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COVID-19 has taught those of us working in affordable housing many lessons – one of the most important is that while New York City and State have been successful in creating and preserving thousands of affordable housing units over the past six years, we have to a large degree developed affordable housing in a silo. The underlying assumption in New York’s affordable housing development program has been that decent, quality housing that is affordable is sufficient to help people stabilize their lives and move ahead in society.
When one looks at the population which needs affordable housing, we know that the primary groups for which affordable housing is essential are those at the lower levels of the income scale and homeless people. These families and individuals need much more than a roof over their heads—they need a foundation under their feet. This foundation needs to include access to affordable health care and mental health services, job training and jobs, and social services. A first step in providing this foundation is to connect affordable housing with access to affordable health care. The coronavirus pandemic has shown that health care takes many forms : community-based health care, urgent care centers, walk-in clinics, hospitals, prescription medications both through traditional pharmacies and online services, and support teams that help individuals access this “system” and support individuals on their journey to better health.
This pandemic has underscored a critical weakness in how we plan and deliver affordable housing, namely that we haven’t developed effective partnerships between housing and healthcare providers. With the exception of supportive housing, few if any affordable housing projects ensure that all tenants be enrolled in a health care plan or connected with a primary care provider.
One barrier to making these connections has been the financing mechanisms used and the restrictions placed on how the funds can be used. Almost all of the affordable housing built in New York has been financed in large part with federal, state and city subsides: Low Income Housing Tax Credits, low interest loans and direct grants. In addition, many of the lowest-income tenants have rent subsidies from the government, such as HUD Section 8 vouchers, which have numerous limiting regulations. These subsidies were created by various levels of government to keep people housed; however, they have failed to recognize the importance of health care as an essential element in stabilizing people’s lives.
The Citizens Housing and Planning Council (CHPC) recently issued a policy paper which urges partnerships between affordable housing projects and hospitals and overhauling the city’s affordable housing lottery system to “make housing placement quicker and target affordable housing to meet our policy goals.” These are essential elements of creating a closer working relationship between health care and housing programs/resources.
In addition to the CHPC recommendations, we should look at existing resources, such as the large number of community-based healthcare providers, which focus more on prevention and are more accessible than hospitals and are poised to serve many more health care consumers than they currently have enrolled. Telemedicine extends their ability to reach underserved populations and provides increased opportunities to employ physician assistants and certified nurses.
Since most of the affordable housing in the city was and is being built with an investment of city and state funds, the city and state should consider making it a requirement that tenants who live in housing built using initial capital funding or ongoing rent subsidy support enroll with a primary healthcare provider. While a requirement such as this might be viewed as an invasion of privacy, the COVID-19 pandemic has demonstrated that without clear rules about how to prevent and contain the spread of disease, the whole society loses. This is a time when the “greater good” has to prevail or we will fail as a democratic society.
To support this expanded definition of quality housing, for tenants who are Medicaid eligible or in private health insurance plans, the cost would be covered by these plans. If the tenant (or prospective tenant) is uninsured, then Mayor de Blasio’s health care initiative to cover all New Yorkers could be accessed. We should also explore the willingness of major healthcare insurance systems to consider alternative healthcare and financing models for serving this population and supporting linkages between housing and health care providers.
New Yorkers can learn from some experiments in linking housing and health care, chiefly on the West Coast. Low Income Investment Fund’s (LIIF) report “Innovative Models in Health and Housing” provides case studies of local governments requiring linkages to healthcare providers before providing public financing for the affordable housing project. Some of the investments to ensure this health linkage have come from health care providers and insurers, such as Kaiser Permanente. This approach appears to have been effective in ensuring that the tenants have a health care provider at the outset of their tenancy. Many of these projects have not utilized Federal Low-Income Housing Tax Credits so that they did not run afoul of the LIHTC regulations that prohibit targeting certain populations, such as vulnerable populations. We need to be creative and develop financing approaches that don’t create these hurdles.
It is clear that we need to step back and look not just at how to finance and build affordable housing, but also at what low-income tenants need, particularly when it comes to healthcare, and how to provide these services in a comprehensive way from the beginning – not as an afterthought. The COVID 19 pandemic boldly underscores the need for housing and health to be coordinated at the front end of planning a development project and how to develop connections between health/housing programs in existing affordable housing developments.
Claire Altman is the president of Altman Strategies LLC.