Portland’s Metro Affordable Housing Bond: How Medicaid Could Fund The Services

By Andrea Bell & Josh Crites

The Portland Metro area just passed one of the most impressive affordable housing bonds in the country.  Voters agreed to a $658 million-dollar bond that will help develop upwards of 4,000 affordable housing units over the next decade.   What populations will be served is not yet known but it is believed that a large portion of the units will be used to serve homeless individuals and families at risk of becoming homeless or currently experiencing homelessness. This is an important step in ensuring that Portland and the surrounding area does not become so expensive that different populations are pushed out of the city like San Francisco, Seattle and other west coast cities.

Now that the bond measure passed, one of the most important questions is whether the funding is in place to ensure access to support services to aid in housing search and permanency.   Important work like case management, transportation to find housing, life skills, being a good renter and dispute mediation will be needed for many of the recipients of housing to be successful. Housing coupled with the necessary flexible support services can serve as a powerful stabilizer and yield positive outcomes—housing retention, decrease in costly emergency and crisis systems, and improvement in quality of life.

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As the planning efforts around the housing bond begin to formalize, the Oregon Medicaid system should have a solid imprint to bring forth the expertise and fiscal supports to ensure  services are made available. Medicaid is the payor for an array of behavioral health, physical health, and non-clinical services to help  people be successful in the community and successful renters.  The most vulnerable in Oregon have their health insurance through Medicaid so it makes sense for the system to leverage their billable services for housing.

The staff at the Oregon Health Authority have been very innovative and convened a supported housing work group to see how they can assist with this work.  Lessons from around the USA show how Medicaid can and should pay for many of these services.  A path forward could be:

  1. Use Medicaid Waiver: Oregon Health could follow the path of other states that have leveraged their Medicaid waiver to pay for supported housing. The Oregon Health Authority could submit a waiver to the Center for Medicare/Medicaid Services (CMS) to carve out and expand the supported housing program specific to this region.  They can choose which populations they wish to serve.  Some states have chosen to provide services for persons who are chronically homeless, individuals with Serious and Persistent Mental Illness (SPMI), Substance  Use disorder, HIV/AIDS or those in Aging and Long Term Care programs
  2. Select the service package: What makes up the services can vary.  The Medicaid system and their health plans can bundle the services based on what is currently being delivered in the community.  Some examples of services that could be paid by Medicaid are case management, transportation while helping the member find housing, life skills like money management, being a good neighbor, cleaning one’s apartment, and landlord mediation.  In the Medicaid world, it it just finding the right billable code to meet the needs of those in supported housing programs.  Some state’s like Washington use one general code (H0043) to cover all supported housing services.
  3. Implementation, Oversight and Monitoring: The Medicaid Authority can work with it’s health care plans to ensure that there are no gaps in services and that there is a high level of fidelity. The services should be low-barrier and individualized.  It will be important for all of the providers to understand what services are covered and how they can bill for them.  The Medicaid Authority can put language into it’s contracts with CCOs and health plans to make supported housing services an expectation and establish deliverable so they can track health plan compliance.

This is a highly simplified summary of how Medicaid can pay for the supported housing services. The Oregon Health Authority is already doing very strong work  In Arizona, supported housing services are paid for by the Medicaid system for thousands of persons with Serious Mental Illness and or General Mental Health/Substance Use Disorder.   The state expects health plans and providers to deliver exceptional services and that Medicaid can be encountered.  The overall health care cost savings are immense when a person who was homeless is housed and given proper supports.

Please let us know what you think about the Portland Metro Bond and services by emailing at info@housing-futures.org or jcrites007@gmail.com

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