Grants Pass v. Johnson Underscores the Need for ‘Housing as Health’ Approaches

Many factors contribute to our health, including how and where we grow up, our income and education, our access to health care, and the policies that shape our society. These factors, which influence health outcomes, are known as the social determinants of health. Of these, housing instability is a widespread and critical issue that significantly impacts the health and overall wellbeing of individuals, families, and communities. Connections between housing and health are numerous: housing instability can lead to environmental health issues like asthma or lead poisoning, as well as mental health impacts from chronic stress. Among unhoused individuals, mortality rates are shockingly high: non-elderly people experiencing homelessness have 3.5 times the risk of death compared to those who are housed. Housing instability and homelessness are inextricably linked to poverty, inequity, and discrimination. People of color – most notably those who are Native Hawaiian/Pacific Islander, Black, and American Indian – are overrepresented among the homeless population, as are LGBTQ youth. Following the COVID-19 pandemic, nationwide poverty increased with 12.8% of the US population living in poverty in 2021, and many more living near to the poverty line. People living in poverty (and especially people of color as outlined above) often struggle to afford necessities such as housing, and frequently experience severe housing cost burden (i.e., paying more than 50% of income towards housing). Poverty coupled with increasing cost of living and lack of affordable housing continues to perpetuate the issue of homelessness across the United States. Against this backdrop, on June 28, 2024 the Supreme Court of the United States ruled on a case titled Grants Pass v. Johnson. In their decision, the Supreme Court held that laws prohibiting camping on public lands do not constitute cruel and unusual punishment. In practical terms, this means states and municipalities can now prevent unhoused individuals from camping or sleeping on public property even if no shelter beds are available. This decision will have an immediate impact in some areas, and longer term effects as new laws are passed in alignment with the decision. In the interim, the Grants Pass decision reinforces the importance of work already underway to address housing instability and homelessness as part of health policy. In fact, the decision could act as a catalyst for further investment in and scaling up of initiatives that focus on housing as a social determinant of health. These types of health policy approaches are called ‘housing as health.’

What are promising practices or examples of housing as health opportunities?

Many states including California, New York, and North Carolina are pursuing housing as health opportunities to improve health outcomes for individuals, families, and communities. States are piloting and further exploring opportunities through Section 1115 demonstration waivers. Below are a few state-led examples for consideration:

• In California, the Department of Health Care Services’ Medicaid program transformation initiative, California Advancing and Innovating Medi-Cal or CalAIM, reimagines what a person-centered, health equity driven Medicaid program looks like to better deliver care to individuals and families where they need it most. The introduction and delivery of the Enhanced Care Management benefit and Community Supports services to those Medi-Cal managed care members experiencing homelessness are two examples of how health policy and service delivery is addressing housing insecurity and the experience of homelessness in a coordinated, health-focused way. In addition, the state’s exploration of transitional rent opportunities for Medi-Cal managed care members, and the ongoing delivery of programs such as Behavioral Health Bridge Housing (BHBH) and Behavioral Health Continuum Infrastructure Program (BHCIP) to develop immediate infrastructure and real estate assets for those experiencing homelessness, speaks to the state’s commitment to housing as health focused initiatives.

• In New York, the Department of Health’s Medicaid Redesign Team (MRT) created various supportive housing programs focused on delivering tenancy support services, rental subsidies, new capital construction and pilot projects to test new models of care focused on high-utilizer Medicaid members. On average, individuals served in the program have a multitude of comorbidities, including mental health and substance use disorders, HIV/AIDS, and one or more chronic conditions. An evaluation team with the Center for Human Services Research State University of New York at Albany found the MRT Supportive Housing Initiative programs had a profound impact on health care costs and utilization. 

• In North Carolina, the Health Opportunities Pilots (HOP) is part of the state’s focus on delivering evidence-based, non-medical interventions related to housing, food, and transportation to high-needs Medicaid enrollees. Through the Section 1115 waiver program, the state is providing these housing-focused interventions to address unmet health-related social needs at an individual and community level. 

These three states are a few of the many examples of how states and Medicaid programs are addressing health through a housing perspective. These examples mirror the White House’s recommended approach to address the topic of the social determinants of health and align closely with the US Interagency Council on Homelessness’s approach of how health systems and hospitals can help address homelessness.Now more than ever, it is critical for communities and states to explore housing as health focused opportunities to address homelessness. These opportunities will require investments from multiple stakeholder groups, including managed care plans, providers, community-based organizations, counties, states, and the federal government.  Aurrera Health Group looks forward to supporting stakeholders to understand, design, test, and implement housing as health focused opportunities. Our team has experience supporting housing as health programs including BHBH and deep expertise in Medicaid program development and delivery including CalAIM. If you would like to discuss how we can help, please reach out to Aurrera Health Managing Principal Jill Donnelly. 

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Authors

Sarah Leff [Deputy Director]

Blake Owens {Senior Policy Consultant]