Government Abstract
The COVID-19 pandemic and the following financial disruption have drawn extra consideration to longstanding points associated to housing and web entry and the way these points can impression well being. As the first supply of medical insurance for low-income populations, Medicaid covers a substantial share of individuals residing in houses which can be unaffordable, insufficient, or have restricted entry to the web. This transient examines housing adequacy, affordability, and web entry inside the houses of Medicaid enrollees utilizing information from the 2019 American Neighborhood Survey (previous to the COVID-19 pandemic) and assesses the restricted position that Medicaid can play in serving to to handle these challenges. Key findings embrace the next:
- Previous to the pandemic, in 2019, the bulk (57%) of Medicaid enrollees lived in a house that was insufficient (outlined as missing full plumbing or kitchen services or being overcrowded) or unaffordable (outlined as costing greater than 30% of family earnings), representing greater than one-third (36%) of all people in such houses nationally.
- We estimate that 13% of Medicaid enrollees didn’t have web entry of their dwelling previous to the pandemic, both by means of a pc or mobile phone, and a further 13% have web however with restricted pc entry of their houses (i.e., a smartphone was the one pc gadget within the dwelling or no pc gadget).
- The probability of Medicaid enrollees residing in insufficient or unaffordable houses have been particularly excessive for Native Hawaiian/Different Pacific Islander enrollees (70%) and Hispanic enrollees (67%), in addition to enrollees ages 18 and below (63%) and enrollees in metro areas (59%). Restricted web and pc entry was highest amongst American Indian/Alaska Native enrollees (43%), enrollees ages 65 and older (41%), and enrollees in non-metro areas (31%).
- Housing issues can negatively impression well being, however Medicaid performs a slim position in addressing these impacts. Medicaid has historically been capable of cowl sure non-clinical companies (together with housing-supports) by means of dwelling and community-based companies (HCBS) applications that help seniors and other people with disabilities. Past HCBS applications, states have restricted methods to leverage Medicaid for supporting entry to some housing helps, although Medicaid typically can not pay the direct prices of non-medical companies like lease and meals.
Whereas housing insecurity and different “social determinants” can have an effect on well being, insurance policies and applications outdoors of Medicaid – and the well being care sector typically – have the best impression on housing points among the many broader Medicaid inhabitants. Current laws has created or prolonged funding for a number of federal housing applications, which probably helped to stabilize housing for many individuals through the pandemic. Moreover. one of many key priorities within the proposed infrastructure invoice, the Infrastructure Funding and Jobs Act, would tackle some points associated to broadband entry in rural and low-income communities if signed into regulation. The Facilities for Illness Management and Prevention additionally applied a short lived eviction moratorium that probably contributed to higher housing stability for individuals behind on lease; nevertheless, the Supreme Court docket ended the moratorium in August 2021, requiring that Congress authorize the moratorium to proceed.
Why is housing essential for well being and the COVID-19 pandemic?
Housing can impression well being in a number of methods. For instance, housing adequacy might have a direct hyperlink to well being by means of its impact on entry to scrub water, potential to retailer meals or drugs, put together wholesome meals, or keep private hygiene. Issues with housing affordability (sometimes outlined as spending greater than 30% of family earnings on housing) can result in housing instability, overcrowding, and doubtlessly homelessness, all of which have been related to a spread of bodily and psychological situations. The causes of housing adequacy and affordability points are extraordinarily complicated differ vastly by locality, with variations typically reflecting state and native coverage choices, native financial situations, availability of federal housing help, and historic and ongoing practices of housing discrimination.
Households with decrease incomes typically have larger charges of residing in unaffordable housing and having severe housing deficiencies or restricted web entry. As the first supply of medical insurance protection for low-income populations, Medicaid covers many enrollees who’re probably experiencing housing points resembling these. Whereas Medicaid has historically been capable of cowl sure non-clinical companies (together with housing-supports) by means of dwelling and community-based companies (HCBS) applications that help seniors and other people with disabilities, Medicaid typically can not pay the direct prices of non-medical companies like housing and meals. Nonetheless, there are extra slim methods wherein Medicaid will be leveraged to assist help entry to some housing helps. Different applications outdoors of Medicaid – and the well being care sector – are designed to handle housing points for low-income populations. On the federal stage, for instance, applications such because the Low-Earnings Housing Tax Credit score Program, Housing Selection (Part 8) Voucher Program, and public housing are designed to enhance entry to inexpensive housing, though these applications have traditionally confronted a spread of distinctive challenges, together with underfunding, lengthy wait lists to obtain advantages, and challenges finding housing items in fascinating neighborhoods.
The COVID-19 pandemic has drawn extra consideration to housing points associated to affordability, high quality, and web entry at dwelling. For instance, information from the Census Bureau’s Family Pulse Survey estimate that, between September 1 and September 13, 2021 (the most recent information accessible), 14.6 million adults lived in households that have been behind on lease or mortgage funds, and 4.5 million of those adults reported that they have been “very probably” or “considerably probably” to be evicted or expertise foreclosures within the subsequent two months. Furthermore, as individuals spend extra time in and round their houses through the pandemic, residing in protected, ample housing with full facilities has additionally grow to be more and more essential for private well being and social distancing. For instance, residing in a crowded family can doubtlessly enhance transmission of the coronavirus to different member of the family and restrict their potential to successfully quarantine. Equally, having web entry within the dwelling has grow to be a typical approach to obtain well being care and attend college, in addition to to work at home the place potential, whereas following social distancing pointers throughout a lot of the pandemic.
What do the information say about housing affordability, adequacy, and entry to web for Medicaid enrollees previous to the pandemic?
On this transient, we observe the definitions for incomplete plumbing services, incomplete kitchen services, overcrowding, and unaffordable housing as outlined by the U.S. Census Bureau’s ACS 2019 Topic Definitions. Notably, this transient’s definition of “insufficient housing” (outlined under) differs from the U.S. Division of Housing and City Growth’s (HUD’s) definition captured by means of the American Housing Survey (AHS). We didn’t use AHS information as a result of the survey doesn’t seize medical insurance data for respondents.
Insufficient housing is both (1) a housing unit missing full plumbing and/or kitchen services as reported within the ACS or (2) “overcrowded” housing items. Within the ACS, full plumbing and kitchen services embrace cold and hot working water, a bathe or bathtub, a sink with a faucet, a stovetop or vary, and a fridge. Overcrowded housing items are these with greater than 1 occupant per room (not counting bogs, porches, balconies, hallways, or unfinished basements, and so forth.).
Unaffordable housing is outlined as paying greater than 30% of family earnings on both (1) gross lease (contract lease plus most utilities) or (2) proprietor prices (mortgage funds, most utilities, actual property taxes, some insurance coverage protection, condominium charges, deeds of belief, and contracts to buy). Housing items with zero or destructive earnings are thought of to dwell in unaffordable housing, whereas housing items who don’t pay money lease are assumed to dwell in inexpensive housing.
Web entry consists of people residing in houses that obtain web companies by means of web service suppliers or by means of a mobile phone firm, whether or not or not the family pays for web companies.
Restricted pc entry consists of people residing in houses that both (1) shouldn’t have a pc or (2) the one means to entry the web is with a smartphone (versus having a desktop, laptop computer, pill, or one other pc gadget accessible within the dwelling, generally referred to as “smartphone dependent”). We solely report restricted pc entry for housing items with web.
Even earlier than the pandemic, the vast majority of Medicaid enrollees (57%) lived in insufficient or unaffordable housing, vastly exceeding the speed of the U.S. inhabitants total (31%). In 2019, previous to the pandemic, practically half (47%) of Medicaid enrollees lived in housing that was unaffordable, and 17% lived in crowded housing, each of which exceeded the nationwide common (26% and seven%, respectively). Few Medicaid enrollees (1%) dwell in houses with incomplete plumbing or kitchen services, much like the nationwide common. Roughly one in 13 (8%) Medicaid enrollees dwell in a house that has two or all three of those situations, exceeding the nationwide price of three%. General, there are roughly 99 million people who dwell in insufficient or unaffordable housing throughout the U.S., and greater than one-third (36% or 36 million) are enrolled in Medicaid. Though these information present nationwide charges, different analysis reveals that the share of individuals residing in unaffordable housing varies vastly throughout localities.
The share of Medicaid enrollees residing in houses which can be insufficient or unaffordable diverse throughout race/ethnicity in 2019. For instance, seven in ten (70%) Native Hawaiian/Different Pacific Islander (NHOPI) enrollees dwell in a house with at the very least one of many chosen housing situations for insufficient or unaffordable housing, and two in ten (20%) dwell in houses with two or all three of the chosen housing situations. Moreover, American Indian and Alaska Native (AIAN) enrollees have the best charges of incomplete plumbing or kitchen services, and AIAN enrollees have been among the many solely demographic group we examined to exceed 2% on this measure. Typically, the shares of individuals of coloration enrolled in Medicaid exceeded the charges amongst White enrollees residing in overcrowded and unaffordable housing.
Amongst totally different age teams, kids enrolled in Medicaid (or CHIP) have been the most definitely to dwell in insufficient or unaffordable housing (63%). This sample might replicate having a number of kids (relative to the variety of adults) inside an insufficient or unaffordable housing unit. Enrollees in metro areas additionally skilled larger charges of insufficient or unaffordable housing in comparison with enrollees in non-metro areas, and the distinction was particularly giant for unaffordable housing (49% vs. 38%). When intercourse, though the variations have been statistically important on the p < .05 stage (Appendix Desk 1), charges of unaffordable housing have been typically related for men and women throughout all measures. For instance, 56% of male enrollees and 58% of feminine enrollees lived in a house with any situation associated to insufficient or inexpensive housing.
In 2019, roughly one in 4 Medicaid enrollees lived in a house with out web or with restricted pc entry. An estimated 13% of Medicaid enrollees don’t have any web entry of their dwelling, both by means of a pc or a mobile phone. An analogous share (13%) of Medicaid enrollees have web entry, however they both lack any kind of pc gadget (1%) or the one pc within the house is a smartphone (12%), limiting the quantity of duties and actions that may be accomplished on-line. Earlier KFF analysis confirmed Medicaid enrollees made up 32% of individuals throughout the U.S. with out web entry of their dwelling. When contemplating web entry along side restricted pc entry, Medicaid enrollees make up a barely bigger share. Of the 47 million people residing in houses with out web or with restricted pc entry, 16 million (34%) are enrolled in Medicaid.
Main as much as the pandemic, web entry and the provision of computer systems within the houses of Medicaid enrollees varies by race/ethnicity, age, intercourse, and metro/non-metro areas in 2019. Greater than 4 in ten (43%) AIAN enrollees had restricted web or pc entry, together with 27% who had no web entry of their houses. Black individuals additionally had among the many highest charges of restricted web or pc entry (34%), together with 16% with no web entry of their houses. Enrollees who’re ages 65 and older additionally had excessive charges, with 41% dealing with web or pc limitations, with practically one-third (30%) missing web of their houses. Non-metro areas additionally had excessive charges of web or pc limitations (31%), with 17% of enrollees missing entry to the web of their houses. Conversely, there was little distinction between female and male enrollees, with 25% and 26% of enrollees reporting restricted web or pc entry, respectively, though variations have been statistically important on the p < .05 stage (Appendix Desk 2).
What are the coverage levers for Medicaid to handle housing challenges?
State Medicaid applications can add sure non-clinical companies, together with housing helps, into dwelling and community-based companies (HCBS) applications to help seniors and other people with disabilities. CMS launched steerage in January 2021 to focus on alternatives to handle SDOH in Medicaid and CHIP. That steerage specified that federal Medicaid matching funds can be found for sure housing-related companies and helps that promote well being and neighborhood integration. These companies are typically accessible for youngsters with particular well being care wants, adults with disabilities, or seniors. Housing-related companies in HCBS applications may embrace: dwelling accessibility modifications (resembling wheelchair ramps or seize bars within the bathe); one-time neighborhood transition prices (resembling fee of a safety deposit, utility activation charges, and important family furnishings); and housing and tenancy helps (resembling assist with a housing search, figuring out adequacy of public transit, and helping in arranging for and supporting move-in); and tenancy sustaining companies (training or coaching on the position, rights, and duties of the tenant and landlord).
Past HCBS authorities, Medicaid has restricted potential to handle housing associated challenges for many enrollees. Primarily, Medicaid can assist to finance many well being and behavioral well being companies that may be vital in serving to individuals get hold of and keep housing. Medicaid can play an essential position in coordinating medical and non-medical companies and act as a bridge to social companies (e.g., case administration). States also can require managed care organizations to display for and supply referrals for social companies. States and plans also can construct partnerships throughout sectors to fulfill fundamental wants for enrollees – together with constructing linkages with supportive housing applications. Plans can also have further flexibilities to offer sure non-medical companies outdoors of contractually-covered companies (by means of what are often called “in-lieu-of” and “value-added” companies), though state Medicaid companies should approve which companies will be counted towards the capitation price paid to the plans. Whereas there are examples of well being plans and supplier methods investing in inexpensive housing applications (e.g., neighborhood funding or reinvestment necessities), these applications are sometimes arduous to scale or replicate broadly given points with housing prices and provide. Additional, screening and referral might not assist to handle housing challenges for Medicaid enrollees. Whereas Medicaid is an entitlement, inexpensive housing/rental help applications are typically capped and never accessible to all who qualify and want help.
Some states have used or are searching for approval to make use of Medicaid waivers to handle housing points for top want populations. For instance, in October 2018, CMS authorised North Carolina’s Part 1115 waiver which gives financing for a brand new pilot program, referred to as “Wholesome Alternatives Pilots,” to cowl non-medical companies that will embrace housing modifications (resembling carpet substitute and air conditioner restore to enhance a baby’s uncontrolled bronchial asthma management). To be eligible, enrollees should have at the very least one bodily or behavioral well being danger issue and at the very least one social danger issue (together with homelessness or housing insecurity). Pilot companies in North Carolina are anticipated to start within the Spring of 2022.
Arizona is presently requesting Part 1115 waiver approval to boost and increase housing companies and helps for enrollees who’re homeless or susceptible to turning into homeless and now have one other high-risk situation. Companies may embrace short-term, transitional housing (as much as 18 months) for people leaving homelessness or institutional settings; neighborhood transitional companies to offer monetary help for non-recurring move-in bills to help members in acquiring housing; eviction prevention companies, which can embrace fee of again lease, utility payments; dwelling modification companies or pre-tenancy and tenancy help companies. The waiver software remains to be pending however, if authorised, might be licensed within the fall of 2021.
In 2016, California started its “Entire Particular person Care” (WPC) pilot program licensed below Part 1115 waiver authority. This program operates in sure counties and targets high-risk, high-utilizing populations together with people experiencing or susceptible to homelessness. Widespread companies supplied by WPC pilots embrace housing-related companies resembling housing navigation, tenancy help, and landlord incentives. In June 2021, California requested CMS approval to sundown Part 1115 authority for the WPC pilot program, indicating plans to as a substitute increase the WPC strategy statewide by way of the state’s managed care supply system (with the introduction of enhanced care administration statewide and a brand new menu of state-approved in-lieu-of companies). This Part 1115 request additionally included federal funding to help capability constructing for this expanded initiative, referred to as “California Advancing and Innovating Medi-Cal” (CalAIM). California intends to implement CalAIM in January 2022.
Along with secure and ample housing, lack of web and computer systems have implications to obtain Medicaid companies by way of telehealth. Previous to the pandemic, state protection of telehealth in Medicaid diverse extensively. States took many components into consideration when establishing non permanent insurance policies through the pandemic to extend telehealth protection and entry, together with price range limitations, affected person and supplier acceptance, scope of apply legal guidelines, operational/expertise challenges and prices for suppliers and sufferers, proof of high quality and effectiveness for companies delivered by way of telehealth, and issues involving potential for fraud and abuse, amongst others. Though state protection of telehealth in Medicaid nonetheless varies extensively, many states vastly expanded the usage of telehealth in response to the COVID-19 disaster. Nonetheless, telehealth requires expertise and web entry that may be a problem for a lot of Medicaid enrollees. Whereas state Medicaid applications can increase the usage of telehealth, Medicaid funds can not tackle broader problems with web and pc entry.
Trying Forward
A rising physique of literature reveals that bettering housing high quality, affordability, and web entry is prime step to bettering particular person and inhabitants well being. As the first supply of medical insurance for low-income Individuals, Medicaid covers a substantial share of individuals residing in houses which can be insufficient, unaffordable, or have restricted entry to the web. Though Medicaid has a restricted position in serving to to handle these points for the broader Medicaid inhabitants, states have some current coverage levers and might use partnerships to offer some entry to housing companies and helps for slim subsets of enrollees.
In response to the pandemic, the federal authorities has taken a number of steps to stabilize housing for low-income households through the pandemic. For instance, The American Rescue Plan Act created or elevated funding for a number of federal housing applications, together with a rise in funding for the Emergency Rental Help (ERA) program to over $45 billion, which is a program administered by means of the states to assist renters pay late lease and utilities. It’s unclear whether or not ERA funds might be sufficient to cowl low-income renters’ late lease and utilities, as estimates of want differ extensively. Moreover, information from the Census Bureau’s Family Pulse Survey estimate that solely 2.8 million of the 8.2 million adults behind on lease had utilized for rental help by means of the state or native authorities, and the bulk have been nonetheless awaiting a response (1.4 million) or have been denied (900,000) as of late August. The present infrastructure proposal being debated in Congress additionally incorporates provisions to increase broadband web entry for rural and low-income communities, in addition to funds for digital literacy coaching in order that people can use the web successfully for every day duties. Furthermore, the proposed infrastructure invoice consists of elevated funding for changing lead service traces, in further to different steps, to enhance entry to protected consuming water. Earlier within the pandemic, the Facilities for Illness Management and Prevention (CDC) issued a short lived eviction moratorium that prevented landlords from evicting tenants as a consequence of unpaid lease (though it didn’t cease lease, charges, penalties, or curiosity from accruing). Nonetheless, the Supreme Court docket ended the eviction moratorium in August 2021, earlier than it was set to run out, requiring that Congress authorize the moratorium to proceed. Housing and web points pose main challenges to Medicaid enrollees and low-income populations typically – and these points typically worsened through the pandemic. The breadth and scope of federal housing applications and helps will finally have implications for Medicaid enrollees’ dwelling lives and related well being dangers through the pandemic.
This transient analyzes information from the 2019 American Neighborhood Survey (ACS) 1-year file. The unit of study on this transient is the person, moderately than households or the housing unit, and we use the individual weights within the ACS information file. Family traits, resembling family earnings, housing prices, and web entry, are the identical for all members of the family. Nonetheless, particular person traits, such race, age, and intercourse, are reported in another way for every member of the family. For instance, kids and adults within the family could also be reported individually in our findings, in addition to people in a family comprised of individuals figuring out with totally different race/ethnicities or sexes. Our findings will differ from different research the place the unit of study is the housing unit, which frequently report demographics based mostly on the householder (moderately than people in the home) and use housing unit weights within the ACS information file. All variations between Medicaid enrollees which can be talked about within the transient are important on the p < .05 stage, that are additionally proven in appendix tables.
Our evaluation excluded individuals residing in noninstitutional group quarters resembling school dormitories and residential remedy facilities as a result of the ACS doesn’t acquire information on plumbing, kitchen services, or web entry for in these housing items. Notably, nevertheless, our evaluation included each renters and homeowners. As famous within the definitions field within the transient, the definitions for incomplete plumbing services, incomplete kitchen services, overcrowding, and unaffordable housing are outlined by the U.S. Census Bureau’s ACS 2019 Topic Definitions. For unaffordable housing, we assumed that individuals with zero or destructive earnings lived in unaffordable housing, and those that don’t pay money lease (however have optimistic family earnings) are assumed to dwell in inexpensive housing. Metro and non-metro classifications are usually not a part of the ACS microdata information. Metro and non-metro areas are outlined by the USDA Financial Analysis Service. For this evaluation, metro areas have been outlined as public use microdata areas (PUMAs) the place greater than 50% of the 2010 inhabitants lived in metro areas, and the remaining PUMAs have been outlined as non-metro areas. We obtained a crosswalk of metro/non-metro populations for every PUMA from a private communication with USDA employees (June 17, 2021), which we joined with the ACS information. Our evaluation used the identical strategies described additional in a one other Peterson-KFF Well being System Tracker transient. |