This commentary is by Paul Manganiello of Norwich. He is co-medical director of the Good Neighbor Health Clinic in White River Junction.
Vermont, we have a problem. Recently, on Nov. 15, our Norwich state representative, Rebecca Holcombe, organized a panel discussion on the topic of housing. The panel consisted of the Vermont state treasurer, Mike Pieciak, who discussed Vermont’s efforts to invest in housing, climate and social equity initiatives; Jeff Lubell, the chair of the Norwich Affordable Housing subcommittee and a national expert on housing and employment zoning; Ann Sosin, a researcher on housing policy at the Rockefeller Center at Dartmouth College; and Neil Odell, a Norwich School Board member and an expert in the relationships between housing and the Vermont educational funding formulas.
From the ensuing discussion, it was apparent that housing is a multifaceted and challenging issue — beginning with the effects of the rising costs of materials due to inflation and supply chain issues; the lack of skilled tradespeople; decisions affecting financial investments; the lack of workforce housing; medical issues affecting wages and one’s ability to borrow; zoning, septic and water accessibility; how affordable housing affects an individual’s ability to access certain school districts for their children; etc.
I would like to focus on individuals with chronic physical or complex health issues, mental illness, and substance use disorders, and how they intersect with the lack of housing. As a physician, I am well aware of the fact that safe and affordable shelter is an important determinant of an individual’s health.
In 1963, then-President John Kennedy signed into law the Community Mental Health Act, shifting the treatment of mental health disorders from institutional custodial care to care offered in outpatient mental health centers. While this has resulted in positive outcomes for millions of affected Americans, lack of adequate funding has resulted in many individuals not receiving care, who would benefit from high quality, effective, mental health support. Those who lack access to these services may need to seek accommodations in local homeless shelters, health care in emergency rooms and, unfortunately, as a last resort, often find themselves incarcerated by the criminal justice system. In the Upper Valley, many of our residents with mental illnesses go unnoticed, but on a trip to any of our major cities, we see the inhumane way we care for our fellow neighbors with risk factors that set them up for inadequate shelter. We literally show more kindness to our pets and animals.
Medicaid is a program that is administered by federal and individual state governments. They devise the rules, and they have, in general, not allowed Medicaid money to be used to pay for housing development or pay for rent. States, however, are encouraged to apply for waivers. One such waiver, a 1115 Demonstration Waiver, is an “experimental pilot, or demonstration project that are found to likely assist in promoting the objectives of the Medicaid Program”. The 1915c Home and Community Based Services waiver is designed to provide services that are less costly than institutions, services that are individualized and person centered. Home and Community Based Services waivers can cover housing pre-tenancy services, tenancy sustaining services and transition services.
There have been numerous studies that have shown a strong association between positive health outcomes and safe, affordable and stable housing. Housing that includes support services reduces excessive use of emergency room services, reduces health care needs of residents of homeless shelters and reduces the necessity to rely on incarceration in our prison system.
The state of Hawaii was granted a Medicaid waiver that was meant to address individuals with mental health disorders, which interferes with their ability to carry out their daily activities; those with substance use disorders; those with chronic physical or chronic health needs; and those with frequent emergency room use.
In Hawaii, public and private “stake holders” have partnered to implement a “Housing First” program. This partnership involves the Hawaii Public Housing Authority, their Mental Health and Alcohol and Drug Division, the Hawaiian governor’s homeless coordinator, multiple social services and private agencies, as well as community health centers.
A report on the Hawaii/ Pathway Project from Aug. 2014 to Sept. 2015 reported that there were fewer ER visits, less involvement with the criminal justice system, a decrease in drug and alcohol usage, a 97% retention rate and a net saving from reduced Medicaid spending among pathway project clients of $2,370 per month.
Will this be easy? No. Shouldn’t we at least try? Yes! Hawaii has given us a blueprint. We need to get all the stakeholders (partners, like minded organizations, etc.) out of their individual silos and into the same room to address this housing issue and come up with a Vermont plan. Not making the effort is not only unjust, but also inhumane.
