March 22, 2017

What Thursday’s Vote on Health Care Means for the People We’re Trying to House

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Woman checking a patient's blood pressure

Earlier this month, House Republicans introduced the American Health Care Act (AHCA) as a partial replacement for the Patient Protection and Affordable Care Act (ACA), also known as Obamacare. President Donald Trump has since endorsed the legislation and the House of Representatives is scheduled to vote on it tomorrow. However, the AHCA has several troubling provisions that would disproportionately hurt low-income households, including families, elderly adults and children.

According to the non-partisan Congressional Budget Office, the legislation could lead to 24 million fewer people with health coverage by 2026. Consequently, as Congress debates the future of health care policy, it is critical that our legislators and our citizens recognize the implications of potential changes on other sectors that affect wellness, especially housing.

There are three big implications to be aware of, and they are as follows:

  • The growing awareness and increasingly strong evidence base that social determinants of health including housing factors, such as affordability, location, quality and stability, play a critical role in one’s health and well-being.
  • Changes to national health care policy are complex, but provisions that reduce the number of people covered by health insurance almost always hurt vulnerable populations, like low-income households, elderly adults and children, the most. This in turn can affect their overall quality of life, including access to stable housing, educational attainment and participation in the workforce.
  • The “whole person” model of care advanced by the ACA is likely here to stay, regardless of the outcome of the current legislative debates on Capitol Hill.

Let’s turn to each of these in a bit more detail.

The Social Determinants of Health

In recent years, the intersections between health and housing have received increased attention. This awareness is not completely new: medical issues stemming from housing quality like lead-based paint poisonings and mold-induced asthma in older homes have been recognized for years. This type of issue continues to have profound effects, as evidenced by the water contamination crisis in Flint and dangerous blood lead levels in children nationwide.

Yet the understanding of how to support improving health through broader but still crucial housing factors, such as affordability, location, and stability, are now emerging. These social determinants of health account for an estimated 70 percent of variance in the health of Americans.

Simply put, where we live affects the kind of life we can have. When households spend more than half their income on rent, there is little left for necessities like non-emergency preventive medical care, healthy food or outlets for physical activity. Low-income households are financially stretched when unexpected medical expenditures occur, and paying medical bills can mean missed rent payments, risking eviction.

Research also shows that our neighborhoods have a sizable impact on our health and well-being, as evidenced by the number of adjacent areas that have vastly different life expectancies – sometimes as different as 20 years. Socioeconomic status and access to public amenities and services are contributing factors in these disparities, and access to high-quality, affordable housing and health care are often interrelated.

Enterprise has been addressing health inequities facing low-income people by not only embedding health-based decision-making in affordable housing, but also cultivating strong cross-sector partnerships with key organizations, including United Healthcare, Kaiser Permanente and Bon Secours. We’ve also created a Health Advisory Council composed of a number of nationally recognized experts across the health care sector. Their insights have been invaluable to our understanding of the connections between health and housing. As Enterprise Board Member and Health Advisory Council Chair Dr. Megan Sandel wrote in a recent op-ed, “As a physician, I know that stable, affordable homes are as necessary as medicines, a good diet, and exercise to help people achieve good health.”

The Impact of Coverage Changes on Vulnerable Populations

When the ACA was signed into law in 2010, health care in America changed dramatically, particularly for low-income individuals and their communities. Thirty-one states and Washington, D.C., expanded Medicaid to cover all adults with incomes below 138 percent of the poverty line, and subsidies were provided to low- and moderate-income families with incomes between 100 and 400 percent of the federal poverty line so they could afford insurance plans.

By providing affordable coverage for millions of households, their cost-of-living goes down, medical conditions can be treated earlier in less costly settings and chronic conditions can be made more manageable. The easing of financial burdens related to medical expenditures has allowed households to spend more on other necessities, like housing, nutritious food and transportation.

Many of the ACA-driven changes to the health care system promote a “whole person” model of care that focus on outcomes, coordinated care and prevention. This emphasis is extended to the community level by calling on hospitals to perform a Community Health Needs Assessment – which requires them to identify the health needs of the surrounding community and adopt an implementation strategy for responding. By moving the health care industry beyond medicine alone and toward patient wellness and community health, the social determinants of health – like housing – are considered, which affects actions.

The House had voted more than 60 times to repeal or replace the ACA during the Obama Administration, but the threat of a presidential veto loomed large. Now, with control of both houses of Congress and the White House, the long-sought Republican goal of undoing the ACA seemed within closer reach. Although it was introduced only a few weeks ago, the AHCA has already passed through four House committees and is now headed to the House floor for approval.

The AHCA preserves two pieces of the ACA: letting young adults stay on their parents’ plan until age 26 and forbidding insurers from denying coverage or charging higher rates to people with preexisting medical conditions. However, the AHCA would also restrict federal contributions to states that expanded Medicaid using a “per capita cap” and create a modest system of tax credits that replaces current federal insurance subsidies.

The federal government currently pays a fixed share of states’ Medicaid costs; however, under a per capita cap structure, the federal government would pay its share of a state’s Medicaid costs only up to a fixed amount per beneficiary. The state would therefore be responsible for all costs above that per-beneficiary cap, which would likely result in Medicaid eligibility restrictions.

The optional block grant structure for states (rather than a per capita cap) that was added into the bill this past week would similarly cap the amount of federal funds that states receive for Medicaid costs. According to an analysis by the non-partisan Congressional Budget Office, the AHCA could result in 24 million fewer people with health coverage by 2026 and drive $880 billion in federal Medicaid cuts over the next 10 years.

The implications of changing the current system of health care are numerous and complicated. However, it is safe to assume that reversing Medicaid expansion and capping federal Medicaid contributions to states would affect both the affordability and availability of health insurance for low-income people – which ultimately affects housing affordability. Additionally, many of the innovative ways states are promoting health through housing is via Medicaid. If qualifications for Medicaid are tightened, fewer low-income households will be covered and the impact of those innovative housing-based Medicaid initiatives will be weakened.

The “Whole Person” Model of Care

It is important to keep in mind that certain practices required or encouraged by the ACA, like the whole person model of care and community health activities, are unlikely to disappear entirely if the law is repealed or replaced. Now that health care and housing practitioners are better aware of the critical connections between the two fields, that knowledge and new practices will likely remain intact, but may become more difficult to pay for up front, even when they reduce costs to the health care and housing sectors in the end. The ACA has started to shift the way health care is approached in the U.S., and contributed to other sectors like housing to become more health-minded, and vice versa.

The ACA made significant strides in expanding health insurance coverage for lower-income Americans and promoting certain population health tactics, like requiring hospitals to conduct Community Health Needs Assessments. Whether the ACA is repealed, reformed, or left intact, those in health care and housing need to continue to address the social determinants of health that account for an estimated 70 percent of variance in the health of Americans.

These include factors such as the location, affordability, quality and stability of the homes we live in. HUD Secretary Ben Carson, a renowned physician, said in his confirmation hearing that he will prioritize healthy housing, which may help to bring the fields closer together to affect the health and wellness of low-income people and communities.

Regardless of the debates taking place in Congress, Enterprise will continue its work to make America healthier, reduce health disparities and lower health care costs through housing solutions. However, we cannot forget that our impact, and that of our partners in the housing and health care sectors, can be magnified when the basic health care needs of low-income individuals and communities are stably provided for.