Reduce Medicaid Expenditures with Stable and Healthy Housing

Jeanette Manning, NAGTRI Program Counsel

Jeanette Manning, NAGTRI Counsel

In our culture we have accepted as a universal truth that we are what we eat. We also know that living a healthy lifestyle, exercising vigorously at least three to four times a week and consuming nutritious foods daily, like fruits, whole grains, and vegetables, make us healthier and less prone to disease and illness. However, living a healthy lifestyle, eating, and exercising alone are not enough. Actually, where we live has been shown to be one of the most significant factors in determining one’s health and health inequalities.[1] Those from low-income areas tend to live in the most dilapidated housing yet have the highest rates of chronic and preventable disease, poor access to quality grocery markets and health care, and virtually no readily available outlets for physical exercise due to environmental conditions and increased violent crime.[2] This same group also heavily relies upon Medicaid for health care coverage. Given cash-strapped budgets and high costs to operate Medicaid programs, especially during a downturn, sluggish economy, a vital question remains about what states may consider doing to decrease these expenditures for the poor.

Medicaid costs for states are quite substantial, even with funding contributions from the federal government. The entitlement program covers short- and long-term care coverage for over 66 million low-income Americans.[3] Of this group, nearly half (32 million) are low-income children.[4] Total Medicaid spending accounted for about one-sixth of all national health care spending to the tune of almost $414 billion in 2011.[5] In the same year on average, states’ Medicaid spending was the second largest program for most general fund budgets, directly behind elementary and secondary education.[6] Under the Affordable Care Act (ACA), states have the option to expand their Medicaid programs and cover more eligible residents. At press time, 25 states and the District of Columbia have opted to expand their Medicaid programs under ACA.

This article will not focus on whether a state should expand its Medicaid program under the ACA. This issue, although relevant, is not the central question here. Public officials within states have assessed and continue to weigh the myriad reasons why expansion may or may not be best for their state. What is critical is that all states currently have a Medicaid program for which a considerable amount of state and federal monies are devoted to its operation. For this reason alone, every state should be thinking about developing mechanisms that make the program more cost-effective and beneficial for its recipients. Since a strong correlation exists between housing and improved health, state promotion of stable and healthy housing may be one creative link to decrease Medicaid expenditures.

Why Housing Matters

Recently, NAAG hosted a public health law fellowship supported by the Robert Wood Johnson Foundation, during which assistant attorneys general met with public health and law experts to explore how public health issues may be remedied at the attorney general level. As a fellowship organizer and former attorney in the Office of the Attorney General for the District of Columbia (OAG) who worked on some public health issues, I found the topics and panelists to be invaluable. Fellows discussed a variety of public health and legal issues, received a general overview on public health and its relevance to attorneys general, and visited with the acting U.S. surgeon general. However, the theme that resonated with me most involved comments that the number one indicator to quality health is a person’s housing.

The commentators discussed how the public health field is evolving where medical treatment is no longer just a “doctor-patient” only relationship but becoming an all-encompassing “doctor-patient-community” holistic, treatment model. They shared how research has shown that poor people who lived with precarious housing situations – substandard units, homelessness, and crime-ridden neighborhoods – had the worst medical histories. Although the concept of inadequate housing and one’s health status seemingly is not farfetched from my own experience working on public health and community issues at OAG, I became intrigued and wanted to explore what states are doing and how they might alleviate this phenomena.

After reviewing available research, it became evidently clear that housing conditions (internally and externally) certainly matter and plainly impact one’s quality of health.[7] Public health officials have recognized this correlation historically with epidemics resulting from poor sanitation, infectious diseases, fire hazards, overcrowding, and poor ventilation.[8] Although the results vary on the extent to which housing matters (depending upon the group and type of illness), research demonstrates that housing conditions affect low-income families differently than other populations.[9] Housing for low-income and poor families often is inferior and located in higher-crime neighborhoods.

The poor living in substandard housing also experience higher rates of morbidity, are exposed to more hazards, and tend to have a poorer quality of life, suffering from medical conditions like chronic respiratory illnesses, infectious disease, asthma, lead-based paint poisoning, stress and anxiety, obesity, and high-blood pressure.[10] These high-risk patients – generally, those with very substandard housing or homelessness – account for approximately 4 percent of Medicaid patients but disproportionately use nearly half of all Medicaid spending.[11] Considering these high costs to states, common sense seems to dictate that efforts are needed to address these chronic illnesses that drive increased spending.

Poor Housing Impacting Children and Increasing Medicaid Expenditures

Although numerous medical conditions contributing to health disparities are linked to substandard housing and affect people of all ages[12], poor children, in particular, suffering from asthma and lead-based paint poisoning certainly increase Medicaid expenditures because they account for nearly half of the recipients. At least one million children have elevated blood levels from lead-based paint poisoning severe enough to affect their cognitive abilities, development, intelligence, and behavior.[13] The National Center for Health Statistics recorded that at least two million people with asthma sought medical care at emergency rooms.[14] Both of these health challenges are basically preventable with improved housing conditions. With state efforts to remove the hazards for predominantly low-income families Medicaid expenditures will decrease for those already afflicted and cease to accumulate for low-income children not yet affected.

Lead-Based Paint

Even though lead-based paint was banned since 1978, many older homes continue to have lead paint that poses a significant health hazard to children, chiefly those younger than six. Children are easily poisoned when paint deteriorates or chips, or a property is renovated and contaminated dust or soil is mishandled or not removed using lead-safe practices; however, lead in homes is not just limited solely to paint but can also be found commonly in lead water pipes and solder used in plumbing, all of which are found in older homes.[15] Poor children are the most likely to live in homes with lead-based paint; living in such conditions has long-term effects.[16] Research has shown that poisoned children are known to have developmental limitations, decreased IQ, delinquent behavior, attention deficits, and harm to the blood, kidneys, brain and the reproductive organs.[17]

Significant progress has been made to reduce the number of children living in lead-based paint homes due to changes in the law and enforcement, awareness campaigns and research studies, and concerted government efforts at intervention. According to a 1998 Boston Medical Center report, an estimated 14 million children younger than age six were living in lead-based paint homes, and the majority at-risk group was white children.[18] Although continued progress is necessary, the figure has been significantly reduced. Lead-based paint reduction in homes serves as a perfect example on how steady action can in fact lessen a serious health risk, obviating the need to seek medical attention and thereby reducing costs.

Asthma

According to a U.S. surgeon general report on promoting healthy homes, there were approximately 15 million asthma-related visits to physicians and outpatient hospital centers and nearly 2 million emergency department visits in 2004.[19] Numerous studies have been conducted and articles written on the dangers of pollutants, allergens, and other environmental conditions that either cause asthma to develop or exacerbate it, especially in children. Asthma is a serious condition where the lungs become irritated and swollen, making breathing very difficult.[20] Although doctors treat asthma patients with medications, the best way to prevent it altogether or minimize exacerbations is to control irritants commonly found at home and in substandard, low-income housing. Cigarette smoke, cockroaches, dust mites, settled and airborne dust, mold, rats, mice, dry heat or lacking heat, mold, water and leaking pipes, excessive moisture, old carpets, holes allowing pests to enter, and overcrowding are common irritants that cause asthma to flare, and all are commonly found in old, dilapidated housing.[21]

Cockroaches, in particular, are almost synonymous with living in public housing and other forms of low-income or subsidized housing. Low-income and poor minority children are far more likely to have asthma, have higher hospitalization rates, and have higher mortality rates than any other group.[22] Children who were exposed to and allergic to cockroaches at home were 3.4 times were likely to be hospitalized for asthma-related flare-ups than other asthma patients; those residing in urban environments were 4.4 times more likely to have cockroach allergen in their sleeping quarters than suburban children; and low-income children were 4.2 times more likely to be exposed to cockroaches than other children.[23] Roughly 21 percent of current asthma cases result from exposure to dampness and mold and cost about $3.5 billon.[24]

Concerted national efforts have been made to lessen asthma’s impact, particularly for children. These efforts have included attempts to partner with public health professionals and low-income families, decrease the number of emergency department visits, hospitalizations and associated costs, and reduce the number of missed school days. Asthma Community Network (ACN), a free online network, serves as a national model with members from throughout the country involved in asthma management programs.[25] Asthma Network of West Michigan – a member of ACN serving over 80,000 people with asthma (30 percent are younger than 18 years of age) via community efforts in three West Michigan counties – has existed since 1994 and successfully reduced health care costs of approximately $800 per child, decreased hospitalizations by 63 percent, and emergency department visits by 30 percent.[26]

Local health entities in states such as Massachusetts, Michigan, Ohio, New York, Pennsylvania, Washington, and California, have partnered with other public health officials in creating “Healthy Homes” initiatives as a means to reduce home health hazards that exacerbate asthma. These partners conduct training for medical personnel, assess hazards within homes and work with families to improve their living conditions, in addition to attempting remediation at the properties.[27] A study was also conducted in Minnesota where approximately 60 low-income housing units in an apartment complex were renovated to improve the residents’ health using green products.[28] The renovation focused on improving ventilation and reducing moisture, mold, and pests that impact the effects of asthma and other respiratory illnesses, and one year after the renovations, both adults and children had some measure of improved health overall.[29] These local and national efforts within states, although not a panacea, made a difference in people’s overall health and helped to reduce costs for low-income families who primarily rely on Medicaid. There is an automatic cost savings from decreased medical visits and hospitalizations.

Models Seeking Savings from Healthy and Stable Housing

Some states are brainstorming the most innovative ways to promote public health and safety for high-risk populations, while simultaneously hoping to contain health care costs. This idea is not nascent in any respect. However, what is an emerging tactic is how some states are changing the landscape in how they define health care. Instead of viewing health care as purely the receipt of medical treatment, some states are expanding the definition to include housing. In other words, housing is equally as important to medical services as doctors’ visits and hospitalizations. Given that high-risk groups tend to heavily rely upon Medicaid and also significantly and disproportionately drive up costs, some states have been promoting two models in recent years that use housing as the critical link to reducing health care expenses.

Stable Housing Model

The concept of states assisting people with securing permanent or long-term housing is not a new idea. In the past many states developed programs that offered affordable and permanent housing to its residents as a matter of general public policy to address homelessness or the limited housing inventory, especially in cities. Cities within states like New York, Washington, California, and Illinois have experimented, however, with implementing stable (or long-term, permanent) housing as a health care strategy to decrease Medicaid costs and other expenses associated with a small number of high-risk Medicaid patients (who disproportionately account for the majority of its expenditures). The states are beginning to focus more on social determinants that impact one’s health. Particularly, the states focusing primarily on high-risk groups of people are those living with HIV/AIDS, substance abusers, homeless, or those with chronic mental illness.[30] The current stable housing model’s objective is a health care strategy that focuses first on a patient’s ability to have a more permanent place to go upon discharge from the hospital, thereby increasing the likelihood that they will abide by a medical treatment plan and not return to the hospital as quickly.

In one particular New York City study, researchers studied whether Medicaid spending could be reduced from fewer inpatient admissions involving the highest risk patients.[31] The group was monitored for one year and had access to intervention services (including housing), and at the conclusion of the study, the researchers noted that the participants decreased their number of inpatient admissions and Medicaid reimbursements also were reduced.[32] New York/New York III is New York’s stable housing model that was established in 2005 and involves an agreement between New York City and the state to provide housing to high-risk groups, including homeless adults with substance abuse problems, mental illness, or frequently homeless families. This stable housing model aims to address homelessness, which is a leading indicator of individuals overburdening public hospitals and driving up the extensive portion of Medicaid costs.[33] New York Gov. Andrew M. Cuomo announced another stable housing model aimed at continuing to reduce Medicaid expenditures, for which he projected the state stands to save $34.3 billion over the next five years and has already saved $4 billion the year prior under New York’s Medicaid Redesign Team Supportive Housing Initiative.[34] The initiative looks at housing as a health care strategy and provides stable and safer housing to high-risk persons, thereby reducing health care costs.[35]

The stable housing model in Seattle, Wash., is the Housing First program, which was utilized in a study to determine its effectiveness at reducing medical costs.[36] Housing First is a supportive housing model aimed at reducing medical visits, admissions and length of stays for individuals who were known to have the highest medical costs and suffer from chronic homelessness.[37] Seeking to ascertain whether medical (Medicaid-funded services) and legal cost savings would have resulted when supportive housing was provided to high-risks groups with severe alcohol problems and histories of medical, psychiatric, and criminal histories, the study’s findings supported its premise.[38] There were noticeable savings with decreased numbers of hospitalizations, emergency department visits, and alcohol use, for which the examiners attributed to the Housing First program offering supportive housing. Despite the results, however, the study received criticism because the participants were still permitted to consume alcoholic beverages in their rooms.[39]

Chicago, Ill., has also used the stable housing model as a means to reduce homelessness and treat housing as a health care need. Presently, Illinois Gov. Pat Quinn seeks to expand his state’s stable and supportive housing model with a new approach to use Medicaid dollars for housing directly because federal law does not permit states to utilize Medicaid funding for building or rental projects.[40] Gov. Quinn has noted that his administration is pursuing the proposal to waive the federal requirements because the program will ultimately save money with reduced health care costs.[41] Los Angeles, Calif., also has a supportive housing model, the 10th Decile Project, where hospitals and social service organizations have collaborated to provide stable housing to its most high-risk, homeless population who were personally known in the community to drive up costs by overburdening medical facilities and public systems.[42] The habitually homeless population tends to frequent hospitals because they are fully aware that hospitals cannot turn them away for assistance they need – medical, housing, or otherwise, driving up Medicaid and other health care costs.[43] An evaluation of the 10th Decile Project revealed that investing in this type of project and group may return favorable outcomes financially. The study found that for the initial 90 enrollees, public cost avoidance amounted to nearly $50,000 per person over a 12-month period, ultimately meaning less money and time spent in hospitals.[44]

Healthy Homes Housing Model

The healthy homes housing model is more recognizable to states where instead of focusing on actually providing low-income and other high-risk groups with housing units, the focus of this model is to improve the existing unit that the family occupies. This model focuses directly on the environmental condition of the housing unit to ascertain whether it may be worsening a family’s physical health and subsequently driving up medical or Medicaid costs, particularly for children with asthma or lead-based paint poisoning. The healthy homes housing model focuses on factors that contribute to dilapidated housing and poor health, including studying air pollution, neighborhood instability, violence, and the surrounding environment outside of the housing unit.[45]

The federal government – through collaboration with at least seven different agencies – established a Healthy Homes Work Group that focused on environmental health and safety risks to children in the home.[46] The group produced a report, highlighting the importance of home interventions and noting specific states that followed the healthy homes housing model and achieved positive results.[47] Ohio, Massachusetts, and New York government officials, nonprofit organizations, and universities partnered in different capacities to improve housing conditions for children, including a weatherization program to improve energy efficiency, pest control management in private and public housing units, home remediation to address indoor air quality, mold, and moisture, and upgrading public housing units using green-built materials.[48] Successful results from these efforts included significant improvement in respiratory symptoms, tobacco control, indoor air quality, mold and moisture, a decrease in asthma-related clinic visits, and an increase in days where children were asymptomatic of asthma-related conditions.[49]

All of the Healthier Homes projects that are members of ACN are examples of healthy housing models. All of these programs provide supportive services to families and engage in collaborative efforts to make the home as safe as possible. For example, Seattle-King County in Washington has a program that focuses specifically on the housing units for children with asthma by reducing their exposure to allergens and irritants that exacerbate their symptoms.[50] Community health workers work directly with families and conduct environmental assessments, create action plans, and for a full year, they work with families to reduce exposures.[51] The Healthy Public Housing Initiative (HPHI) in Boston, Mass., has a similar program to make housing units safer for families suffering from asthma and living in low-income homes. HPHI connects public health officials from Boston universities, task forces, tenants’ rights groups, and the City of Boston government agencies to work jointly with the resident community to reduce hazards within their home that trigger asthma.[52]

A dangerous home is a trigger for many chronic illnesses, deaths, and injuries that naturally increase health care expenses. It is estimated that national health care costs associated with housing-related injuries and illness may amount to billions of dollars annually.[53] Costs associated with unhealthy homes from dampness and mold that trigger asthma events are estimated to cost several billion dollars annually.[54] Some research has been conducted and shown that implementing healthy homes models curb health care expenses, especially for the poor. Although more research is needed to analyze the full amount of cost savings, it is known that low-income children (and other high-risk populations) tend to live in substandard housing, resulting in them seeking medical services more frequently than necessary if their homes were safer. Working to minimize these home health hazards would therefore benefit states economically.

Possible State Responses

Undeniably, the health and social issues identified in this article are highly complex. The potential remedies are equally as challenging because of initial costs to implement programs, unpredictable social ills and crime, lack of education and lifestyle decisions among the disproportionately affected populations, unknown actual program costs or savings, and the need for more research on the financial viability of treating housing as a health care need. However, the current trend in many states is to explore alternative strategies to lessen the effect of increased health care costs from high-risk groups and accompanying social ills and illnesses.

Financial assistance has been offered from sources outside the federal government to research cost savings and program viability, including exploring the importance that housing has on people’s health and well-being. The MacArthur Foundation recently awarded nearly $3 million in grants to discover how housing matters and how it affects children, families, and communities.[55] With these new grants, the MacArthur Foundation has supported at least 42 studies in a five-year period to study housing.[56] One of the newly-awarded grants will directly study whether healthy housing improvements can reduce Medicaid expenditures.

Regardless of eventual research findings on cost savings or money spent to explore housing as a health care strategy, every state right now still has to contend with the best way to address issues that impact them. Low-income families and limited housing, high-risk groups utilizing Medicaid at disproportionately high rates, crime and public costs, injurious housing causing health problems or death for residents, and lead-based paint poisoning and asthma in children are inescapable issues for every state to varying degrees. State attorneys general throughout the nation already do and can continue playing a critical role in helping to alleviate some of the challenges raised in this article, given their enforcement authority or advisory role to state agencies. The attorney general’s office itself can be quite effective and has plenty of arsenal at its disposal to either raise awareness or directly address issues of public concern, including exploring ways to improve housing or reduce state Medicaid expenditures that offer a financial benefit to the state. Some suggestions include the following, which involve enforcement action and partnership development:

Lead-Based Paint Abatement

Given the number of existing lead-based paint hazards nationally, attorneys general can arrange for their attorneys to prosecute these cases. The prosecutions help to facilitate larger numbers of abatement, thereby making children safer. Prosecutions may involve criminal or civil prosecution against any party who is legally obligated to abate the problem or responsible for creating the problem. In most instances, these suits will be against property owners who fail to remove known hazards or against persons who stir up dust or soil when renovating homes known to have lead-based paint. In instances where remediation requires that families move temporarily until abatement is completed, AG offices should be prepared to deal with custodians of children who are aware of lead poisoning or the hazard but fail to remove their children from the dangerous environment. Often, custodians – fearful of the housing shortage – do not want to move during the remediation process for fear that they will be unable to return upon abatement. Such actions may border on being neglectful towards their children. Non-profit organizations and child protection and welfare agencies should be involved to work with the custodians when necessary. Assistant attorneys general (AAG) representing child protection and welfare agencies may need to be prepared to take action, if the children’s well-being and health continues to be compromised. AG offices may also want to work with state environmental and health departments to ensure that quality in-home assessments for lead-based paint are conducted and that community outreach campaigns are a priority.

Property Owner Engagement and Housing Code Enforcement

Attorneys general offices may want to open the lines of communication proactively (if necessary, in conjunction with client agencies) with property owners and engage them to abate housing code violations on their properties that render them unsafe. Prior to taking any legal action, AG offices could simply engage property owners in discussions and encourage them (or mandate) to fix their rental units according to code. When owners fail to address violations, rendering their properties unsafe, AG offices could enter into agreements with a delineated timeline when property owners must repair and rehabilitate their rental units in lieu of further legal action. Any failure on behalf of the property owner to act could result in AAGs taking legal action, or legal action could be the preferred option at outset to immediately address poor housing conditions.

With a group of recalcitrant property owners known to be slumlords, AG offices could use their office to reach a larger audience and file one large, comprehensive lawsuit against multiple property owners as opposed to individualized suits naming one owner at a time. Receivership actions are also potentially effective legal means to encourage or require property owners to repair their properties. AG offices may also want to consider working closely with client agencies responsible for enforcing housing code violations and advising them on available legal remedies and the importance of conducting thorough inspections, properly citing violations, and preparing airtight cases.

Zoning and Cross-Sectoral Planning and Engagement

When public finance projects are negotiated, there generally is a government lawyer involved in the process to review contracts and ensure legal compliance. Commonly, when locales are considering revitalizing neighborhoods or upgrading the current housing stock, there typically is an open comment period for community input and plenty of cross-sector collaboration and planning. AG offices should have a seat at the table for these projects at the initial planning stages and throughout the discussions until it is completed. AG offices may also play a pivotal role in helping to facilitate the collaboration of essential players, provide advice to their clients when they make decisions that affect the community, or provide the legal perspective and related implications of group decisions. Multiple sectors are almost always part of the discussions related to zoning, building projects, or revising housing codes. In these instances, AG offices can also engage advocacy or tenant groups and public health experts to work with architects, builders, local, state, and federal officials, property owners, urban planners, law enforcement, and the like, to ensure that best practices are implemented.

Exploring Housing as a Health Care Strategy

AG offices interested in exploring whether Medicaid expenditures may be decreased to put more money in state coffers may want to consider exploring housing as a health care strategy. Attorneys general offices may contact states directly where housing is viewed as a health care strategy to decrease costs. Attorneys general also could collaborate with state agencies to address the needs of low-income families and other high-risk groups using the stable housing or healthy housing models. Attorneys working in policy sections for AG offices could apply for grant funds to study whether high-risk populations are disproportionately increasing medical costs and costs for the public within a particular state (or use allotted grant money to provide services to these groups via partnerships with nonprofits or government entities). AG offices could also develop task forces and engage public health officials at hospitals, nonprofits, and academic institutions to explore areas of concern and guarantee community involvement. Any initiatives being considered in states that involve affordable housing deals should also include AG office input, even if limited, because social determinants and environmental concerns could ultimately impact their office and the public’s overall health.

Conclusion

In my own experience at the DC Attorney General’s Office, I regularly used the office in my official capacity to bring about fruitful change in the community. I supervised a section where we preemptively forced property owners to take action when they contributed to community blight and affected the public health or sued them when they failed to correct the harm. We closed brothels; prosecuted property owners and drug dealers who created dangerous nuisances and increased crime in communities; compelled property and business owners to speak with us and negotiated agreements with them to minimize violent crime at their illegal businesses or subsidized low-income housing units (using collaborative efforts with law enforcement and other government agency officials, when appropriate); abated lead-based paint hazards when children were poisoned; filed a comprehensive lawsuit against 23 recalcitrant property owners who failed to abate housing code violations in substandard housing; and advised agency clients on an array of related issues. From this work I know firsthand how an attorney general’s office can think and act creatively and use the office to make a difference in people’s lives while promoting the public interest.

I also worked directly with high-risk groups and understand discreetly from my many visits to poor neighborhoods littered with crime and witnessing their substandard housing conditions how low-income children and adults are disadvantaged socially and medically for myriad reasons. Of course, providing housing and making it healthier will not eradicate all of the medical conditions or social ills associated with the poor, high-risk, or low-income communities. It is also questionable how much of an interest attorneys general offices should take on these issues. Moreover, the verdict may still be out on the extent to which Medicaid expenses could be reduced from improving or providing housing to these groups. Nevertheless, every state has evidence of spending considerable amounts of money on law enforcement in high-crime neighborhoods, on correctional staff who man the prisons, on poor children who are chronically ill and use Medicaid, or on mental health services for those with severe diagnoses. Perfectly reasonable minds can differ about how much money should be spent on government services or entitlements, including Medicaid. There is plenty of room for debate on that issue. Instead, the focus here is simply to lay out some items for consideration on whether there are potential cost-saving measures available for exploration and implementation. I am pretty confident that we all can agree on the importance of money to make sure that we know whether it could be saved, or at the very least, that it is being spent wisely.



[1] Ernie Hood, Dwelling Disparities How Poor Housing Leads to Poor Health, 113 Envtl Health Persp, A311, A315 (2005), available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1257572/pdf/ehp0113-a00310.pdf (last visited Feb. 5, 2014).

[2] Id. at A312.

[3] Vernon K. Smith et al., Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013-2014, Kaiser Fam. Found. 8 (2013), available at http://kaiserfamilyfoundation.files.wordpress.com/2013/10/8498-medicaid-in-a-historic-time-of-transformation.pdf [hereinafter Kaiser Fam. Found., Medicaid] (last visited Feb. 5, 2014).

[4] Id. at 7.

[5] Id.

[6] Id. at 8.

[7] David E. Jacobs, et al. The Relationship of Housing and Population Health: A 30 –Year Retrospective Analysis, 117 Envtl Health Persp, 597 (2009), available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2679604/pdf/ehp-117-597.pdf (last visited February 5, 2014); James Krieger & Donna L. Higgins, Housing and Health: Time Again for Public Health Action, 92 Am. J. Pub. Health 758 (2002), available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447157/pdf/0920758.pdf (last visited February 5, 2014); Rebecca Cohen, The Impacts of Affordable Housing on Health: A Research Summary 1-10 (2011), at http://www.nhc.org/media/files/Insights_HousingAndHealthBrief.pdf (last visited February 5, 2014).

[8] Id.

[9] Id.

[10] Id.; see also Hood, supra note 1, at A312, A315.

[11] Maria C. Raven, et al., An Intervention to Improve Care and Reduce Costs for High-risk Patients with Frequent Hospital Admissions: A Pilot Study, 11 BMC Health Services Research 270, 1 (2011), available at http://www.biomedcentral.com/content/pdf/1472-6963-11-270.pdf (last visited February 5, 2014).

[12] See generally, Krieger & Higgins, supra note 9, at 758-768.

[13] Id. at 758.

[14] Id.

[15] U.S. Dep’t Health and Human Servs., The Surgeon General’s Call to Action to Promote Healthy Homes, Off. Surgeon Gen. 13 (2009), available at http://www.ncbi.nlm.nih.gov/books/NBK44192/pdf/TOC.pdf [hereinafter Surgeon General] (last visited February 5, 2014).

[16] Id.

[17] Id; Boston Medical Center Children’s Hospital, Not Safe at Home How America’s Housing Crisis Threatens the Health of its Children, Department Pediatrics 12 (1998), available at http://ghc.illkd.com/wp-content/uploads/2009/08/docs4kids_report.pdf [hereinafter Boston Medical Center] (last visited Feb. 5, 2014).

[18] Boston Medical Center, supra note 19, at 13.

[19] Surgeon General, supra note 17, at 7.

[20] Boston Medical Center, supra note 19, at 8.

[21] Surgeon General, supra note 17, at 9-10; Boston Medical Center, supra note 19, at 8-9; Krieger & Higgins, supra note 9, at 758-768; Hood, supra note 1, at A312, A316.

[22] Boston Medical Center, supra note 19, at 8.

[23] Id. at 9.

[24] Surgeon General, supra note 17, at 8.

[25] Who We Are, Asthma Community Network, http://www.asthmacommunitynetwork.org/about/whoweare (last visited Feb. 5, 2014).

[26] Asthma Community Network, A Systems-Based Approach for Creating and Sustaining Effective Community-Based Asthma Programs – Snapshot of High-Performing Asthma Management Programs, Communities in Action National Asthma Forum 6-7 (2011), available at http://www.epa.gov/asthma/pdfs/snapshot_060111.pdf [hereinafter ACN] (last visited Feb. 5, 2014).

[27] Krieger & Higgins, supra note 9, at 762.

[28] Jill Breysse, et al., Health Outcomes and Green Renovation of Affordable Housing, 126 Pub. Health Rep. 64 (1st Supp. 2011), available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072905/pdf/phr126s10064.pdf (last visited Feb. 5, 2014).

[29] Id. at 67-68.

[30] Joe Rojas-Burke, Trend Watch 2014: Housing as health care (January 7, 2014), available at http://healthjournalism.org/blog/2014/01/trend-watch-2014-housing-as-health-care/ (last visited February 5, 2014); Raven, supra note 13, at 1-2.

[31] Raven, supra note 13, at 1-10.

[32] Id.

[33] Id. at 1-2.

[34] Press Release, Office of the New York State Governor, Governor Cuomo Announces Medicaid Redesign Team Initiative to Provide Housing to 5,000 High-Need Individuals (Sept. 12, 2013), http://www.governor.ny.gov/press/09122013-medicaid-redesign-individual (last visited February 5, 2014).

[35] Id.

[36] Mary E. Larimer, et al., Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems, 301 JAMA 1349, 1349-1350 (2009), available at http://jama.jamanetwork.com/article.aspx?articleid=183666 (last visited Feb. 5, 2014).

[37] Id.

[38] Id. at 1350.

[39] Id.

[40] Carla K. Johnson, Illinois Medicaid pursues housing as health care (January 22, 2014), available at http://www.sfgate.com/news/article/Illinois-Medicaid-pursues-housing-as-health-care-5165192.php (last visited Feb. 5, 2014).

[41] Id.

[42] Rojas-Burke, supra note 32, at 2.

[43] Susan Lee, The 10th Decile Project: Impressive Early Outcomes in Los Angeles (September 25, 2013), available at http://www.csh.org/2013/09/the-10th-decile-project-impressive-early-outcomes-in-los-angeles/ (last visited Feb. 5, 2014).

[44] Id.

[45] Hood, supra note 1, at A316.

[46] U.S. Dep’t Housing and Urb. Dev., Advancing Healthy Housing A Strategy for Action, Healthy Homes Work Group 7 (2013), available at http://portal.hud.gov/hudportal/documents/huddoc?id=stratplan_final_11_13.pdf [hereinafter HUD Healthy Housing Strategy] (last visited Feb. 5, 2014).

[47] Id. at 16-17.

[48] Id.

[49] Id.

[50] James Krieger, et al., The Seattle-King County Healthy Homes Project: Implementation of a Comprehensive Approach to Improving Indoor Environmental Quality for Low-Income Children with Asthma, 110 Environmental Health Perspectives 311 (2nd Supp. 2002).

[51] Id.

[52] Hood, supra note 1, at A315.

[53] HUD Healthy Housing Strategy, supra note 48, at 14.

[54] Id.

[55] Press Release, MacArthur Foundation, MacArthur Awards $2.8 Million to Support Research on How Housing Matters (October 23, 2013), http://www.macfound.org/press/press-releases/macarthur-awards-28-million-support-research-how-housing-matters/ (last visited February 5, 2014).

[56] Id.

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