the primary form of federal rental assistance that can be quickly expanded to serve more households.[34] Housing Choice Vouchers can be tenant-based or project-based,[35] allowing people flexibility to live in the type of housing of their choice. Even project-based vouchers allow tenants flexibility because they can move out of the building with an available tenant-based voucher after one year. This ensures that tenants do not risk losing housing assistance if they wish to live somewhere else.

In recent years, federal policymakers have mostly provided enough funding so that no household loses assistance due to federal funding cuts, but there haven’t been major funding increases to extend assistance to more families. However, federal policymakers have targeted some assistance under the voucher program toward addressing the housing needs of specific groups of people. For example, the Veterans Affairs Supportive Housing program, created in 2008, has provided 98,000 targeted Housing Choice Vouchers and services for veterans experiencing homelessness, most of whom have had physical, substance use, or mental health conditions and been homeless repeatedly or for a long period of time.[36] And in 2017 and 2018, Congress allocated $385 million for new housing vouchers targeted to adults with disabilities who are under 62 years old, which is expected to provide housing assistance to nearly 50,000 people.[37] These increases haven’t been sufficient to make significant progress in closing the gap between those who need assistance and those who receive it.

Establish a renters’ tax credit program. A well-designed renters’ credit would reduce rents to levels that extremely low-income families can afford, in both developments that have received tax credit subsidies and those that have not.[38] (The Low Income Housing Tax Credit (LIHTC) provides tax credits for investments in certain housing developments that must meet certain affordability standards. But rents in these developments, while lower than market rate, are still unaffordable for very low-income families without further subsidies.) Under a proposal that the Center has advanced, property owners would receive a tax credit that would subsidize their operating costs and allow them to collect less rent from residents. The proposal would authorize states to allocate a capped amount of credits to landlords, property owners, or property management entities, subject to federal income eligibility rules and state policy preferences. Each state’s share of the credits would be set based on its population with a minimum allocation for small states. A credit with an annual cost of $6 billion once fully phased in could help about 720,000 households afford decent stable housing, we estimate.

Strengthen LIHTC and the National Housing Trust Fund (NHTF) to build more affordable housing in high-opportunity areas. Development subsidies can support the creation of more affordable housing in certain high-cost, low-vacancy areas and some rural areas where rental assistance alone may be difficult to use. They are also helpful tools to renovate and re-configure housing to help special populations, such as seniors and people with disabilities, live independently in the community and out of institutional care. The federal LIHTC is the largest source of development funds. Federal and state LIHTC policy should incentivize developers to build in high-opportunity areas, target resources to poor communities as part of a broader effort to revitalize them, help and require developers to make units affordable for people with extremely low incomes, and market the availability of new units in high-opportunity areas to low-income tenants who are underrepresented in the communities with LIHTC properties.[39]

The NHTF, while relatively new, is another important source of federal development funding. It helps states build, preserve, rehabilitate, and operate housing that is affordable to people at the lowest incomes. Policymakers should significantly expand its funding and use it to complement other federal rental assistance programs.[40]

To ensure that housing is built in diverse communities and does not result in segregation, local officials should be prohibited from blocking LIHTC and NHTF affordable housing developments, fair housing cases should be pursued when appropriate, and resources should be dedicated toward improving the collection and reporting of resident demographic information.

Expand smaller federal programs that provide rental assistance to special populations. A number of smaller programs provide rental assistance to certain groups such as people experiencing homelessness, seniors, non-elderly people with disabilities, and people living with HIV/AIDS.[41] These programs can make it easier to target and couple housing assistance with support services for people who are particularly ill or needy.

Maintain and boost state and local rental assistance programs. An increasing number of states and localities are funding their own rental assistance programs. These programs are typically targeted to people identified as having low or extremely low incomes and who have other barriers to housing, including people with serious health conditions who are experiencing homelessness, people preparing to leave jail or prison, or people trying to move back into the community after a stay in a nursing home or psychiatric facility.

State or locally funded rental assistance won’t fill the gap in the availability of affordable housing without significantly more federal rental assistance. It is, however, a useful tool for starting new or building on existing innovative strategies that seek to integrate housing and services for vulnerable populations, such as supportive housing programs. For example, Connecticut’s state housing agency administers a rental assistance program that serves over 5,500 people, many of whom have a mental health condition or history of homelessness. Iowa’s state housing agency has a small rental assistance program that services about 360 people who receive services through the state Medicaid Home- and Community-Based Services program.[42]

Continue housing investment resources from managed care organizations, hospitals, and health systems. As explained above, several health entities invest in housing developments and subsidy programs.[43] These projects are generally small but help local efforts move forward in an environment of stagnant federal resources. They also allow communities to test new housing and services practices for certain target populations. These entities should continue their initiatives while looking for ways to align with other local resources, to maximize the impact of health system resources and serve as many people as possible.[44]

Strategies for Increasing Access to Services for Vulnerable Populations

As described above, Medicaid can be an important source of support for households struggling to pay rent and make ends meet. Health insurance coverage helps people, including those experiencing or at risk of homelessness, afford care that can help them through a health crisis or access ongoing supports if they have chronic physical or behavioral health care conditions. States can use Medicaid to further promote housing stability by:

Expanding Medicaid. The Affordable Care Act gave states the opportunity to expand Medicaid to cover nearly everyone whose income is at or below 138 percent of the poverty line, which includes most people who qualify for federal rental assistance. But 14 states have not expanded Medicaid, and in those states, only people with certain disabilities, seniors, or low-income families with children are eligible.[45] Barriers to proving disability status preclude many from Medicaid eligibility, especially homeless people with mental illness or substance use disorders. Expanding Medicaid in the states that have not done so would be an important step toward providing housing support services for more of those who need it. Eviction rates have fallen in states that expanded Medicaid, a recent study in the American Journal of Public Health showed.[46]

Providing a broader range of Medicaid-funded services and supports, including services to help find and maintain housing. While not well understood, some affordable housing property owners and public housing agencies deliver health services to their residents. Medicaid could cover many of these services if the provider meets Medicaid standards for billing, or housing services agencies could seek certification, if appropriate.

As explained above, state Medicaid agencies can request permission from CMS to provide services such as in-home personal care services, behavioral health care services, intensive case management, and housing-specific supports like help searching for housing and working with landlords, if these services are necessary for someone to maintain their health and keep them out of expensive institutional care.[47] But relatively few states have used the Medicaid authorities available to them to provide these services, and when they do, states often have different rules for the same services depending on a beneficiary’s eligibility category. This inconsistency can make it hard for providers who must track delivery and payment differently for their clients due to the lack of coordination within the state’s Medicaid program. More states should take advantage of their flexibility to provide these services and streamline these services across their Medicaid programs.

Helping more providers, especially providers of substance use treatment and recovery and housing supports, secure Medicaid reimbursement. Many social services providers that provide housing-related services don’t bill Medicaid for services that are eligible for Medicaid reimbursement. The same is true for substance use treatment and services providers that lacked expertise in, and an infrastructure for, billing Medicaid before their services became eligible for reimbursement under the Affordable Care Act.[48] States and managed care organizations should provide training and outreach to encourage these providers to bill Medicaid where appropriate.

Figure 2
Stakeholders in the Housing and Health Care Sectors

Appendix A: Summary of Sample State Medicaid Programs That Provide Housing Related Services

APPENDIX TABLE 1
Examples of State Medicaid Waiver and State Plan Amendments That Include Housing-Related Services
State Authority, Waiver Name Services Eligible Population Service Providers Effective Date
Alabama 1915(c), Home & Community Based Services Waiver for Persons with Intellectual Disabilities
  • Housing Stabilization Services
Persons with Intellectual Disabilities Department of Mental Health Transition Services Providers 10/01/2014 – 09/30/2019
California 1915(i), State Plan Amendment
  • Individual Housing Transition Services
  • Individual Housing and Tenancy Sustaining Services
Persons with Intellectual and/or Developmental Disabilities Individual or business entity licensed at the discretion of the county 07/01/2018
1915(c) Home & Community Based Services Waiver
  • Individual Housing Transition Services
  • Individual Housing and Tenancy Services
Persons with an Intellectual and/or Developmental Disability Individual or business entity licensed at the discretion of the county 01/01/2018 – 12/31/2022
1115, Medi-Cal 2020 (Known as Whole Person Care Pilots)*
  • Tenancy-based Care Management Services
Including (but not limited to) High-Risk, High-Utilizing People with:

  • Repeated emergency visits or hospital admissions;
  • Multiple chronic conditions;
  • Mental health and/or substance use disorder;
  • Experiencing homelessness; and/or
  • At risk of homelessness
Individual or business entity licensed at the discretion of the county 12/30/2015 – 12/31/2020
Hawaii 1115, Hawaii QUEST Integration
  • Pre-Tenancy Supports
  • Tenancy Sustaining Services
Individuals with:

  • A mental health condition;
  • substance use disorder; and/or
  • A complex health need;

AND are:

  • Chronically homeless;
  • At risk of homelessness upon release from an institution; or
  • Living in public housing and at risk of eviction
Community Integration Services Providers 10/03/2018 – 07/31/2024
Illinois 1115, Illinois Behavioral Health Transformation
  • Pre-Tenancy Supports
  • Tenancy Sustaining Services
Persons with:

  • Repeated incidences of emergency department use (4+ per year); or
  • Two or more chronic conditions;

AND

  • Will become homeless upon release from an institution; or
  • Are at imminent risk of institutional placement
Assistance in Community Integration Services Providers 07/01/2018- 06/30/2023
Maryland 1915(c), MD Community Supports Waiver
  • Housing Support Services
  • Transition Services
  • Housing Tenancy Sustaining Services
Persons with Developmental Disabilities Housing Support Service Provider or Professional 01/01/2018 -06/30/2024
1115, Maryland HealthChoice (Known as Assistance in Community Integration Services) Pilot
  • Tenancy-Based Case Management Services
  • Tenancy Support Services
Persons with:

  • Repeated incidences of emergency department use (4+ per year); or
  • Two or more chronic conditions

AND

  • Will become homeless upon release from an institution, or
  • Are at imminent risk of institutional placement
Case Manager and Supervisory Case Manager 07/01/2017-12/31/2021
Massachusetts 1915(c), MA Community Living
  • Transition Services
Persons over age 22 with an Intellectual Disability Qualified Individual Providers, Individual/Family Support Provider Agency, and/or State Provider Agencies 07/01/2018-06/30/2023
1115, MassHealth
  • Pre-Tenancy Supports
  • Tenancy Sustaining Supports
  • Home Modifications
  • Nutrition Sustaining Supports (including transportation, food delivery, and preparation supplies)
Individuals who:

  • Have a mental health and/or substance use disorder;
  • Have a complex physical need;
  • Require assistance with one or more activities of daily living;
  • Have repeated use of the emergency department (4+ visits annually); or
  • Are experiencing a high-risk pregnancy (if applicable);

AND

  • Are homeless;
  • Are at risk of homelessness, either upon release from an institution or from housing or financial instability;
  • Are at risk of nutritional deficiency or imbalance due to food insecurity
Tenancy Preservation Services Contractors and Nutritional Support Services Contractors 07/01/2017 – 06/30/2022
Michigan 1915(i) State Plan Amendment
  • Transition Navigator Case Management Services
  • Community Transition Services
  • Home Modifications
Individuals with:

  • A functional limitation in one or more of the following areas: self-care, communication, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency;

AND

  • At risk of not increasing or maintaining sufficient level of functioning to achieve their individual goals without the services
  • Qualified Mental Health and/or Intellectual Disability Professional
10/01/2018 – 10/01/2022
Minnesota 1915(i), State Plan Amendment
  • Housing Stabilization Services (Housing Sustaining and Transition Services)
  • Individuals with a disability and/or long-term condition who are:
  • Experiencing homelessness;
  • At risk of homelessness; or
  • Transitioning from an institutional setting
Individuals and/or Agencies that meet Housing Stabilization Standards 07/01/2020-6/30/2025
North Carolina 1115, NC Medicaid Reform Demonstration
  • Tenancy Support and Sustaining Services
  • Housing Quality and Safety Improvement Services
  • Legal Assistance for Housing Issues
  • Securing Housing Payments
  • Short-Term Post-Hospitalization Housing
  • Individuals with:
  • Two or more chronic conditions, or
  • Repeated emergency room use (4+ visits annually)

AND

  • Experiencing homelessness and housing insecurity,
  • Food insecurity,
  • Transportation insecurity, or
  • At risk of, witnessing, or experiencing interpersonal violence
Providers to be determined by Lead Pilot Entities 11/01/2019-10/31/2024
Texas 1915(i), State Plan Amendment
  • Transition Assistance Services
  • Housing Supportive Services
  • Minor Home Modifications
Individuals must:

  • Require services to improve or maintain functioning, prevent relapse to a lower level of functioning, and maintain residence in the community; and
  • Have a history of extended or repeated stay(s) in an inpatient psychiatric hospital (3 or more years of cumulative hospitalization in the 5 years proceeding enrollment in services)
HCBS Provider Agency 09/01/2015 – 09/01/2020
Washington 1115, WA Medicaid Transformation Project (Known as Foundational Community Support Program)
  • Pre-Tenancy Supports
  • Tenancy Sustaining Services
  • Adults Who:
  • Have a mental health need and/or substance use disorder,
  • Require assistance with daily living, or
  • Have a complex physical need

AND

  • Are experiencing homelessness and/or a history of stays in an institutional setting, or
  • Have a history of frequent adult residential care stays, or
  • Have frequent turnover of in-home caregivers, or
  • Have a PRISM score of 1.5 or higher
  • Community Support Services Providers
11/21/2017-12/31/2021

* Lucy Pagel, Tanya Schwartz, and Jennifer Ryan, “The California Whole Person Care Pilot Program: County Partnerships to Improve the Health of Medi-Cal Beneficiaries,” Harbage Consulting, updated February 2018, https://harbageconsulting.com/wp-content/uploads/2018/04/WPC-Summary_Final_02282017_Revision_-4-2-2018.pdf.

Note: Not a comprehensive list of waivers and amendments that integrate housing into health care delivery. For links and more detail to some of the waivers/amendments listed above see https://nashp.org/wp-content/uploads/2019/01/Service-definitions-for-tenancy-support-final-3.11.19.pdf To understand the various waiver and state plan amendment authorities within the Medicaid program and their relationship to housing-related services, see this explainer by the Kaiser Family Foundation: https://www.kff.org/report-section/linking-medicaid-and-supportive-housing-issue-brief/.

Topics: 

End Notes

[1] Center on Budget and Policy Priorities, “Three Out of Four Low-Income At Risk Renters Do Not Receive Rental Assistance,” 2017, https://www.cbpp.org/three-out-of-four-low-income-at-risk-renters-do-not-receive-federal-rental-assistance.

[2] Joint Center for Housing Studies at Harvard University, “The State of the Nation’s Housing,” 2019, https://www.jchs.harvard.edu/state-nations-housing-2019.

[3] While the term “affordable housing” — relative to household income — is often used loosely, in this paper, unless otherwise noted, we are using it broadly to refer to housing that renters earning 80 percent of the area median income or below can afford using no more than 30 percent of their income, regardless of their receipt of rental assistance. Renters using over 30 percent of their income on housing costs are known as “cost burdened”; those using over 50 percent of their income on housing are referred to as “severely cost burdened.” For more, see https://nlihc.org/resource/nlihc-gap-2019-report-calls-significant-investments-address-shortage-7-million-affordable.

[4] David L. Stern, Andrea K. Blanch, Ph.D., and Sarah M. Steverman, “Impact of Toxic Stress on Individuals and Communities: A Review of the Literature,” Mental Health America, September 2014, https://www.mentalhealthamerica.net/sites/default/files/Impact%20of%20Toxic%20Stress%20on%20Individuals%20and%20Communities-A%20Review%20of%20the%20Literature.pdf.

[5] Robin Hacke and Katie Grace Deane, Center for Community Investment, “Improving Community Health by Strengthening Community Investment,” Robert Wood Johnson Foundation, March 2017, https://www.rwjf.org/en/library/research/2017/03/improving-community-health-by-strengthening-community-investment.html.

[6] For an explanation of the health system’s goals to improve costs, access, and outcomes, also known as the “Triple Aim” of the health care system, see http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx.

[7] Ehren Dohler et al., “Supportive Housing Helps Vulnerable People Live and Thrive in the Community,” Center on Budget and Policy Priorities, May 31, 2016, https://www.cbpp.org/research/housing/supportive-housing-helps-vulnerable-people-live-and-thrive-in-the-community.

[8] Julia Paradise and Donna Cohen Ross, “Linking Medicaid and Supportive Housing: Opportunities and On-the-Ground Examples,” Kaiser Family Foundation, January 27, 2017, https://www.kff.org/medicaid/issue-brief/linking-medicaid-and-supportive-housing-opportunities-and-on-the-ground-examples/view/print/.

[9] National Center for Healthy Housing and the America Public Health Association, “National Healthy Housing Standard,” June 2018, https://nchh.org/resource-library/national-healthy-housing-standard.pdf.

[10] Paula Braveman et al., “Neighborhoods and Health,” Robert Wood Foundation Commission to Build a Healthier America, Exploring Social Determinants of Health Series, Issue Brief #8, May 2011, https://www.rwjf.org/en/library/research/2011/05/neighborhoods-and-health-.html.

[11] Jack P. Shonkoff et al., “The Lifelong Effects of Early Childhood Adversity and Toxic Stress,” Pediatrics, Vol. 129, Issue 1, January 2012, https://pediatrics.aappublications.org/content/129/1/e232.

[12] Anirban Basu et al., “Comparative Cost Analysis of Housing and Case Management Program for Chronically Ill Homeless Adults Compared to Usual Care,” Health Services Research, November 2011, pp. 523-43, https://www.researchgate.net/publication/51812631_Comparative_Cost_Analysis_of_Housing_and_Case_Management_Program_for_Chronically_Ill_Homeless_Adults_Compared_to_Usual_Care.

[13] Barbara Sard et al., “Federal Policy Changes Can Help More Families with Housing Vouchers Live in Higher-Opportunity Areas,” Center on Budget and Policy Priorities, September 4, 2018, https://www.cbpp.org/research/housing/federal-policy-changes-can-help-more-families-with-housing-vouchers-live-in-higher; Raj Chetty et al., “Race and Economic Opportunity in the United States: An Intergenerational Perspective,” March 2018, http://www.equality-of-opportunity.org/assets/documents/race_paper.pdf. For background on MTO, see https://www.hud.gov/programdescription/mto.

[14] Center on Budget and Policy Priorities, “Policy Basics: Federal Rental Assistance,” November 15, 2017, https://www.cbpp.org/research/housing/policy-basics-federal-rental-assistance.

[15] Center on Budget and Policy Priorities, “Three Out of Four Low-Income At-Risk Renters Do Not Receive Federal Rental Assistance,” updated August 2017, https://www.cbpp.org/three-out-of-four-low-income-at-risk-renters-do-not-receive-federal-rental-assistance.

[16] National Low Income Housing Coalition, “Housing Spotlight: The Long Wait for a Home,” Fall 2016, https://nlihc.org/sites/default/files/HousingSpotlight_6-1_int.pdf.

[17] Anna Bailey, “With Federal Funds Insufficient, States and Localities Funding Their Own Rental Assistance Programs,” Center on Budget and Policy Priorities, April 15, 2019, https://www.cbpp.org/blog/with-federal-funds-insufficient-states-and-localities-funding-their-own-rental-assistance.

[18] “The State of the Nation’s Housing 2019,” Joint Center for Housing Studies of Harvard University, 2019, https://www.jchs.harvard.edu/sites/default/files/Harvard_JCHS_State_of_the_Nations_Housing_2019.pdf.

[19] Center on Budget and Policy Priorities, “Policy Basics: Introduction to Medicaid,” updated August 16, 2016, https://www.cbpp.org/research/health/policy-basics-introduction-to-medicaid.

[20] Corianne Payton Scally et al., “Emerging Strategies for Integrating Health and Housing: Innovations to Sustain, Expand, and Replicate,” Urban Institute, July 2017, https://www.urban.org/sites/default/files/publication/91941/emerging_strategies_in_integrating_health_and_housing_final_6.pdf.

[21] Hannah Katch, “Medicaid Can Partner With Service Providers and Others to Address Enrollees’ Social Needs,” Center on Budget and Policy Priorities, January 17, 2020, https://www.cbpp.org/research/health/medicaid-can-partner-with-housing-providers-and-others-to-address-enrollees-social.

[22] Enterprise Community Partners, “Enterprise and Kaiser Permanente Announce New Funds,” January 2019, https://www.enterprisecommunity.org/blog/2019/01/enterprise-kaiser-permanente-announce-new-funds.

[23] Mercy Housing and The Low Income Investment Fund, “Innovative Models in Health & Housing,” 2017, http://www.liifund.org/wp-content/uploads/2017/07/LIIF_whitepaper_pages.pdf.

[24] These are known as community benefit programs. For more detailed information on community benefit programs, see: Julia James, “Nonprofit Hospitals’ Community Benefit Requirements,” Health Affairs, February 25, 2016, https://www.healthaffairs.org/do/10.1377/hpb20160225.954803/full/.

[25] Kathryn Reynolds et al., “Affordable Housing Investment: A Guide for Nonprofit Hospitals and Health Systems,” Urban Institute, August 2019, https://www.urban.org/research/publication/affordable-housing-investment-guide-nonprofit-hospitals-and-health-systems.

[26] Markian Hawryluk, “Hospitals are Buying Up Housing Units, Helping ‘Stranded’ Hospital Patients Find a Home,” USA Today, October 2, 2019, https://www.usatoday.com/story/news/health/2019/10/02/denver-health-hospitals-buying-housing-patients/3840199002/; Kate Santich, “Newly renamed AdventHealth announces grant of up to $500K for housing homeless,” Orlando Sentinel, January 2, 2019, https://www.orlandosentinel.com/health/os-ne-advent-health-homeless-grant-20190102-story.html; “Family Housing,” Bon Secours, https://bonsecours.com/baltimore/community-commitment/housing/family-housing; “Increasing Capital for Underserved Communities,” Dignity Health, https://www.dignityhealth.org/about-us/community-health/increasing-capital-for-underserved-communities; “Affordable Housing,” Nationwide Children’s, https://www.nationwidechildrens.org/about-us/population-health-and-wellness/healthy-neighborhoods-healthy-families/affordable-housing; and Ryan Frank, “Oregon healthcare organizations invest $21.5 million in innovative programs to support housing, medical services,” Central City Concern, September 23, 2016, https://www.centralcityconcern.org/housingishealth.

[27] Medicaid and CHIP Payment Advisory Committee, “Medicaid’s Role in Housing,” October 2018, https://www.macpac.gov/publication/medicaids-role-in-housing/; and Vikki Wachino, “Coverage of Housing-Related Activities and Services for Individuals with Disabilities,” Center for Medicaid & CHIP Services, June 26, 2015, https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf.

[28] Department of Housing and Urban Development, “Homeless Emergency Assistance and Rapid Transition to Housing: Continuum of Care Program,” June 28, 2012, https://www.hudexchange.info/resources/documents/CoCProgramInterimRule_FormattedVersion.pdf.

[29] Carol Irvin et al., “Money Follows the Person 2015 Annual Evaluation Report,” Mathematica Policy Research, May 11, 2017, https://www.mathematica-mpr.com/our-publications-and-findings/publications/money-follows-the-person-2015-annual-evaluation-report.

[30] Molly O’Malley Watts, Erica L. Reaves, and MaryBeth Musumeci, “Money Follows the Person: A 2015 State Survey of Transitions, Services, and Costs,” Kaiser Family Foundation, October 16, 2015, https://www.kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/.

[31] U.S. Department of Housing and Urban Development, “Measuring the Cost and Savings of Aging in Place,” Evidence Matters, Fall 2013, https://www.huduser.gov/portal/periodicals/em/fall13/highlight2.html.

[32] Center for Health Care Strategies, “Fact Sheet: Medicaid Adult Dental Health Benefits: An Overview,” January 2018, https://www.chcs.org/media/Adult-Oral-Health-Fact-Sheet_011618.pdf; and Julia Zur, MaryBeth Musumeci, and Rachel Garfield, “Medicaid’s Role in Financing Behavioral Health Services for Low-Income Individuals,” Kaiser Family Foundation, June 2017, https://www.kff.org/medicaid/issue-brief/medicaids-role-in-financing-behavioral-health-services-for-low-income-individuals/.

[33] Many state HCBS cover people with higher incomes (up to 300 percent of the federal poverty line).

[34] The three largest rental assistance programs are Housing Choice Vouchers, Public Housing, and Project-Based Rental Assistance (PBRA). Policymakers ceased the expansion of public housing and PBRA in the mid-1990s. For more information, see Center on Budget and Policy Priorities, “Policy Basics: The Housing Choice Voucher Program,” updated May 3, 2017, https://www.cbpp.org/research/housing/policy-basics-the-housing-choice-voucher-program; Center on Budget and Policy Priorities, “Policy Basics: Public Housing,” updated November 15, 2017, https://www.cbpp.org/research/policy-basics-introduction-to-public-housing; and Center on Budget and Policy Priorities, “Policy Basics: Section 8 Project-Based Rental Assistance,” updated November 15, 2017, https://www.cbpp.org/research/housing/policy-basics-section-8-project-based-rental-assistance.

[35] Public housing agencies can dedicate project-based vouchers to specific units by contract, for an initial term of up to 20 years. For more information, see Center on Budget and Policy Priorities, “Policy Basics: Project-Based Vouchers,” updated March 1, 2017, https://www.cbpp.org/research/housing/policy-basics-project-based-vouchers.

[36] Department of Housing and Urban Development HUD-VASH program website: https://www.hud.gov/program_offices/public_indian_housing/programs/hcv/vash.

[37] “2018 Mainstream Voucher Awards,” Department of Housing and Urban Development, https://www.hud.gov/sites/dfiles/PA/documents/2018MainstreamVoucherFinalChart.pdf.

[38] Will Fischer, Barbara Sard, and Alicia Mazzara, “Renters’ Credit Would Help Low-Wage Workers, Seniors, and People with Disabilities Afford Housing,” Center on Budget and Policy Priorities, March, 9, 2017, http://www.cbpp.org/research/housing/renters-credit-would-help-low-wage-workers-seniors-and-people-with-disabilities.

[39] Will Fischer, “Low-Income Housing Tax Credit Could Do More to Expand Opportunity for Poor Families,” Center on Budget and Policy Priorities, August 28, 2018, https://www.cbpp.org/research/housing/low-income-housing-tax-credit-could-do-more-to-expand-opportunity-for-poor-families. Currently only 15 percent of LIHTC buildings are located in low-poverty areas, those with poverty rates lower than 10 percent.

[40] See http://nlihc.org/issues/nhtf/resources for more information.

[41] See Appendix for a list of federal rental assistance programs and the people served by each program.

[42] For more, see Anna Bailey, Peggy Bailey, and Douglas Rice, “Innovative Approaches to Providing Rental Assistance: States and Localities Seek to Support Health and Human Services Goals,” Cityscape: A Journal of Policy Development and Research, Vol. 20, No. 2, 2018, https://www.huduser.gov/portal/periodicals/cityscpe/vol20num2/ch4.pdf.

[43] Payton Scally et al.

[44] Board of Governors of the Federal Reserve System, “Community Reinvestment Act (CRA),” updated December 7, 2018, https://www.federalreserve.gov/consumerscommunities/cra_about.htm.

[45] “Status of State Action on the Medicaid Expansion Decision,” Kaiser Family Foundation, May 13, 2019, https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

[46] Naomi Zewde et al., “The Effects of the ACA Medicaid Expansion on Nationwide Home Evictions and Eviction-Court Initiations: United States, 2000–2016,” American Journal of Public Health, Vol. 109, No. 10, pp. 1379-1383, https://doi.org/10.2105/AJPH.2019.305230.

[47] Vikki Wachino, “Coverage of Housing-Related Activities and Services for Individuals with Disabilities,” Centers for Medicare and Medicaid Services, June 26, 2015, https://www.medicaid.gov/federal-policy-guidance/downloads/cib-06-26-2015.pdf.

[48] Prior to the Affordable Care Act, substance use treatment and services were largely not covered by Medicaid and people with a primary substance use diagnosis weren’t eligible for Medicaid . Matt Broaddus, Peggy Bailey, and Aviva Aron-Dine, “Medicaid Expansion Dramatically Increased Coverage for People with Opioid-Use Disorders, Latest Data Show,” Center on Budget and Policy Priorities, February 28, 2018, https://www.cbpp.org/research/health/medicaid-expansion-dramatically-increased-coverage-for-people-with-opioid-use.