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Shenell Anderson of West Allis, Wis., was struggling with anxiety, depression and postpartum depression while recovering from an unplanned Caesarean section in 2017. She cycled in and out of the emergency room daily with panic attacks she thought were heart attacks.
Anderson, now 29, landed a phlebotomist job at a hospital, then lost it because of the panic attacks. She neared homelessness as the sister of her children’s father, whose home she and her two young sons were staying in temporarily, gave them a timeline to move out. Money was tight.
But as the deadline edged closer, a chance health screening with the insurer UnitedHealth UNH, -0.48% put Anderson on the conglomerate’s radar: With her frequent ER visits, she was a candidate for an early version of its MyConnections program, an effort to target and house high-cost, high-need Medicaid members whose annual cost of care totals $50,000 or more. The intervention aims to boost patients’ health outcomes and drive down their emergency-room and inpatient-services use, while reducing the total cost of their care.
Steve Wewerka Shenell Anderson
UnitedHealth is one of several insurers enlisted by states to operate so-called managed-care organizations, which deliver care to Medicaid recipients. These MCOs, also operated by companies including Anthem ANTM, -0.56%, CVS Health’s Aetna CVS, -1.21% and Centene CNC, -0.94%, receive a fixed payment per Medicaid member each month from states. UnitedHealth’s health plans receive $500 to $1,000 a month on average, according to Jeffrey Brenner, a family physician and UnitedHealth’s senior vice president for clinical redesign, who leads the MyConnections program.
Given a budget range of $700 to $850 a month, Anderson found a quiet, little two-bedroom in West Allis, located just outside of Milwaukee, for $725. The program also connected her with counseling services, a nutritionist and a yoga instructor, and helped coordinate her doctors’ appointments and transportation.
Having secure housing and “wraparound” services enabled Anderson to focus on herself and allayed her fears of ending up on the street with her kids, she said. “It gave me a new level of confidence that as long as we maintain this roof over our head, that we’ll be able to grow as a family, and I’ll be able to invest more into my children,” she said.
“Hospital beds have become our most expensive homeless shelter in the country.”
An increasing number of hospitals and insurance companies have put money toward homelessness and housing insecurity-related initiatives in recent years. They have a vested interest: People experiencing homelessness have higher rates of emergency-department usage, longer hospital stays and extremely high hospital-readmission rates. They have a greater prevalence of health problems, and their unstable housing can make them harder to treat.
Some people experiencing homelessness even resort to seeking shelter in the emergency room, or end up as long-term residents in hospital rooms because they don’t have a place to live.
“Hospital beds have become our most expensive homeless shelter in the country,” Brenner said.
UnitedHealth, which contracts with external housing vendors and spends between $1,200 and $1,800 monthly for each MyConnections participant, piloted its program in Arizona, Nevada and Milwaukee; it now has patients housed in more than a dozen states and plans to scale its reach to 30 states by the end of 2020, starting with 10 units in each location, Brenner said. Patients can generally have their rent covered for up to a year.
MyConnections has housed and provided wraparound services to 246 people in Arizona and Nevada since 2017. Accounting for regression to the mean — the statistical phenomenon of a member’s health costs improving on their own without the program intervention, due to spontaneous and hard-to-predict factors — Brenner found an 8% to 19% reduction in ER visits, a 14% drop in inpatient admissions, and a 9% to 13% decrease in the average monthly cost of care for members in those states.
All told, around half of MyConnections members do better, a quarter stay the same, and a quarter increase in spending, Brenner said. “If you help people take care of themselves, they don’t need to go to the hospital; they don’t need to go to the ER,” he said. “Institutionalized health care is so expensive that you can generate savings just by keeping people out.”
Bobby Watts, the chief executive of the Nashville, Tenn., nonprofit National Health Care for the Homeless Council, said he had been hearing of health-care-related housing endeavors for at least five years. Kelly Doran, an assistant professor of emergency medicine at NYU Langone Health who studies homelessness, said an increasing number of insurers and hospitals had announced plans to pay for various housing interventions in the past two years.
“Even if it hasn’t just recently started, the attention to it has been somewhat more recent,” she said.
One precursor to the growing interest in health-care-driven housing interventions was a focus on reducing frequent use of the health-care system, Doran added, and a recognition that many frequent health-care users were experiencing homelessness.
Of course, UnitedHealth, which began investing in affordable-housing initiatives in 2011, isn’t the only player in this health-care-housing crossover episode: The California-based nonprofit hospital-insurer hybrid Kaiser Permanente, for instance, announced in January 2019 that it would work with a community partner to house 515 over-50 Oakland residents who were experiencing homelessness and had at least one chronic condition; by June, the company said nearly 300 had been housed.
“The health-care system sort of bears witness to the fact that the housing crisis is slowly but surely killing people.”
In October, the nonprofit Denver Health teamed up with the Denver Housing Authority to turn a hospital-campus building into affordable housing for seniors, including 15 units for homeless hospital patients.
And the University of Illinois Hospital in 2015 partnered with the nonprofit Center for Housing and Health to launch Better Health Through Housing, a program that helps hospitals identify chronically homeless ER patients and move them into permanent supportive housing. The pilot program has housed 60 patients to date, overseeing a 41% reduction in ER utilization, a 52% reduction in inpatient utilization and a 46% cost reduction.
“We all believe that the solution is probably cheaper than the problem,” Stephen Brown, UI Health’s director of preventive emergency medicine and director of Better Health Through Housing, told MarketWatch.
Many such interventions subscribe to the “housing first” model, which posits that people need to be quickly moved into permanent housing before they can begin to address other issues like substance abuse or employment. These housing-for-health initiatives aim to address what researchers call the social determinants of health, which include housing, education, safety, transportation, food security and economic stability — factors, in other words, that range far beyond medical care.
A new analysis published in the journal Health Affairs found that 57 U.S. health systems, including a collective 917 hospitals, had announced investments to the tune of $2.5 billion in 78 unique programs aimed at addressing social determinants of health between 2017 and 2019.
Housing-related interventions were the most prevalent, with $1.6 billion committed by hospitals or health systems across 52 programs. These programs included the building of affordable housing, “often with a fraction set aside for homeless patients or those with high use of health care,” and almost all were administered through partnerships with community organizations, local or state agencies, or community development financial institutions, the study said.
“As hospitals and hospital systems are getting more interested in the social determinants of health, it’s reframing our mission,” Brown said. “Just basically doing clinical work is not going to be enough to improve the health of Americans.”
But the United States’ spending doesn’t reflect that thinking. The country has the lowest ratio of social-services expenditures to health-care expenditures of any nation in the Organization for Economic Cooperation and Development, an intergovernmental organization of 36 countries, “and countries with lower ratios on average have worse health outcomes,” wrote the co-authors of a 2017 article published in QJM: An International Journal of Medicine.
Steve Wewerka Shenell Anderson with her children.
Housing groups in New York City were “true pioneers” in the field of permanent supportive housing, “having begun to build housing specifically for homeless adults living with mental illnesses in the early 1980s with private funds with New York City at the epicenter of modern mass homelessness,” said Shelly Nortz, the deputy executive director for policy at the New York nonprofit Coalition for the Homeless.
“But both New York City and New York state soon realized the need to help finance the twin and mutually beneficial purposes of preserving a dwindling stock of single-room occupancy housing and providing permanent homes with supportive services for this population,” she said.
Programs in which health-care systems pay to house people experiencing homelessness are “highly experimental,” Nortz added. “But some of the data suggest very high returns on investments for providing services to certain people who otherwise are going to be consuming a lot more very expensive health-care services,” she said.
UnitedHealth’s extra investment needs to be offset by the expected savings from patients not being hospitalized or visiting the ER, Brenner said. “If we’re very careful about choosing the right people, the cost saved is enough to pay for the model,” he said.
One 43-year-old Medicaid member in Phoenix named Ted, for example, experienced homelessness alongside health conditions like congestive heart failure and cirrhosis of the liver, according to data shared by Brenner. Ted’s average medical costs reached $13,096 a month in the 12 months before he entered the program, the product of eight ER visits, eight inpatient admissions and 103 days in the hospital. In the six months after he moved into housing, he had zero ER or hospital visits and just $1,348 in average monthly medical costs.
These interventions are also “the right thing to do” to address what Brown sees as the dangerous health condition of homelessness, he said: Many of these individuals have experienced traumatic brain injury, neurocognitive disorders, and physical or sexual assault, he said. People who experience homelessness also have higher mortality rates than those who don’t.
“It’s not just ROI [return on investment],” he said. “There’s a humanitarian effort in this, too.”
Watts, the CEO of the National Health Care for the Homeless Council, said money shouldn’t be the main driver of such interventions. Health care and housing are human rights, he said, “whether it is cost-effective or not.”
Hospitals may have other incentives, too: Under the Affordable Care Act, for instance, the Internal Revenue Service requires that nonprofit hospitals conduct a “community health-needs assessment” every three years to consider health needs and disparities in the communities they serve.
While experts believe that targeting high-cost individuals with housing interventions is a positive move that might help reduce health-care costs, they generally agree that it isn’t the antidote to homelessness. After all, high-cost health-care users make up “a relatively small subsegment” of people experiencing homelessness in the U.S., Doran said.
UnitedHealth’s Brenner agreed. “This is a solution to part of that problem of the hardest-to-reach, most difficult and challenging patients who are often ending up in our hospitals, both medical hospitals and psychiatric hospitals, or jails,” he said.
Nearly 568,000 individuals in the U.S. experienced homelessness on a single night in January 2019, according to the Housing and Urban Development Department’s most recent point-in-time estimates, with 63% staying in sheltered locations and 37% in unsheltered places like the street. The rate of homelessness rose by 3% over the previous year, largely fueled by increased homelessness in West Coast states like California, HUD said.
Barbara DiPietro, the senior director of policy for the National Health Care for the Homeless Council, suggested that hospitals were filling a gap left by the federal government. “If the federal government was fulfilling its role in providing a housing platform, then you wouldn’t see hospitals need to fill that with their resources,” she said. “There’s no one turning off the faucet into homelessness.”
“By the health-care system taking this on, they are exonerating the larger system from dealing with issues of housing,” added Sandro Galea, an epidemiologist and dean of the Boston University School of Public Health who has researched social determinants of health.
As for the future of interventions like UnitedHealth’s MyConnections, Brenner suggested that housing for people with complex health and social needs could eventually become carved into normal Medicaid benefits, with traditional housing dollars and social-services dollars braided in.
Housing investments aside, health-care professionals must work to effectively screen for patients’ housing issues and take those into account in providing high-quality day-to-day care, Doran said. The health-care system needs to reckon with the role it can sometimes play in contributing to individuals’ poverty, she added, including through medical bills and debt.
Doran also sees a future role for health-care workers as advocates. Medical providers, including those in the emergency room, see firsthand what a profound impact the affordable-housing crisis has on the health of people who are unstably housed or homeless, she said, including their capacity to go to medical appointments, seek preventive care, take medications and recover from surgery.
“The health-care system sort of bears witness to the fact that the housing crisis is slowly but surely killing people,” she said.
Providers can shed light on such perils, Doran said, and push for what patients need in order to be healthy — “which often is not a medication or a surgery, but housing.” DiPietro said she would love to see hospitals testifying at their state housing-budget hearings, or advocating for a housing plan with their congressional delegation.
Anderson, who participated in the MyConnections program, began working as a community health worker for UnitedHealth last June after she impressed a hiring manager with a speech about her experience during a town hall. She assumed responsibility for her rent payments in September, and is now earning a master’s degree online in marriage and family counseling.
“One of the largest essentials to life,” Anderson said, “is being able to live somewhere without extra worry.”
