when they are ill it's difficult to get back out of homelessness. working on housing and work in and getting a job. if you are fighting your addiction or mental health it's hard to get out of a shelter or off the street. one example of how when a health center population people who are homeless have disproportionately high rates of any disease you can imagine. that brings us to supportive housing. when we think about what a supportive housing typically it is helpful to think about it in terms of attrition additional model that emphasizes recovery first printers owner 20s we require people to get clean and sober and require people to enter into treatment and be successful before we get them into housing unit. if everyone follows the rules and you continue to follow the rules maybe one day you can be an independent house and while that certainly works for some rigid work for people who have serious health care condition is

hard to get clean when you are living on the streets. the supportive housing with that model. any of us can go home tonight and have a drink and is perfectly all right to do in our homes. it's an opportunity as well. we need to work with people where they are in the stabilizing and for housing so we have got that stability so people have a place for medication they have a place to put an appointment cards and keep track of time and a stable place where we can visit them. our outreach workers can't find them when they should drown on the streets and in camas change a lot. we need to think about our recent porting housing in this way? a wide range of team-based services, when you combine the stability of housing with health care services a wide range of the things listed here we can really help people be stable in their housing. this is mainstream right now for seniors and people with disabilities. my grandmother gets meals

delivered to her and she can having have them come here to help her with her bathing helper keeping the house clean. all of these things are things we take for granted with home and community-based services. think about extending that into this population so we are supporting the housing and the services people need in keeping with that same theme. i want to talk about relapse as part of recovery. these are the things we need to expect. recovery and mental health and addiction doesn't look like luck and white. it looks like a struggle and where we have people in zero-tolerance or recovery oriented housing even doubt one slipup jeopardizes your housing incorporated you could be back on the streets. it's important we are able to work with people and adjust services as they need that. there's no requirement for sobriety and the services are voluntary but what we have found is people are excited when they get into a unit that so many things look possible that didn't

before. we have been evaluating the effect of supportive housing in the peer-reviewed literature for 25 years and consistently what we find his housing improves health and improves health outcomes and it lowers the total cost of health care. i think this is where we need to be in rethinking housing because we are so focused on cost understandably so but we need to think about where is it that we the may king and roads and partnerships. we can read the slide. their consistent findings along these issues but we want to focus on how is it that bringing these two together is bringing out the things that we need? there is a lot of opportunity at the federal state and local levels that are important to be aware of. all states are working on strategies to end homelessness and improve health and also looking at determinants of health with one of the things i think is important particularly in through member is we need

federal support for the housing piece that goes along making this work. my colleagues will talk about what they are seeing in their sectors but again the cuts required by sequestration if we don't have the housing supports to put people and no amount of our health care services are going to make this work well. what we need is to come together. another thing i would recommend us to take away point for all of you that are health staffers and all of you who are housing staffers get to know each other. you have a lot in common and a a lot of times we are not working to get at the federal level like we are asking people to do with the local level so those would be a couple of things i would recommend. what we are doing is trying to build that ridge between health and housing and his health care providers we are in a rapidly changing environment to medicaid is one of the rapidly changing areas.

we are focused on outcomes that we also need to be focused on horrible people and getting them what they need but nothing works well as a health care provider when people are living on the streets. we want to reorient health care intervention that we really need and my colleague from hud will talk about hud is focused on building this bridge from housing to health that is an illustration of working together to make this model work and achieve the outcomes we wish to achieve. i want to point out that colleague if anyone is interested in learning more can take your card and get back to you but really appreciate your being here today. thank you. >> thank you. we'll turn to jennifer ho. >> thank you barbara. i am jennifer ho the hud secretary senior adviser on housing and services. i like to joke. and the one person that hud that those difference between the

care and medicaid everyday. you know what i'm talking about, don't you? my background isn't the first 10 years of my career and managed care largely medicare and medicaid managed care and it was in that work that i was first brought to the table to consider their relationship between homelessness and health in the impact that they order passing would have on health outcomes but also spending. i've been doing that ever since for the last 18 years. i want to assure you there is an unprecedented level of collaboration between hot and hhs not because that's my job but because it really is the case. hud is talking to the center for medicaid almost every day and we are talking with folks at hrsa and folks at samhsa.

we are talking to folks in the administration on children and families almost every day. i know it feels sometimes like housing and health care are miles apart and no one is talking pretty want to promise you in this administration there is an unprecedented level of collaboration. there's a simple fact about how we invest in housing federal that health care people to my style because you operate in a mandatory budget and entitlement programs. federal housing assistance is the only means tested benefit that is not entitlement. when someone becomes eligible for medicare or medicaid they get it. if you fill out an application you will get in line. when we asked congress to invest in more affordable for supportive housing they worry about the renewal burden, the fact that this increases our total legend in future years something i like to call pete --

keeping people in their homes. the conundrum is today medicaid could pay for, medicaid is a lot of financial incentives for there to be more affordable accessible in supportive housing in the budget environment is such that we are not doing what we know works and not doing anything at scale that matches that's why i'm excited to be here with you today because sure interest in housing could help create the consensus we need to make the investment that will matter. so thanks for being here and thanks for allowing me to be on this incredible panel. i will talk about how this plays out in three areas aging disability and homelessness. americans are living longer and the aging ab boom is going to test our commitment to the relationship doing housing and health. age is a great equalizer. as we grow older we are more likely to live alone have more chronic health conditions less mobility and we grow poorer.

sorry for that down over lunch. studies project a number of older households eligible for rental assistance will increase by 2.6 million people between 2011 and 2030. today at hud we provide rental assistance for 1.2 million seniors. that's one out of every three seniors who is income eligible. that means we would need 900,000 more subsidized housing units by 2030 just to keep up with one in three people who needed and are getting it. yet we have not made significant investments in more hud assistance and housing for seniors for some time. think about where you live today or where your parents or grandparents live. less than 1/2 of 1% of existing housing is currently accessible to someone in a wheelchair. only 5% is livable for someone who has mobility impairment and

only 40% is modifiable. most americans existing housing stock is not designed for them to age safely. imagine a 20-something million people the age of 84 and they can return to their homes or they don't fall but they just can't afford where they live. where will they go? how do we have a strategy for aging in place that people will not be able to a wart or navigate the place of that call home today? the health care system i would argue has a huge stake in meeting the affordability and accessibility needs of an aging america if there is not consensus that this is an investment of federal government should be making. a lot of work we are doing his rant disability and institutionalization. largely through new and improved program called section 811 supportive housing or

individuals with disabilities. 811 forces partnerships between the state finance agency and the state medicaid agency. in some places like colorado the partnership as they are pretty leverages sources of funding creates integrated housing were medicaid provides community-based services in a unit that is a deep breath substitute your hud. we have rounds of funding. 35 states have this money and the last around $30,180,000,000 for 4511 units. a drop in the bucket but at least we have made investments. the health care system i would argue has a huge stake in creating more integrated housing options for individuals with disabilities who would otherwise be an institutional setting yet there is not consensus this is an investment that federal norman should be making a cheer. each year. h

year. i came to washington to help with chronic homelessness. i appreciate barbara covering all the chronic arguments. i want to add a couple things. first, the president's budget request last year and this year have included investments to create a sufficient supply of supportive housing to end chronic homelessness in america. in 2016 he requested $255 million to hundred $55 million to create 25500 additional units of supportive housing but leverage the creation of many more. so supportive housing is proven to help homelessness people. it improves health and reduces er visits. the healthcare system, i would argue, has a huge stake in our creating a sufficient supply of supportive housing to end homelessness in america.

yet there is not consensus that this is an investment the federal government should be making. second we are learning something in the work that we are doing with the veterans affairs. here there has been confessing this consensus. we have had a one third reduction in homelessness between 2010 and 2013 and we are on a path to end their homelessness. imagine if we could get this aligned with medicaid to repeat this with individuals with disabilities who have lived on our streets and in our shelters for years. my my focus has been to work with cns to find ways we can better align housing and medicaid. i'm really thrilled with the housing related services report they just published. there there is a link to it in the documents and all of the information you

have in your packet. i'm increasingly meeting state medicaid directors who understand that if they are going to achieve the goals of health reform, bend the curve, they will need to deal with housing and homelessness and they have a new best friend who is a house. this new document brings clarity to something that was pretty unclear. if housing is over here and health care is over here, there is a a whole lot in the middle. what cannot medicaid do to pay for for whom and when? if medicaid were were paying for all the services in support of housing that it can pay for, we would have better health outcomes for seniors, individuals with disabilities and we could end chronic homelessness. i believe if medicaid became a major player in supportive housing we could build the consensus needed to make the level of investments

necessary to help seniors age in a home they can navigate and afford. individuals with disabilities who have a right to to live in an integrated setting have more choices of where to live and there would be more housing available because they value and service partnership. let me finish right started. the conundrum is, hud pays for a lot of services in housing that medicaid could pay for. medicaid has a lot of financial incentive for there to be a lot more affordable, accessible and supportive housing and the budget environment is such that were not going to do what we know works and were not doing anything at scale.

that is why i am excited to be here. your interest in housing, your understanding of the relationship between housing and health, your advocacy for supportive housing for older americans, individuals with disabilities, including folks with disabilities living on the street, could help create the consensus we need to make the investments we need to make the investments that will matter. thank you. >> thank you jennifer. before we we go on, if i can, let's clarify, you are talking about the kind of services that medicaid could pay for in supportive housing. i wonder if if you could be a little more explicit and say a couple words about what is stopping that from happening now. >> for example, in our homeless assistance programs we spent over $400 million per year on services. we only need $265 million to create more supportive housing to end chronic homelessness but were spending $400 million million dollars a year on services. that's everything for things medicaid can't pay for but a lot of that is exactly the type of

and reach, engagement, assistance that is described in the new housing related bulletin. the the biggest barrier is that states don't know what will be approved and what to ask for, everybody is afraid that what we are saying is medicaid should pay for housing. that's not what were saying. were saying medicaid should pay for health and these services that we are doing naturally now, keep grandma out of the nursing home or keep someone not of an institution, we just need to extend that. were also paying for services for service coordinators in our senior housing, we pay for service corps nadirs and public housing and a lot of that service coordination is really health system navigation and

wellness activity so we don't have an ambulance pulling up every night and we can keep people in their homes longer. >> okay, very good. let'sxd turn to gretchen from colorado. >> thank you all for inviting colorado to participate in this very interesting conversation. as jennifer mention, colorado is working very diligently on this issue and it's a privilege to be able to share with you some of the things we are doing. first i would like to provide a little context. everything we do within our state government at this point in time is really driven by our governors platform for health. that is the state of health. our very bold goal is to be the healthiest state in the nation. we take that goal very seriously not only because we have a great place to leave live, but we have health disparity in our community that are holding us back. we are we are working very hard to move those forward. it really is around this interconnected nature of health for our economic growth, social

conditions, for health care system to work more effectively than it does today, to help healthier people and to create a healthier bid business environment. we believe when we look at those things holistically we are able to put the right services, support and finances in place. if anyone anyone is familiar with the triple aim, the best care for the best value and that is our translation of that very important concept. that is a commitment to starting with prevention and wellness, which is a lot of what we talk about when we talk about the issues were discussing today. the nature of the healthcare system needing health insurance most of time to access the services you need and making sure we have the capacity within our healthcare system to meet the needs of the

residents of colorado. we invest a lot of money in across the nation in our healthcare system and we have some opportunities to get better value for the dollars we invest. some of that requires infrastructure investments, things like healthcare capacity, primary primary care medical homes, having integrated care between various types of healthcare so we don't have one person with one body going to three different places to get their healthcare needs met. it is our high-level, holistic view of colorado and how were looking to move our agenda forward. we did expand medicaid in colorado. one of those buckets, as you remember, is a coverage remember, is a coverage and capacity area of focus. prior to september, or in september 2013, prior to the first day of enrollment in the affordable care act we had many

residents and now we are up to 1.2 million covered by medicaid. you can see in the breakdown there is a diversity of a diversity of populations we cover. this is housing conversation has really been accelerated by this expansion. colorado did some state-based activity and expanded early for those living at 10% of the federal poverty level or last. let me remind you, that is $11,000 a year in income. we expanded to 10% of poverty or last. prior to the full expansion of poverty or last. prior to the full expansion of the affordable care act and we built on that as we moved into january 1, 2014. it was an important step for us to understand the needs of both of those primarily homeless individuals. understand how to engage with them and support them and getting access to coverage. we wanted to begin to understand what their healthcare needs

would be and other kinds of services they would need. our expansion has been an important piece of our work. coupled with that expansion has been discussion about permanent support of housing. when our current governor was mayor of the city of denver he had a very important platform around homelessness and has continued on into our state -based administration. a lot lot of that focus has been around supportive housing which is a trend you will notice across the three comments so far. that really has required us to look at the capacity of our housing system. how can we identify and mobilize resources? colorado is a very, very nice place to live. i have lived there almost all of my life and it is very expensive place to live two. given that housing is one of those issues that is directly impacted by the other

components of the marketplace that are around media income and other things, it's really a challenge challenge at times in a very expensive environment. colorado has one of the hottest real estate markets in the nation at this point in time, to figure figure out how affordable housing can be made available. this dual focus of both a health platform and a housing platform platform has really set us up very well to look at how we can begin to expand the relationship between these two areas. health and housing has been an important piece of what we've been working on. we are involved in some of these discussions which means how can we be sure were using those investments appropriately so things are being paid for in a way that makes sense and other housing related expenses can be leveraged in the same way.

we engaged in a study and i wanted to talk a little bit about the findings from that. we looked at fiscal year 13, 14 which begins at the first six months of the full expansion of medicaid. when we looked at our data there was about 37 enrollees reported homelessness during the year. 24,000 reported thousand reported it during the entire year and the rest of them had talked about being homeless at least some point. i think that is an important piece to call out that when we think of homelessness just like we think about coverage, it's a point in time piece for many people. that could be a and of time in your life where you're homeless homeless in a period of time where you have coverage. that may not be how you exist in

the world throughout the year. it's important to look at that variance in people's lives. when we didn't and analysis on the spend for the services for those people it was about $160 million. through this exercise we began to break down those expenses. we've been talking a lot about money and i'd like to believe that what we can recognize about that number is those people were very, very ill. they probably didn't feel very good. i think it's important for us to recognize that we have an opportunity to not only potentially save resources if we do this work better, but also help people feel better and help people have a better existence as they move through the world. this is a very important piece that we are looking at both from a budget perspective and from an overall health perspective. when we want to be the healthiest state in the nation, that's for everybody. for everybody.

it's a really important balance to look at the spend and the experience that people have. as we hear about these new opportunities, the clarity that came out in june of this year, it's really a chance for us to have more clarity as we work to see what can we do to bridge between health and housing to not only address these individuals but more permanent structures in place overall. to do that, these services can also exist in silos at the state government level. we have started a cross agency group and they meet twice a week. some of the basic work that we have had to accomplish is just clarifying language. all bureaucratic programs have

their own speak and use acronyms that only we understand so you have to step back and figure out what all of those letters mean. it's been an important clarification of language. we also have to recognize that if it's taking us some time to learn how to interact with each other, in the 64 counties across the state of colorado, there is obviously going to be some confusion and opportunity for better education. that's where we are focusing our energy now. helping all of our providers, both on the housing side and the healthcare side, understand what are the opportunities to be working together. how can we begin to break alignment to the funding and synergy. we are all looking at the new waivers and there's a new document out relating to waivers

and substance abuse. that is a piece of the conversation we haven't highlighted but an important piece of how those services can be delivered. lastly, some of the technology pieces, we have a homeless management information system and a medical management information system and as our state is going through a procurement of those we are looking to see if there's opportunity to have connection between those since we are now at a time where technology can help us if we let it. lastly i would conclude that, again, i'll circle back that the people who are the hardest at these efforts, we are talking about and learning about what the experience of those living in affordable housing and their healthcare experiences. one of the most heartbreaking thing is the lack of dignity they felt they were afforded from the healthcare system. it was a gift that we had a chance to be there but if they were just smarter they could figure out how to navigate are very complicated healthcare system that i myself challenge to navigate at time.

it doesn't cost us any additional resources to have respect and dignity for those folks. it is important that we think three visas but there are some things we can do to help improve their health and mental well-being and all of our society and communities with just some recognition that these are hard issues and the folks that are in the middle of them need some support and respect as we work to resolve them. >> thank you gretchen. now on to doctor o'sullivan. >> i'm very happy to be here today. i speak from another additional perspective. i am a family physician and i have cared for and exclusively homeless population. is that better, can you hear me? four and exclusively homeless population since 1996.

so, i experience every day in trying to give good patient care the trickle-down effect of policy and of spending decisions in the lives of my patient and how our ability to make good policy and spending decision influences health outcome of very real people .. medicaid expansion state. i am happy to say. there is still is still legal challenge pending in the courts. we have other successes that i would like to tell you about.

one is that arizona decreased chronic homelessness by 15% between 2013 and 2014. on a note which i experience personally, we began in the phoenix area which is a very large and sprawling county with a homeless population of approximately 17000. i started a prophet called circle the city and we did that as a community, as a grassroot effort to bring people together to meet the incredible need of those who were too sick, too frail to be on our streets and in our shelter. in 2012 we open a new a new facility in the phoenix area. the name for this service is medical respite. the respite

word word is somewhat confusing, it's recuperative care. you could think of it as bridge housing with a very intensive medical support. this has been a crucial part of our ability to provide the sickest, the frail list and the most vulnerable. another good piece that has happened is that the number of supportive housing units is growing. 1600 housing units were funded with individuals with a serious mentally ill designation by the continuum of care who funded the rental subsidies and medical medicaid, through a regional public and private initiative that was united way bringing partners together.

another 1000 units were targeted to chronically homeless individuals in that county. however, the challenge, we still have a supportive housing need and face challenges. we think think it would take about 1000 more units to end chronic homelessness in that county. our arizona medicaid plan covers a comprehensive bundle of services. the flipside of that is that in supportive housing those services are only available to persons with a sears mental illness designation. our nonprofits participated in a

pilot project with one of the local large medical centers. frequent users of systems engagement is an acronym of the corporation for supportive housing, a tremendous, active, wonderful partner in trying to get supportive housing available to us. in this pilot project, we engaged the most frequent, most expensive homeless utilizer's of care. we engaged, we offered the services of our medical respite center and able to stabilize assess, and then quickly move to supportive housing. the vouchers were donated by several agencies in the community. that pilot project realized a 73% reduction in emergency room visit and a 74% reduction in inpatient utilization. after patients are placed in permanent supportive housing,

the diagnosis is homelessness. these these are patients that we took care of through the pilot program. they didn't have just one chronic disease. some had to, most had three, four, or five. that doesn't take into account the acute problem of heart failure exacerbation, diabetic, the crises for what people cycle in and out of emergency room. why do people cycle in and out of emergency care? in our our population these are reasons we probably believe, and as you can

see, the next one on there is that the primary care system might not be responsive to the population issues or the multiple issues that barbara talked about earlier that are simply the recurring phenomenon of being homeless and living on our streets. so i would like to show you, just briefly, one case study of a patient a patient who was in our pilot. we call him mr. 280. he was well was well known to the phoenix fire department because he hit 911 all the time for transport to local hospitals. we think he had 280 visits. with the hospital we worked with, he had been to the emergency room 192 times between 2007 and 2013. we engaged him, brought him to the respite center for three weeks and then we discharged him

to permanent supportive housing. this is mr. 280s hospital bill. page. page one, page two, page three, page four, page five, page six, page eight, page nine and page ten. during that time of he had 192 visits 92 visits to the emergency department but not one inpatient admission. i can tell you when we actually engaged him, we found out he was living almost in the hospital parking. $358,000 in charges at one hospital. this is a graph of his hospitalization visits during that time. as you can see there are three

places in 12 and 13 when he wasn't in the emergency room for the month and we can show you three mugshots that correspond to those months. so since being housed, he has been to the emergency room twice. both were appropriate visits. he has has never been admitted to the hospital. he is stably housed and has remained stable he housed over that time. he is receiving care in the traumatic brain injury clinic at our local neurologic inst., he has his food handlers car and he is employed part-time at a local restaurant. so, what are our challenges? i think you have heard the talk

of care coordination, and we love it when we can get someone in the permanent supportive housing to have the opportunity and i'm going to get that diabetic in housing. i'm not going to get him healed if he's in a shelter or under a bridge. we need to coordinate the services we provide. we haven't exactly figured out who is responsibility that will be. that's that's another one of those issues where we have to work together. we have to prioritize the support in terms of medical need. i think if you've not seen the work done in boston by how the people are dying on our streets, we have good data to show that persons with chronic illnesses, who are medically vulnerable will not survive and yet our

system, our electronic systems, our silos, if you will, we have to learn how to cross them to prioritize those limited supportive housing resources we have to the person who needs them the most. one thing we are really interested in is developing new and innovated models for delivering primary health care efficiently in supportive housing. once we get people there, how do we deliver the care in the most efficient way possible? do we take the services to them? do we we provide the transportation and the follow-up to get the fix right? all of those are possibilities. we know that it's important to place people immediately.

they'll get sick, for one thing. the second thing is if we can locate the people that need the housing, we need to try to put them there. i'd like to put in a plug for medical respite care for the homeless and the growing of these programs at pivotal points where patients who are too ill, sometimes for direct placement without the stabilization that ill this can use medical respite for bridge housing. my recommendations, housing is healthcare. if we could increase availability of those prominent supportive housing units, we need the vouchers and we need the services. anything we can do to solidify our states to cover those array of services in permanent supportive housing, medicaid is wonderful. medicaid alone can't do it.

we need the support from our mental health providers. we need hud. we need housing. when we can get those wraparound services, those positive outcomes that people think aren't possible, i'm here to tell you, are possible. thank you. thank you. >> that's terrific. thank you sister adele. we are now at a point where we would love to hear your questions at one of the microphones with the green card that you can fill out and hold up and someone will bring forward or you can tweet it and we will go from there. let me just start with sister adele if i can. can you talk, and i would welcome other panelists to chime in, about the kinds of money, which pockets were you able to pick

>> >> as for our as housing is concerned with continuing muscari and also a united way we could put together some funds from the department of housing from the state, a kolkhoz of the cities in the maricopa area and philanthropy. those are the of vouchers. >> maybe people are confused by victor muscat to deal of care. so i was just going to jump in. the homeless programs are delivered in communities through community collaborations' and that is confusing to the health care system. i wish we named it something else especially for a are not navigating for that

model of care anymore. so when she said she got money that was probably renta assistance or capital development cost from the assistance programs that is river try to get the funding for additional units so just a little plug for that. >>. >> what experience do any of you have with those who have gone on medicaid as a result to experience a national disaster losing housing they had before? >> i would love to talk

about what i have observed in new orleans. this timely with the anniversary of hurricane katrina. it is tragic the number of people who lost their homes was devastating that community was devastated by what they did with the rebuild was amazing. because there was a lot of flexible disaster recovery of money, they got low income housing tax credits they got a block grant money which is the most flexible money after a disaster recovery got vouchers like assistance and shelter vouchers which is homeless rental assistance all was voucher recovery many but the amazing thing that they

did they use the community development block grant to pay for services while they created supportive housing with the tax credits ashley vouchers to subsidize the units for those who had homelessness while they built that medicaid system and then started a process for those who had the vulnerability now i said that even in a state where the governor did not extend medicaid but it shows what is possible when medicated and housing used strategically together. i hope that reflects some of what you were asking. >> i should call attention to the screen which is the incentive program of flowers

along -- of hours to get you to fill out the blue form if we reach 50% per dissipation rates the alliance will make a contribution to the community of hope here in town that deals with some of these problems we have been discussing including homelessness and health care on the ground here in washington d.c.'s settled leave without filling out your evaluation form to make sure the person next you fill set out as well. >> with the institute of social medicine and community health is pitiless a great example. a and yet i am not hearing a focus on standard of care

that we would expect all hospitals and health care providers to be aware of. mr. 280 that sister sullivan introduced a scud is an example of hospitals taking the advantage of the medicaid program to extract as much money as they can't rather than identifying the source of this man's needs and to make recommendations to address them whether through the hospital or the resources of the generic community. i think the colorado's story is interesting because they want to be the healthiest state. not just the healthiest for homeless people but for all people. where are the

recommendations on how the health care system should be integrated into the determinants of health? shouldn't be required regulatory authority common standards of health when health care providers identify or should be forced to identify the social causes of the problems that they are expected to retreat? a think it is a great opportunity to raise those issues to have generic solutions and not just be proud to reduce homelessness for one segment of the population. >> i will start. i completely agree and appreciate your passion. but what we're trying to do is get the health care system to a place that you just describe not just for a

special population but all of us. what we're all looking for is the outcome driven, how are we as individual human beings getting healthier to demonstrate that to put the resources of the health care system behind that? and i'd be the actual integrated system with resources to deliver the kind of care that we envision. we are trying to build the capacity in our communities to get their old lot of that has to do with the partnership described among people who are in charge of those social determinants not related to housing but nutrition and education and jobs and stability so when we talk about investments of housing and the partnerships we need to have it is informed by recognizing this

man does not have housing and it is contributing at 280 emergency room visit so hospitals partner with the primary care provider as well as the housing provider to get into housing to identify those resources that our insufficient in almost every community in this country. i envision and applied we you are describing. we have to get there. we just need to be serious and honest. >> that addresses it beautifully. >> i would add one of the ways we're seeing movement, that there has been a broader recognition of life's circumstances, but in addition to the medicaid delivery system through the accountable care collaborative structure where they have key

performance indicators that they get additional resources for growth some of those are very strategic with the use of high cost averaging that mr. 280 experienced. and nobody likes to have anything that is not needed. so i had both components. very quickly the health care system working toward those indicators recognize there may be underlying social factors that with some attention and we could meet the key performance indicators. those are transforming over time now we have well child visits and we have been talking about homelessness and a general term but there are families as well as we believe all of those indicators can help to broaden the focus of the

entire individual needs beyond engagement with the health care system. >> if i can follow-up with a point, this population largely was ineligible for medicaid up until the point of the affordable care iraq extended medicated was not even part of the system still remember eligible for probably not to enroll. >> director. ; if you had a disability but the vast majority were not disabled or not tell the that were not eligible so this is the first time leaving get them into the system to look at their needs. >> for mr. 280 that was before medicaid expansion so he had no insurance. >> i am with the infectious diseases society.

thank you so much for the panel. so while you were speaking but to go to permanence supportive housing, are there mechanisms in place to help individuals so they can sustain their own housing and their own medical needs? is there any metrics to determine when somebody can phase out? >> i am happy to start that one. in the world of homelessness the term was created to distinguish from what was the paradigm of transitional housing indignant it was not limited to to stay as long issue needed a and the ability to stay in the same

home without a clock ticking is supportive recovery. the stress associated knowing you have to have your act together and go someplace else coming is counterproductive to having long storm -- long-term stability with long-term goals. but obviously we hear stories every day of people who don't need any more and get a job rand want to move out to make room for somebody else this is also the portfolio we also do support for the elderly. the expectation when she turns 90 to move somewhere else. but the concept the housing is your home where you live coverage that idea of home is the idea of a life changing event that happens

when somebody moves into the home of their own into an apartment of their own. while we want to support people to move off and whenever that is possible and with people who have severe disabilities living on the streets, a memory aid to presume it would be for the rest of their lives. i am sure you live this but those people you get off the streets that have been there 25 years then they are scared to die of their own home and dying on the streets. >> those things happen very frequently.

>> i have heard a couple of the visitors lady different among the speakers and maybe there can be some dialogue. medicates to pay for housing and that it just needs to pay for housing services are those related to that and homelessness is a diagnosis the other safe target to those with relatively severe needs to make frequent users. is there any way to resolve these? to rec cannot think there is any contradiction of what we are saying but when people said medicare should pay for housing there really are say that we need more housing in the federal there fran is investing but we need to get somewhere with a health impact but is prohibited

from paying for housing so as a result therefore i talk about medicaid to pay for the things that it does pay for mature the health services to allow us to move somebody off the street into a home of their own. i don't think those are at odds that all. >> the piece that is important with in colorado in particular a population in dense for our range from denver to colorado springs but also have ruled communities with individuals that experience homelessness. ea but then we have large spots of oil communities that also have individuals who experience homelessness. to some make stent, the flexibility of letting local partnerships figuring out what resources are available in their community and how to leverage those appropriately is the other

piece that doesn't make them in conflict with each other but reflects the diversity of our nation. >> i'm coming from his local perspective where we should really have to pull together, you know, public, private, faith-based, philanthropic. everybody had to pull together and this can't go on in our community that we are not providing for the most vulnerable on our streets. i guess that is what we are saying to you is we just hope that we can all pull together. i just think, i'd be in heaven if i had three had three things, if i had enough supportive housing units and if everybody was insured and we had the supportive services to surround the person in the housing. those three things.

>> that's mind to. >> if i can, i want to follow up with the question that got raised by the previous question and it involved a former administrator of the health care finance administration and runs medicare and medicaid. someone had asked him about the reasons we ought or ought not to meld the funding streams between front housing and medicaid more fully. i think the problem with funding housing or seeking to fund it through medicaid is that medicaid is already under all kinds of particle pressure because of expense. you start to say that anything might benefit a medicaid beneficiary if you start to say that anything that might and a

fat ought to be covered by medicaid you are really opening up a bottomless pit and making the program even more vulnerable to those who want to cut or eliminated. i wonder if i could elicit some responses. >> i'm really confident that he isn't in the room but i couldn't disagree with the short side of that perspective. i think the case studies that are told say that. i think the important thing from our perspective at hud, we have this conversation with other agencies is that medicaid should pay for housing has the whole history of medicaid is doing housing and really institutional horrible, horrible ways. every

time i think they're doing it better ten years later, it's trying to figure out how to downsize and divest itself from what they thought was a really good idea ten or 20 years ago. they do not know how to provide housing. conveniently, we do. i think it's not a question of should medicaid pay for housing, i think think it's a question of should the federal government invest in a housing program that have enormous human benefit and cost offset on the mandatory side of the budget in order to deal with budget deficit issues globally and deal with the aging americans and americans with disabilities who are living on the street. i don't see see that is a slippery slope and i don't see it as a flat pole. i see that a sound public policy to go fix the problems that are costing $328,000 for mr. 280, sorry i got a little attachment there, it it was very on federal of me. >> i note in one of our handouts there is this chart of state initiatives in this area and the state of new york, in fact, did

ask for medicaid money to build housing. >> and i went and talked to jason harbison before he submitted it and i said why are you asking medicaid to do the very thing it cannot do. he submitted it anyway and medicaid said no and what he didn't do is include in that same request, i hope jason's not here, everything that medicaid could have paid for, all of the services and instead they are paying for that on a state general operating fund instead of levering the federal match of medicaid. i don't know why they did that. >> sounds like some technical assistance is in order here. yes, you've been very patient. >> hello, i'm from families usa. i appreciate all i appreciate all the focus that you have put on to homeless issues in regard to housing and health but i'd like to read and that a bit. you mentioned the federal

government has the collaboration between key agencies and that's unprecedented right now. i wonder if there are conversations going on where you are discussing improving housing conditions rather than just getting people into housings. for example some children who have a chronic condition like asthma often are increasingly going to the emergency room because of the mold in their house. i'm wondering if there's any work going on around that. >> yes, absolutely. there's a time hud is doing around the intersection of housing and health and it's everything from the environment that we live, to how communities are designed and what's happening in a home. is there mold, is there lad? and also we need more. when we do more, hopefully we do it well. we have offices that focuses specifically on how to we

renovate, how do we do home modifications to deal with the causes of asthma, how can we partner with the healthcare system and the public health system so we can do that at scale? i think one of the challenges, especially, especially with highly mobile families, is there can be a tendency for the healthcare system to go in and completely overhaul this unit and then you don't live there anymore. i think it will be great as we have one more healthy unit in the world but who pays for it? we would love to pay for it if we had the budget dollars to do that and do it at scale, but i think in the absence of those dollars, and we do some funding

in this area, but we are really trying to figure out how to do partnerships. i had to think of, for example, partnership we have with johns hopkins university and try to do a very targeted strategy in that community. there are some things we're doing in california where we are partnering with the city and health care system trying to figure out how to do a very concerted effort on that. it wasn't a part of my it wasn't a part of my remarks today but that certainly doesn't mean it is up important part of the work that hud and hhs are doing together. >> i would just add from a state perspective that that kind of thinking is great thinking and as yet another state agency to the mix in our world. as part of the state of health, they have guiding principles around those battles that include the kinds of things from a health perspective we know we could win. childhood asthma and other things, it is important reminder to us, and again, perhaps we should contemplate adding them to our interagency group but it is a piece that is also from it

different perspective and in a different place from our state government structure. the agencies work very closely and it may be a next step for us contemplate. >> yes ma'am. >> i am a local official and represent hundreds of low income residents who receive medicaid and medicare. there is a push for concentrated poverty where families have many chronic illnesses or health it issues. there is a push to reduce their housing to create mixed communities. most of my constituents live in fear that within the next few years they

will not have housing. that leaves them to become sick, ill, and in some cases they die because they don't know what is going to happen in the future, because a lot of people don't like to see hundreds of low income residents concentrated in certain areas of the city. my question is, how do we secure housing for those that are already housed in low income housing, particularly public housing using its, so we can work on their health issues and they don't continue become ill. they are afraid they're going to lose their connection to their community. >> that is a terrific question and think you for asking it. we have learned a lot at hud about community redevelopment over the course of the last five decades, and i think, when we did it poorly, we kicked everybody out of the building, we tore it down, we built mixed income communities and then we didn't know where the people were that had been sent away.

i had an opportunity last year to visit that community inkk

performing schools in the atlantic area. people of all incomes want to move to this neighborhood so their kids can go to that school. they started as a charter school, k through three, or something and just three, or something and just built a high school that's just opening now. they have a ywca. i have never been in a place where i saw a young children of color in the hallways at school learning with as much pride in a community in atlanta. we can do this. we can do this. the old ways, we didn't do it well. people have a right to be afraid

i wish i could take your community down to see this community in atlanta because it is a testament to what it is when we do it right. >> thank you very much. >> in terms of innovation and up-and-coming services,. >> can you introduce yourself? >> oh, i'm darren and we are looking at telehealth for providing health over the internet or tablets or smart phones like keeping people from traveling very far within rule areas or underserved areas. it is sort of a new service to help provide quality care for people.

i guess my question is, do you see this playing a role in housing? this could save a lot of money on examples like mr. 280. telehealth usually prevents people from going to the hospital. 70% of the time they don't need to go to the hospital. >> telehealth is absolutely an emerging model that has a lot of promise and is being implemented in a lot of area. we are seeing more opportunities to implement that, in rural areas in particular. from a service provider, i think it gives us some opportunities to access a specialty care care where it may not be available and often times public transportation is not available or feasible. i think this is a really intriguing idea on how we can maybe implement this where

we can. i think we might also be overlooking that there are lots of reasons why mr. 280 and a lot of our patients go to the hospital, and it's not always strictly out of medical necessity. no doubt, the clients we see are acutely ill, but because there is a lack of stability, sometimes the nurses there know these folks by name and it's because of a social connection social connection that they are looking for, to be in a care environment where people actually touch you. i think we shouldn't overlook the quality of care that our healthcare institutions provide from a compassionate perspective. i know sr. adele can speak to the fact that very few of our clients are touched by anyone else except in violence or anger. when when you have had a healthcare provider put your their hands on you and a loving, caring way, for the first time

in 25 years, years, that can be life-changing. i am excited about telehealth but for our clients, being together is really important. all allow all allow sister to add onto that. >> i agree. i know for rural areas and for people who have no access, when what they really need is a specialist, it's wonderful. i have that same concern that, you know, just to go back to mr. 280, we had him for three weeks in the rest center and i can tell you he has a traumatic brain injury and poor impulse control. every time he felt unsafe he would say to us, i have to go to the hospital. no, you are fine, but he went

there really because it was safe, it was clean, it was sheltered and he needed a human a human contact to tell him he was all right. now can we do that with telehealth? well, i would be careful about implementing it but i think it certainly has its place. >> our clients need a group hug, really. the so the compassion you are hearing here is born out of that realization that that is an intense human need for all of us. >> okay we have the last question. >> thank you i will try to make it a good one. i'm janet what the national housing conference. i'm curious to get your thoughts on the panel about housing navigation services, internet,

medicaid doesn't pay for housing and shouldn't pay for housing. is there there a role for these housing organizations, to even start to think about how to find a home. whether it's permanent supportive housing or some other type of unit, what role role do you think that plays in some of these comprehensive care services? : : :

the was said to have housing available for the coordinators of the facility are often the first people when they open the mail from the state department this year making it easier because those of us faced what does that mean? that is the first place they can ask a question.

so at the point of where their houses and effective mechanism as well. >> thank you for coming today and for your attention to this message and relief for whenever you can do to provide the collaborative effort to provide services for the full verbal thank you. >> first of all, jennifer has mentioned the mark that what you said earlier talk to the housing and the

veterans about the is issues to make sure each of you know, what is going on in the others dominion. you can see the evaluation form is still up there the contribution which to community health is still being deleted your hands. >> vitter doing amazing work. >> there you go. with the organizational privilege and i can take 30 seconds, we have one more slide. the interns have done in such as a great job for us this summer. fake you very much it has been great. [applause] the selection of materials is largely it lollies the hands.

my apologies if you wrote good question is and i was not able to get to. this is not an easy topic there are lots of good things to be done on a friday afternoon in washington and he stuck with us and we appreciate that. [applause] and thanks to our colleagues for their support to point to us with a program of exceptional there is an excellent panel for a multifaceted topic.

[inaudible conversations]

>> first of all, over the last six years american people have worked really hard to do bounceback. way have jobs numbers to create another 210,000. that makes 65 consecutive months with private sector job growth may have seen and that is the testament of the american people even as the focus rebuilding our economy and working on leaving a legacy for the next generation for those guys giving lessons the some of

the greatest national treasures then i am able to sign this legislation enacted by the house of representatives this designates in a great state of idaho. is a remarkable area it is used by fishermen, hunters fishermen, hunters, rafters, people taking hikes, not only beautiful but also an important economic engine for the state.

thanks to the workover broad based coalition but spearheaded by your congressmen who was able to receive not a single novo to that does not happen often in the house of representatives. [laughter] something we have been working on for quite some time. we want to congratulate them and urge the american people to visit the wilderness areas bowdoin last point i want to make everyone to be thinking about the firefighters across the western states to see a

consistent escalation of of fire season the climate change and more vulnerability for law enforcement out there with less water. we're trying to work out with congress we can properly fund firefighting efforts the also so that is the project that you get a lot of bipartisan support. congratulations. i will no sign the

legislation. i have a lot of practice but i want even more. there you go. [applause] >> good afternoon. happy friday.

to date marks the one-year anniversary of the air strikes in a iraq against the isil targets a they have advanced as areas saturday fallen for cuts and isil and was advancing rapidly were personal was located in threatening genocide. isil commits atrocities against all of iraq diverse communities but in the last

your the have made considerable progress in the effort to register or 81. the coalition hit with more than 6,000 airstrikes to take of thousands of fighting positions. in iraq it was an 30 percent of the territory that they held last summer and overall it has lost more than 17,000 square kilometers of northern syria over the course of the last year now they are cut off from all but 68 miles of more than 500-mile long border between syria and turkey. coalition forces every repeatedly struck isil leadership targets to read and no longer have a safe haven. to make it more difficult to

to attract ford fighters. -- foreign fighters but we have made progress and old in mbb will prevail so the commanders said there is one thing they can do is vote on the authorization from nearly six months ago. wellman and women put themselves in harm's way. so with that let's go to questions. >> you had chuck schumer how big of a blow to that is to the administration?

for those who are choosing over diplomacy? shouting death to america? >> to stand by a the statements he made in his speech on wednesday. but coming now to an opposition leader up to 12 members of congress that is seven in the house and five in the united states senate. so certainly the two members they mentioned have one folks. to show how persuasive the president's speech was in the case he was making to members of congress and to

the public. >> but to be classified. >> the neck of what he to gone directly in his speech that the individuals by this same people to make the same argument in 2003 to the march toward iraq. this includes mitch mcconnell and more recent newcomers like donald trump that is why on the other side those who are supporting the agreement are those that oppose the iraq war from the beginning or have knowledge the congressional vote was a

mistake. senator gillette brand and senator baldwin our new covers but they have strong records on these matters. anybody covering politics of the last 12 for 13 years so this is a difference of opinion that they have had dating all the way back but that said this is the announcement was not surprising to anybody at the white house.

with the substantial majority of the democrats in the house and the senate. >> because you mentioned that. [laughter] put the president wouldn't answer the questions. what was his reaction in? >> he indicated he did not watch the debate last night. i was disappointed it started so late so there was the point i did doze off. [laughter] but i woke up and was transported back to 2012 with a variety of publications outlandish claims about the country and

i don't think with the use full line of attack. >> we surprised by what you saw? >> not particular a. >>. >>. >> some of us of violation of international travel ban would is the reaction to that with the russia and iran perspective?

>> i am not able to independently confirm them. does we have indicated from the very beginning the it to reach the agreement from obtaining nuclear weapon would not address the long standing concerns we have. mentioning him, he has the subject to u.s. sanctions with the efforts to undertake for around the role. the with the specific reports as an indication of ongoing concerns with iran and their behavior to make it that much more important that we pursue the best

available strategy to prevent iran from gaining a nuclear weapon and. >> we have found over the course of this diplomatic engagement that russia has been an effective partner in the international community with a willingness to cooperate with the of community. to reach an agreement from obtaining nuclear weapons and. as they continue to act can -- cooperative play. >> i am not in a position to confirm that.

but what is not surprising moray a disappointing change for a lobbying campaign. >> i do not anticipate they will spend a lot of time making calls on vacation. it is possible but it will be spent on the golf course. >> but is still has a way to go. >> what is clear for those who have not announced a position on this issue and that is why there will be continued discussions with

members of congress over the next several weeks that congress is out of town. we do continue to be confident in our ability to have strong majorities in the house and the senate's but that is one of the reasons that is the case as there is data to indicate that democrats across the country support with majorities of jews who support this agreement. and that continues to give confidence as they consider this strategy will have a strong case to make that

this is the best approach. >> but to suggest from what schumer said about obamacare in the past, i am wondering if says prop that position to the white house? >> this is the vote cablecast in early 2017. as he watched his retirement i said it's the time that

this white house would not take a position on the future leadership elections that continues to be true today with the senate democratic caucus that would consider the voting record. >> earlier in the wake to require federal contractors and then to have comments so far etiquette's to the regulatory language is there any reason it went employment? >> if they don't have any

comments line your consideration in pursuit of priorities. it has certainly made clear that middle-class families would benefit to help middle-class workers with the obligation is they have at home and read their implemented they have a way to improve productivity to boast will take that is why we have seen so many private sector companies take action on their own and netflix got a lot of attention for the paid leave policy their implementing at that

company. they don't do it at a charity but i am confident they think it is good for business. but i don't have any announcements to make at this point. >> to put up a political transition and we don't have to worry about the stability there. says this is an issue for nuclear talks with dutch but

secondly but are there any policy changes before you can take advantage of this moment? >> it just sounds like an accurate characterization. the beauty was on his own analysis to have the grip on power i don't have any specific conversations but there is reason to believe

with those interested parties to reach a conclusion as well. but does the president pointed out to offer a little bit more hope that our political reconciliation might be slightly more attainable. >> but could day back them financially? with the assad regime? >> i don't think any of those to make that more

likely to be constructive. but to consider a range of options to improve that is an awful situation. spin if united states has committed significant resources but for those of taken on so much responsibility there is a variety of reasons to be concerned and why the watch closely. >> did senator schumer

called the president to inform him of his decision? >> did she call him himself? >> i don't know. >> you said you wouldn't be surprised if the house would take this into consideration? how provocative if senator schumer would start pulling against the deal? >> i think ultimately that is the decision individual members will have to make. i am not sure my opinion matters. that will not stop me from weighing in on the other thing is. [laughter] >> can you measure the frustration level inside the white house right now?

>> i think i would stick with my description before. this dates back more than a decade that they have had for quite some time. to make a strong case for the president to impose the will on a sovereign country and previous efforts to do that with those that occurred in and 2003. that is the essence of the disagreement last night. >> getting back to the debate, was there one comment made?

what struck you that you had no problem last night? >> i will resist the urge to choose because there was so many. [laughter] >> i'll try another one then. if i am not mistaken for when that occurred is that possible that the ferry service to the small island? >> i don't know what the vacation itinerary will be but i would not rule out they may cross paths.

we are in a position to let you know, . >> the first, do you have more insight? >> i don't have an overall number in front of me. >> but to illustrate the persuasive power those individuals that publicly announced their support and i highlighted to tally them up but just the raw numbers one vote per gram of congress so that momentum

that we hope to build on the then dash caucus and in the house. >> but you said would you say about those in georgia? >> i have not seen mr. scotts statement. >> on another subject with the debate last night there was of verbal fisticuffs with is trustee and president obama. >> in your opinion so was

the president surprised? >> shirley after that public display of affection occurred. [laughter] what it symbolized to a lot of people is the willingness to set aside their own partisan identity particularly in a time of crisis for those of our elected to serve our projected. you have an instance shortly before an election werke effective way to try to meet the needs of the people. that were negatively affected by the storm. that is the expectation

people have for their government that we expect to have robust debates with differences of opinion. but when the chips are down in the midst of a crisis in american lives are at stake the american people have an expectation their leaders will put aside the political differences to focus on their constituents. and this particular situation got attention because just 84 a national election but this is the kind of a governing style the people rightly expect and the approach that president obama has prioritized even in the less high profile situations it is not uncommon for him to travel to other areas of the

country after a natural disaster for example,. and it is clear the vast majority of the local did not support him in the election, the american people and communities appreciate that the president is their purpose in having that opportunity in both oklahoma and arkansas that were affected by tornadoes. even i was struck by it. there is a lot of obama voters in the crowd and those taking through the rubble in a neighborhood betty churn -- but each turn that is a case american people one of the reasons the president is prior to the back country. >> there is eight months

left but in that time time, reducing as people reach across the aisle, ideas think with all he has to do was try a to reach across the aisle? >> i think some of you just saw him sign legislation into law to create a wilderness area in the state of idaho standing over his shoulder was a republican congressman from idaho one example of him trying to find common ground. in this case with president obama despite the political differences i'm sure they have. that is another illustration of not just the president's effort when it is most

important but also the expectation of the american people into of the darkest read congressional districts in and the country that there is the expectation that the member of congress will work with a democratic president in the interest of their community and that is what happened in this case. >> i wasn't there. you should tell me. >> you called the decision disappointing but not surprising. but on tuesday think he had contact with him. were you under the expectation but isn't clear to me what expectation anybody has with the timing

of his decision. what the administration sought to do was to work closely with him to help him understand the facts of the agreement and the details to give the president so much confidence. i mentioned on tuesday that the efforts by the administration to ring gauge senator schumer predated the completion of the agreement to indicate their willingness to interact with the president's national security team to understand the details. it would have been foolish for the administration to rebuff his interest because of his widely known views as it relates to the iraq war

2003. we engaged and in pursuit of an opportunity to support the deal but it did not turn out that way. but that would account for the disappointment that i expressed. . . expressed. >> and there is a suggestion that maybe the president will be working during his vacation. >> was my intent to convey to you that there would not be much time spent on making phone calls but i certainly went rule out that he would make some calls. that would have been true regardless of