Oregon Health Policy Board considers Housing in 1115 waiver discussion

Today, the Oregon Health Policy Board met to discuss the renewal application of the state’s 1115 waiver. A significant part of this initial discussion involved including housing as part of the renewal application to CMS.

The existing waiver expires on June 2017. Lori Coyner, State Medicaid Director, shared that the deadline for submission of the application is June of this year. Currently, the agency is in the process of “refining ideas” to engage in a more robust discussion at the next Policy Board meeting.

In this initial talk, Coyner presented the overall goals of the renewal in a broad framework:

1. Build on transformation including integration (particularly oral and behavioral health)
2. More deeply address social determinants of health and health equity
3. Commit to maintain a sustainable rate of growth in expenditures (changing how providers are paid and encourage use of flexible community services)
4. Expand the coordinated care model (focus on dual eligibles and the most vulnerable OHP members)

Coyner then opened the floor to discussion on strategies to align state and federal resources around housing.

“Medicaid is not in the business of paying for rent or brick and mortar businesses, but there are certainly many opportunities to build supports around housing, and that’s what we’re here to talk about,” said Coyner.

Bill Wright, Director of the Center for Outcomes Research and Education (CORE), presented the findings of health savings across 145 different transitional housing units in Portland.

CORE researchers matched residency and Medicaid records, creating utilization profiles. On average, the effect of housing alone, with no other health services, decreased health expenditures by 12% per person, or $50 per person, per month.

“That may not sound like a lot of money, but if you are in this business, multiply that number by twelve months and a few thousand members, and you have real [savings] fast,” said Wright.

In a sample of permanent supportive housing for seniors and those with disabilities, those savings were closer to $90 per person per month. Those residences that offered health services on site had a savings of $115 per person per month.

Patterns of utilization in the study revealed an increase of 20% in primary care utilization and a comparable decrease of about 18% in the use of emergency department services.

While no member of the Board disagreed with the opportunities presented in these findings, there was push back on the practicality of including housing in this waiver.

“What I’m concerned about is that we’re creating another demonstration project. We’re going to CMS with another piece, when I actually feel like there are a lot of things CCOs could be doing right now to bolster these services,” said Felisa Hagins, OHPB Board member. “For example, we had two years of conversations on community health workers, where they are located, and how they can support communities. And we haven’t reached that level. We made a commitment to the federal government to have a large number of those community health workers functioning in our current system, and we haven’t met that yet.”

“I’m worried about not digging down with current CCOs in those [existing] projects,” she added.

Joe Robertson, OHSU President and OHPB Board member, praised the spirit of the discussion. However, he commented that housing, while an important piece, still doesn’t look deeply enough into prevention and the social determinants of health.

“As I listen to this discussion, I am reminded that we are about more than just the health policy of Medicaid or the Oregon Health Plan,” said Robertson. “If we look at the situation as it pertains to the homeless, this is groundbreaking, incredible work. But I view it as necessary but not sufficient,” said Robertson.

Robertson argued that before housing is included in the waiver, there needs to be more “root cause analysis running the full gamut of social determinants.”

The Oregon Health Policy Board will convene again on May 3, 2016. State of Reform will continue to track this issue as it unfolds.