Executive Summary

The United States is on the cusp of a dramatic demographic shift.

With baby boomers entering retirement, the American population aged 65 and older is expected to more than double from 46 million today to more than 98 million by 2060.[i] This unprecedented growth, coupled with the increasing number of people with disabilities and dementia, particularly amid a housing affordability crisis, will have profound public health and housing implications for the United States. Now more than ever, it is imperative that housing and health authorities come together to create policy recommendations that will improve the well-being of Americans on a holistic level.

The U.S. Department of Housing and Urban Development (HUD) and the U.S. Department of Health and Human Services (HHS) have operated in silos for decades. With mounting evidence suggesting that “social determinants of health”—the conditions in which people are born, grow, live, work, and age[ii]— play a larger role in health outcomes than medical factors, the two agencies have recently begun working more closely together.[iii] But they have just scratched the surface of a daunting undertaking. In the absence of well-established collaborations, health plans, local health and housing agencies, and other organizations have taken it upon themselves to create innovative pilots to bridge the health and housing gap.

The 61 health plan members of the Association for Community Affiliated Plans (ACAP) are investing in innovations that directly address social determinants, even if they fall outside the traditional bounds of Medicaid health benefits. This paper focuses on neighborhood and built environment, one of the five areas of social determinants as outlined by Healthy People 2020.[iv] It explores the challenges faced by Medicaid recipients in institutions, who are unable to transition back to the community in the face of unaffordable housing. It provides an overview of federal and Medicaid laws that have changed the landscape of long-term services and supports, and gives a general background of housing policies impacting Medicaid recipients. Finally, it highlights the work of five ACAP-member Safety Net Health Plans to help transition institution-bound enrollees back into the community.


There are more than 3,100 counties and county-like entities in the U.S. Not one has enough affordable housing for its low-income residents. Nationwide, just 28 available, affordable housing units exist for every 100 low-income households.[v] The low supply of affordable housing stock has exacerbated the issue of homelessness nationwide, and has significant implications for health and housing policy.

This paper focuses on people who experience transitional homelessness for clinical reasons. This could be someone who is admitted to a hospital, a skilled nursing facility, or long-term care, subsequently loses their home, and therefore cannot be discharged. People who find themselves in this situation face an extra layer of complexity: housing agencies that could help find homes for these individuals typically do not classify them as “homeless.”[vi]

People who face transitional homelessness for clinical reasons typically include seniors and people with disabilities. The two categories are not mutually exclusive. Many are enrolled Medicaid recipients, whereas others have Medicaid and Medicare at the same time. Such people are referred to as “dual eligibles,” or “duals.” Duals tend to be among the poorest and sickest beneficiaries covered by Medicare and Medicaid, and represent a disproportionate amount of healthcare spending, largely due to their greater need for long-term services and supports (LTSS).[vii]

Tectonic shifts in demographics in the U.S. portend a rapid rise in seniors and people who may be dually eligible. More than 79 million seniors will be living in America by 2035; the number of older adult households with a disability will top 31.2 million by then, and the number of older adults with dementia will reach 7.6 million.[viii]

An estimated 70 percent of these older adults will need long-term care. While most such care can be delivered at home, some will require the services of skilled nursing facilities. Many older adults today are assisted by family caregivers for self-care tasks, however, it is widely believed that in the future there will not be enough family caregivers to take care of older adults. Over time, paid care will become even more necessary; without caregiver support, the only option for many will be long-term care facilities.[ix]

Today, 1.4 million Americans reside in nursing homes. Two-thirds of these people receive Medicaid coverage.[x] However, one study found that up to 1 in 5 of these seniors—up to 280,000 in all—could live in less-restrictive environments if they had affordable alternatives with wrap-around services (Appendix).[xi]

While this paper focuses on transitionally homeless individuals, we must note that chronic homelessness and episodic homelessness may overlap. Homelessness among seniors is expected to rise by a third by 2020 and to double by 2050. [xii] The scarcity of alternative housing solutions raises the risk of institutions serving homeless older adults as a high-priced substitute for affordable housing. Even today, homeless seniors are often caught in an ‘institutional circuit’ cycling between living on the street or in a shelter and living in an institution. Since many homeless older adults have considerable health care needs and need support in activities of daily living, sometimes the only permanent shelter available to them is a nursing home—or worse, a psychiatric hospital or jail.[xiii] Because Medicaid pays for nursing homes, many times these individuals are forced to stay there when they could be living in a community-integrated setting at far lower cost.[xiv] While the federal government is taking steps to address this challenge, the need is greater than can be met—and the need is expected to continually grow.[xv]

Other Medicaid beneficiaries faced with unaffordable and inaccessible housing options are non-elderly adults with physical, intellectual or developmental disabilities (I/DD). One study finds that more than 200,000 non-elderly people with disabilities reside in nursing homes.[xvi] These individuals face a severe housing crisis; many live on Supplemental Security Income (SSI). The average SSI payment in 2014 was $721, while the national average one-bedroom unit was $780 and $674 for a studio. While government housing subsidy programs exist, many, like the Section 8 program, are frequently underfunded and have long wait lists. The high cost of housing coupled with disabled individuals’ limited incomes leads many individuals to becoming chronically homeless.

[i] Bipartisan Policy Center. (2015) America’s Growing Senior Population: Assessing the Dimensions of the Demographic Challenge. Retrieved from http://bipartisanpolicy.org/wp-content/uploads/2015/09/BPC-Housing-Health-Senior-Population.pdf

[ii] World Health Organization. (2017) Social Determinants of Health. Retrieved from http://www.who.int/social_determinants/en/

[iii] Yale Global Health Leadership Institute. (2015) Leveraging the Social Determinants of Health: What Works? Retrieved from https://bluecrossmafoundation.org/sites/default/files/download/publication/Social_Equity_Report_Final.pdf

[iv] Healthy People. (2014). Social Determinants of Health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

[v] Urban Institute. (2015). The Housing Affordability Gap for Extremely Low-Income Renters in 2013 Retrieved from https://www.urban.org/sites/default/files/publication/54106/2000260-The-Housing-Affordability-Gap-for-Extremely-Low-Income-Renters-2013.pdf

[vi] University of California, San Francisco and Berkeley. (2017). The Impact of Cal MediConnect on Transitions from Institutional to Community-Based Settings. Retrieved from http://www.thescanfoundation.org/sites/default/files/


[vii] The Kaiser Family Foundation. (2015) Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS. Retrieved from http://www.kff.org/medicaid/issue-brief/financial-alignment-demonstrations-for-dual-eligible-beneficiaries-compared/

[viii] Joint Center for Housing Studies of Harvard University (2017). The State of the Nation’s Housing. Retrieved from http://www.jchs.harvard.edu/sites/jchs.harvard.edu/files/harvard_jchs_state_of_the_nations_housing_2017.pdf

[ix] Ibid.

[x] Center for Health Care Strategies, Inc. (2017). Design Considerations for Nursing Facility Quality Improvement Initiatives in Medicaid Managed Long-Term Services and Supports Programs Retrieved from https://www.chcs.org/media/Nursing-Facility-Quality-Improvement-MLTSS-Brief_082417.pdf

[xi] Mercy Housing and The Low Income Investment Fund for The California Endowment and The Kresge Foundation. (2017). Innovative Models In Health And Housing. Retrieved from http://www.liifund.org/wp-content/uploads/2017/07/LIIF_whitepaper_pages.pdf

[xii] Justice in Aging. (2017). Senior Poverty. Retrieved from http://www.justiceinaging.org/take-action/senior-poverty/

[xiii] Justice in Aging. (2016). How to Prevent and End Homelessness Among Older Adults. Retrieved from http://www.justiceinaging.org/wp-content/uploads/2016/04/Homelessness-Older-Adults.pdf

[xiv] Ibid.

[xv] Joint Center for Housing Studies of Harvard University. (2017). The State of the Nation’s Housing. Retrieved from http://www.jchs.harvard.edu/sites/jchs.harvard.edu/files/harvard_jchs_state_of_the_nations_housing_2017.pdf

[xvi] Technical Assistance Collaborative. (2015). Priced Out in 2014: The Housing Crisis for People with Disabilities. Retrieved from http://www.tacinc.org/media/52012/Priced%20Out%20in%202014.pdf