ho. : i am jennifer ho, the d secretary. i like to joke saying that i'm the one person that knows the difference between medicare and medicaid every day. you know what i'm talking about, don't you? iy background is actually -- spent my first 10 years and care -- in managed care. it was in that way that i was brought to a table to consider link between homelessness and health and the impact that public housing would have on health. i have a doing that ever sense for the last 18 years -- i have been doing that ever since for the last 18 years. i want to assure you that there is an unprecedented level of andaboration between hud hhs. not just because that is my job, but because it really is the case. hud is talking to the center for medicaid almost every day. we're talking to folks at , at the and medicare ndministration on children' and families almost every day. i know and feel sometimes that housing and health care are miles apart, and no one is talking, by want to promise you that in this administration, there is an unprecedented level of cooperation. civil fact about how we invest in things federally that health care people don't always know. you operate in a world of mandatory budgets and in tyler programs. iseral housing assistance the only benefit that is not an entitlement. when someone becomes eligible for medicaid or medicare, they get it. a voucher forout housing option, you get in line. we ask congress to invest more in housing, they worry about the renewal burden, the fact that this increases our total budget in future years. something i like to call keeping people in their homes. the conundrum is that hud pays for a lot of services that medicaid could pay for. medicaid has a lot of financial incentives for there to be more affordable and accessible housing, and the budget environment is such that we are not doing what we know works, and not at the scale that matches the needs. that is why i'm excited to be here with you today. your interest in housing could help create the consensus that we need to make the investments that matter. 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 baby-boom will test our commitment to the relationship between housing and health. as we go older, we are more likely to live alone, have more chronic health conditions, and less of mo mobility, and we go poorer. the number of eligible households for assistance will in 2030.between 2011 fory, we provide assistance 1.2 million seniors. one out of every three singers who is income eligible. that means that we would need 900,000 more subsidized housing units by 2030 just to keep up with one in three people who need it getting it. we have not made significant new investments in housing for seniors in some time. think about where you live today , or what your parents or grandparents live. less than one half of 1% of existing housing is currently accessible to someone who uses a wheelchair. only 5% o is livable for someone who has mobility impairments. most american existing housing stock is not designed for them to age in place safely. imagine twentysomething million people over the age of 80 fall, and they cannot return to their home, 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 and people will not be able to afford or navigate the place of the call home today. the health-care system, i would argue, has a huge stake in needs of an aging america, get there is not consensus that this is an investment that the federal government should be making. a lot of the work that we are doing with hhs has been around disability and the institutionalization. money follows the person largely through section 11. it forces partnerships between the finance agencies and medicaid agencies. and some places -- in some places, like colorado, it did not have to be forced, the partnership was there. we have two rounds of funding. 35 states now have money. in the last round we funded hundred $50 million for about 4000 units. inob in the bucket -- drop the bucket. the health care system, i would argue, has more of a stake for creating options for the not aled, yet there is consensus that this is an investment that the federal government should make each year. i appreciate barbara for covering all the arguments. sister adele will be the closer on this dear gretchen will provide the state o perspective -- sister and double wille closer, and gretchen provide the state perspective. i want to add a few things. supportive housing is a proven intervention to end chronic homelessness. it works for people, it improves health, it reduces unnecessary er visits and hospitalizations. the health care system, i would argue, has a huge stake in creating a sufficient supply of housing to end chronic homelessness in america. yet, there is not consensus that this is an investment of the federal government should be making. it is not in the house or senate budgets. second, we are learning something from the v.a. -- here there has been consensus on assistance. we have seen a one third reduction in veteran homelessness between 2010 and 2014, and we are on a path to effectively and veteran homelessness. imagine if we could get an investment in support of housing -- and support of housing in line with medicaid for those who have lived on our streets and shelters for years, sometimes decades. my focus has been to work with cms to think about ways in which we can better online housing and medicaid. i'm thrilled with the new information on housing related services that they have published. i think there is a link to it in the documents in your packets. increasingly, state directors, like gretchen, understand if they are going to meet the goals of health reform, they will need to deal with housing instability and homelessness. they have a new best friend, the ouser. this document brings clarity to something that has been unclear. of housing is over here, and health care over here, there is a whole lot in the middle. for,can medicaid pay for whom, and when? i believe is medicaid were paying for all the services that it could pay for, we would have better outcomes for seniors, better outcomes for people with disabilities, and we could end chronic homelessness. i believe that medicaid became a major player in housing, we could create the consensus needed for the level of investments necessary for seniors to age in a home that they can navigate and afford. people would have more choices of where to live, and more would make their housing available because they valued the service partnership. the conundrum is today hard hud pays fory is housing that medicaid could pay for. medicaid has financial incentives for there to be more affordable and accessible housing and the budget environment is such that we cannot do what we know works. that is why i'm excited to be here because your interest in housing, your understanding of the relationship between housing forhealth, your advocacy more targeted investments in supportive housing for older americans, individuals with disabilities, including false with disabilities living on the streets, could help create the consensus we need to make the investments that will matter. thank you. thank you jennifer. before we go on, if i can't, let me ask you a clarifying question. you were talking about the services that medicaid could pay for in supportive housing. i wonder if you could be a little more explicit and say a couple of words about what is stopping that from happening now. example, and are homeless assistance program, we spent over $400 million a year on services. we only need to under $65 million to create more supportive housing and end chronic homelessness, but we are spending $400 million on services. that is everything from the things that medicaid can't pay for like employment assistance, but a lot of that is exactly the engagement,each, assistance that is described in the new housing related bolton. the biggest barrier is that states don't know what cms is approved, they don't know what they will asked for. everybody is afraid that what we are saying is medicaid should pay for housing. we are not saying medicaid should pay for housing. we're saying medicaid should pay for health. we are also paying for services, for service coordinators in a senior housing. we pay for service coordinators and public housing. a lot of that service coordination is really health system navigation and wellness activity so that we don't have an ambulance pulling up every night and we can people -- can keep people in the homes as long as we can. mr. howard: we will turn out to gretchen hammer from colorado. ms. hammer: terrific. thank you for inviting colorado to participate in this conversation. it is a privilege to be able to share with you some of the things we are doing. first, i would like to provide some context. everything we do in our state government at this point in time is really driven by our platform for health. our bold goal is to be the healthiest day and the nation. we take that goal very seriously . not only because we have a great place to live, but because we have health disparities within archimedes bell holding us back, and we are working very hard to move -- we have health disparities within our andunities holding us back, we're working very hard to move those forward. atbelieve, when we look things holistically, we are able to put the right services, support, and f are in place to make colorado the healthiest state in the nation. the nature of the health care needing health insurance, most of the time, to access services that you need, and making sure that we have the capacity within our health care system to meet the citizens of colorado needs. then, looking at a health care system that can have better value for what it provides today. we invest a lot of money across the nation in a health care system, and i think we have some opportunities to get better value for the dollars that we investigate some of that requires infrastructure integrated-- highly care between physical, behavioral services, so we don't have one person with one body going to three different locations to get their health care needs met. also, look at health care technology. the state of health is a high-level holistic view of colorado and how we are looking to move our agenda forward. we did expand medicaid in colorado. a coverage and capacity area of focus. in september 2013, prior to the first open enrollment period of , we havedable care act less than one million coloradans enrolled and medicaid, now we have about 1.2 million. mothers who get coverage through chip. peoples a diversity of who we cover. -baseddo did some state activity and expanded early for those living below poverty. that is $11,000 per year in income. be expanded to 10% of poverty or less. and we built on that as we moved into dead way to that of 14. it was an important step for us to understand the needs of most of those primarily homeless individuals to understand how to best and with them, how to support them getting access to coverage, and begin to understand what the rest of the health care needs would be, and other types of services. i expansion has been an important piece of our -- our expansion has been an important our work.rt there is a specific person working in the governor's office on the issue of homelessness. oft are governor was mayor denver, he worked on homelessness, and that has the government should. we have been able to look at the health careour system. what other animations do we need? colorado is a very nice place to live. i have lived there almost all of my life. it is also very expensive place to live. given that housing is one of those issues that is directly impacted by the other components of the marketplace that are around him, and other things, it is really a challenge at times and expensive environment overall -- colorado has one of the hottest real estate markets in the nation at this point in time, to figure out how affordable housing can be made available. this dual focus of both a health platform and a housing platform to lookus up well at how we can expand the relationship between these two areas. health and housing has been an important piece of what we have been working on. we having gauged in some discussions that have created this crosswalk, that i think jennifer was referring to, which is how can we be sure that we are using investments appropriately so that medical related supports are being paid for in a way that makes sense, and other housing related services can be leveraged in the same way. we have engaged in a crosswalk study. i wanted to take a moment to talk a little bit about the findings from that. we looked at fiscal year 2013-2014 which looks at the first six months of our full expansion of medicaid. when we look at our data, there were about 30,000 who reported homelessness. 24,000 had reported homelessness throughout the entire year, and them talkedrest of about being homeless at least at some point. i think that is an important piece to call out. when we think about homelessness , just like when we think about coverage, it is a port in many people. it may not be how you exist in the world throughout the world. it is an important piece more like a programming to recognize that variant in people's lives. but we did analysis, it was about $160 million of services on those people. through this exercise, we began 37,000 intose deciles. i know we have been talking a and i wouldney, like to believe that we can recognize from that number is that those people were very very ill, and probably didn't feel very good. i think it is 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 from both a budget perspective and an overall health perspective. what we want to be the healthiest in the nation, that is for everybody. it is a very important dolls to alsoat what to spend, and the experience that people have. what we hear about these new opportunities, the clarity that 26 of this june year, it is really a chance for us to have more clarity as we work to see what we can do to , it's health and housing not only address these individuals, but put more permanent structures and place overall. to do that, i think we have talked a little bit about -- services can exist in silos at level.ernment we have created a cross agency thep that has members of division of housing, the governor's office. that group meets twice a week. some of the work we have to do is clarify language. all bureaucratic programs have acronyms that we only understand. you have to step back and say, what do those letters mean? it has been an important and alsog of language, recognizing that if it takes a some time at the agency level two interact with each other, in colorado,nties across there's going to be some confusion and opportunities for better education. that is where we are focusing helping ours now -- providers both on the housing site and the health care site understand what are the opportunities to be working bring inand how can we alignment and synergy to the funding available to all of us. we also look at waiver authorities made available. there is a re rece document out -- recent document out that is perhaps appease of the conversation that we haven't highlighted, but a piece of how those services can be delivered. lastly, the technology piece. we have a homeless management information system and a health care information system. we're looking at the opportunity to have a connection between those because we are now in a time where technology could help us if we let it. bytly, i would conclude circling back on the reality of the people who are at the heart of these efforts. we had a chance and it former life to talk about and learn about the experiences of those living in a ford will housing, their health care expenses. one of the most heartbreaking things about that was the lack of dignity that they felt they were afforded from the health care system. treated as though it was a gift that they had a chance to be there, that if they were smarter, they could navigate are very complicated health care system, that i frankly stole to navigate at times. what we concluded and talk to our partners about is it does not cost us any additional resources to respect and give dignity to votes. some basic things that we can do to help improve people's health, their mental well-being, and all our societies and communities with some recognition that these are hard issues and those in the middle of them need respect as we work to solve them. you, gretchen.nk i now turn to dr. o'sullivan. i'm very happy to be here today. from another perspective, i am a family physician and i have cared for and exclusively homeless population. can you hear me? for an exclusively homeless 1996.tion since 1 experience every day and trying to give good patient care the trickle-down effect of policy and spending decisions in the lives of my patients. ability to make good policy and spending decisions influences the health outcomes a very real people. i come from arizona. i'm going to speak to you about our local situation, which, as all of our environments are, is somewhat unique. arizona is a medicaid expansion state, i'm happy to say. there is, however, a legal challenge pending in the court to that expansion. we have other successes that i would like to tell you about. one is that arizona decreased chronic homelessness by 15% 2014.n 2013 and on a note, which i experience began in thee phoenix area, which is a very large and sprawling county with a homeless population of approximately 17,000. i started a nonprofit called "circle the city." we did that as a community, as a grassroots effort to bring people together, to meet the incredible need of those who to beoo sick, too frail in our streets and honest -- on our streets and in our shelters. in 2012, we opened a 50 bed facility in the phoenix area. isrvice for the surface recuperative care for people experiencing homelessness. you can think of it as bridge housing with very intensive medical support. part of been a crucial our ability to provide for the sickest, the frail us, and the most notable. piece that happen is that the number of supportive housing units is going. in maricopa county, 1600 supportive housing units were funded for individuals with a seriously mentally ill designation. through regional public and private initiative, it was our united way bringing partners together -- another 1000 units of supportive housing were targeted to chronically homeless .ndividuals in maricopa county however, the challenge. we still have a supportive housing need and resource challenge. we think it would take about 1000 more supportive housing units to end chronic .omelessness in maricopa county arizona medicaid plan covers a comprehensive bundle of services. is that ine of that supportive housing, those services are only available to persons with the seriously mentally ill designation. nonprofit participated in a local project with a medical center. frequent users of system engagement is an acronym for supportive housing. a tremendous, active, wonderful partner and try to get supportive housing available to us. project, wet engaged the most frequent and most extensive homeless utilizes of care. we engaged, we offered the services of our medical respite stabilize,rder to and quickly moved to supportive housing. the vouchers were donated by several agencies in the community. that pilot project realized the a 73% reduction in emergency rooms visits and reduction in inpatient utilization after patients are placed in permanent supportive housing. diagnosis is homelessness. these are the patients that we took care of through the fuse pilot. they did not have just one chronic disease. o.me had tw most had 3, 4, or five. that does not take into account the acut problem -- heart failure exacerbation, the for which people cycle in and out of emergency room care. why do people cycle in and out of emergency room care? in our population, these are the reasons we probably believe. as you can see, the last one on there is that the primary care system might not be responsive population issues or the multiple issues that barbara talked about earlier that are simply the co-occurring phenomenon of being homeless and living on our streets. i would like to show you just briefly one case study of a patient that was in our fuse pilot. we call him mr. 280. he was well known to the phoenix fire department because he called 911 all the time for transport to hospitals. in adding up all the hospitals, he had 280 visits. in the hospitals that 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. 's80 is mr. two hospital bill. page 1, 2, three, 4, 5, 6, 7, 8, 9, and 10. time, he had 192 visits but not one inpatient admission. when we engage mr. 280, we found out that he was living almost in the hospital parking lot. overal account charge of $300,000 at one hospital. this is a graph of the emergency room visits during that time. as you can see, there are three places there in 12 and 13 when he was not in the emergency room for the month. we can show you three mugshots that correspond to those months when he did not appear in the emergency room. since being housed, he has been to the emergency room twice -- both appropriate visits. he has never been admitted to the hospital. he is stably housed, and has remained stably housed over that period of time. he is receiving care at the local new logical institute. he got his food handlers card. he is employed part-time at a local restaurant. what are challenges on the ground? the talkou have heard of care coordination. we can gett what somebody into permanent supportive housing because we have the opportunity -- i'm going to get that diabetic foot in housing, not on the street or under the bridge. theeed to coordinate services that we provide. we haven't exactly figured out whose responsibility it will be. as another one of those issues where we have to work together. we have to prioritize the support in terms of medical needs. i think, if you have not seen the work done out of boston with mcconnell, are medically vulnerable are dying on the street. we have pretty good data to show that persons with chronic illnesses, who are medically vulnerable, will not survive. and yet, our systems -- are electronic systems, our silos, if you will, we have to learn how to cross them to privatize the limited resources that we have to the persons who need them the most. one thing that we are really interested in is developing new and innovative models for delivering primary health care efficiently. once we get people there, how do we deliver the care and the most efficient way possible? do we take the services to them? do we provided transportation and the follow-up? all of those impossibilities. we know it is important to place people immediately. they will get sick, for one thing. the second thing is what we can locate the person that needs the housing, we need to try and put them there. plugld like to put in a for medical respite care for the homeless, and the growing of these programs as pivotal points ille patients, who are too sometimes for direct placement without the stabilization of the illness can use medical respite as bridge housing. my recommendation -- housing is health care. if we could increase availability of those permanent supportive housing units, we need the vouchers, and we need the services. anything we can do to incentivize are states -- our states to cover the array of competence of services in medicaid isusing, wonderful, but medicare alone cannot 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 are possible, i'm here to tell you that they are possible. thank you. mr. howard: that is terrific. thank you, sister adele. we are now at a point where we would love to hear your questions. fill out and hold up a green card, and someone will come forward, or you can tweet it, and we can go from there. let me start with sister adele, if i can. i would welcome other panelists to chime in as well. can you talk about the kinds of pockets you were able to pick to put together what looks like an incredibly of housing with services that have allowed you to make such progress? o'sullivan: as far as housing is concerned, through care, and theof united way, we were able to put together some funds from the department of housing, the state department of housing, from a couple of the cities in the metropolitan maricopa county area, and from philanthropy. those are the vouchers. ho: health care officials might be confused about the continuum of care. programsess assistance are delivered into communities through loose community collaborations that we call continuums of care. that is confusing for the health-care system, i wish we would have called it something else, especially because we are not advocating for a continuum of care. when she is saying money -- that is probably better assistance¿ assistance. mr. howard: ok. observation. your if you would identify yourself, and keep the question as brief as you can, we would very much appreciate it. >> thank you. , a.m. media. what experience do any of you have with those who have gone on medicaid as a result of ,xperiencing a natural disaster and losing the housing they had before? ho: i would love to talk observed in new orleans. it is timely with the anniversary of hurricane katrina and rita. one of the things -- tragic. the number of people who lost their homes was devastating. what happened to that committee was
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