#SeaHomeless: Interview with HCA Chief Policy Officer Nathan Johnson

Nathan Johnson is the Chief Policy Officer at the HCA, and one of the primary architects of the state’s 1115 Medicaid waiver application.  We asked him a few questions about state policy and the logic of including a supportive housing element in the waiver application.

DJ: What was the impetus for the HCA to include a supportive housing element in its new waiver application?  What is the connection between housing and health?

Nathan Johnson: Several things contributed — First, much has been written about the significant relationship between housing status and health care outcomes. Seattle’s own 1811 Eastlake project is a prime example and Providence CORE recently released a report detailing the impact these services have on Medicaid costs in Portland, OR. The state of Utah has had their own very favorable experience. In addition, the Medicaid program has changed significantly with the expansion in 2014 and we now serve 600,000 newly eligible adults, many of whom suffer from complex health conditions and housing instability. We serve more adults than kids for the first time, and our delivery system and benefits approach must adapt to effectively serve this new population.

In addition, during the 2014 session, the state Legislature passed Senate Bill 6312 which created supportive housing and supported employment as optional benefits under the Medicaid program, subject to available funding. Needless to say, the budget has been tight and early on, we saw the potential of funding this policy priority through the Medicaid Transformation Waiver. In June of 2015, CMS released an informational bulletin identifying the specific supportive housing services allowable under Medicaid, and the authorities under which the services could be provided. Initiative 3 of the waiver allows the state to leverage federal dollars to test a model of targeted supportive housing and supported employment services while determining the return on investment and sustainability model for this critical set of services.

 DJ: How can the system generally but the HCA in particular foster community linkages between the organizations working on homelessness and housing insecurity, and the health care system?

NJ: HCA was proud to sponsor the Health and Housing workgroup in 2014 and 2015 which gathered key stakeholders across state agencies and both sectors to discuss ways that we could better serve our shared population. This work contributed a great deal to our thinking on Initiative 3 of the waiver and has fostered a much stronger connection between our respective sectors. In addition, local Accountable Communities of Health have recognized the critical importance housing plays in achieving health and have incorporated strong representation of housing and homeless service providers in their membership and governance structures. We would expect to see this connection grow stronger as we move towards implementing the 1115 waiver.

DJ: Are the obstacles to successfully integrating housing security into the spectrum of health primarily cultural, financial, or administrative?  How would you characterize the elements holding our region back from dealing with these issues?

NJ: I believe this state has made great strides in addressing all 3 obstacles. The cultural issues that have long been a reflection of strict programmatic and funding silos around housing and health have started to dissipate, as evidenced across the state around Accountable Community of Health tables and between stage agencies (like HCA, DSHS, Commerce and DOH). Since passage of SB 6312, it is primarily financial obstacles that have limited the broader provision of supportive housing and supported employment services to Medicaid beneficiaries. We are hopeful the waiver will help address this . I think this region is better poised than most to stand up a sustainable and evidence based approach to an additional array of services through the waiver and a better connection of those services to the health system through regional partnership and collaboration.

DJ: Tell me about the HCA’s expectations of its Medicaid health plan (with which it contracts to provide health benefits) related to housing and managing the homeless population?

NJ: As we work toward waiver approval, many of these expectations are works in progress. However, it is our intent that Initiative 3 benefits be provided through existing Medicaid delivery system partners, including MCOs, BHOs, Long-Term Services, and Tribes. This will be a business model adaptation for plans and housing providers who have not previously been engaged in typical plan-provider contracting, but a change that both parties welcome.

DJ: Is this a new consideration for you and the HCA – housing the housing insecure?  Did this become a relevant issue as a result of Medicaid expansion?

NJ: The Medicaid expansion had a lot to do with it, adding over 600,000 adults to our program, many who lack stable housing and have significant health issues. From the beginning of our health innovation planning process in 2013, addressing factors that impact health outside of four walls of a clinical setting has been a key priority for the state. Housing security has figured prominently in that discussion, with notable contributions from housing providers as well as hospital CEOs, health plans and public health. We now see this priority reflected in our state’s 5-year health care innovation plan, established in statute, and a key construct for the state’s Medicaid transformation waiver. While housing stability was clearly connected to health outcomes before expansion, the complex needs of many in the New Adult population elevated the connection between housing and health to the system level.