Hard to get clean when you are living on the streets. The Supportive Housing with that model. Any of us can go home tonight and have a drink and is perfectly all right to do in our homes. Its an opportunity as well. We need to work with people where they are in the stabilizing and for housing so we have got that stability so people have a place for medication they have a place to put an appointment cards and keep track of time and a stable place where we can visit them. Our outreach workers cant find them when they should drown on the streets and in camas change a lot. We need to think about our recent porting housing in this way . A wide range of teambased services, when you combine the stability of housing with Health Care Services a wide range of the things listed here we can really help people be stable in their housing. This is mainstream right now for seniors and people with disabilities. My grandmother gets meals delivered to her and she can having have them come here to help her with her bathing helper keeping the house clean. All of these things are things we take for granted with home and communitybased services. Think about extending that into this population so we are supporting the housing and the Services People need in keeping with that same theme. I want to talk about relapse as part of recovery. These are the things we need to expect. Recovery and Mental Health and addiction doesnt look like luck and white. It looks like a struggle and where we have people in zerotolerance or recovery oriented housing even doubt one slipup jeopardizes your Housing Incorporated you could be back on the streets. Its important we are able to work with people and adjust services as they need that. Theres no requirement for sobriety and the services are voluntary but what we have found is people are excited when they get into a unit that so many things look possible that didnt before. We have been evaluating the effect of Supportive Housing in the peerreviewed literature for 25 years and consistently what we find his housing improves health and improves Health Outcomes and it lowers the total cost of health care. I think this is where we need to be in rethinking housing because we are so focused on cost understandably so but we need to think about where is it that we the may king and roads and partnerships. We can read the slide. Their consistent findings along these issues but we want to focus on how is it that bringing these two together is bringing out the things that we need . There is a lot of opportunity at the federal state and local levels that are important to be aware of. All states are working on strategies to end homelessness and improve health and also looking at determinants of health with one of the things i think is important particularly in through member is we need federal support for the housing piece that goes along making this work. My colleagues will talk about what they are seeing in their sectors but again the cuts required by sequestration if we dont have the housing supports to put people and no amount of our Health Care Services are going to make this work well. What we need is to come together. Another thing i would recommend us to take away point for all of you that are health staffers and all of you who are housing staffers get to know each other. You have a lot in common and a a lot of times we are not working to get at the federal level like we are asking people to do with the local level so those would be a couple of things i would recommend. What we are doing is trying to build that ridge between health and housing and his Health Care Providers we are in a rapidly changing environment to medicaid is one of the rapidly changing areas. We are focused on outcomes that we also need to be focused on horrible people and getting them what they need but nothing works well as a Health Care Provider when people are living on the streets. We want to reorient health care intervention that we really need and my colleague from hud will talk about hud is focused on building this bridge from housing to health that is an illustration of working together to make this model work and achieve the outcomes we wish to achieve. I want to point out that colleague if anyone is interested in learning more can take your card and get back to you but really appreciate your being here today. Thank you. Thank you. Well turn to jennifer ho. Thank you barbara. I am jennifer ho the hud secretary Senior Adviser on housing and services. I like to joke. And the one person that hud that those difference between the care and medicaid everyday. You know what im talking about, dont you . My background isnt the first 10 years of my career and managed care largely medicare and Medicaid Managed Care and it was in that work that i was first brought to the table to consider their relationship between homelessness and health in the impact that they order passing would have on Health Outcomes but also spending. Ive been doing that ever since for the last 18 years. I want to assure you there is an unprecedented level of collaboration between hot and hhs not because thats my job but because it really is the case. Hud is talking to the center for medicaid almost every day and we are talking with folks at hrsa and folks at samhsa. We are talking to folks in the administration on children and families almost every day. I know it feels sometimes like housing and health care are miles apart and no one is talking pretty want to promise you in this administration there is an unprecedented level of collaboration. Theres a simple fact about how we invest in housing federal that Health Care People to my style because you operate in a mandatory budget and entitlement programs. Federal Housing Assistance is the only means tested benefit that is not entitlement. When someone becomes eligible for medicare or medicaid they get it. If you fill out an application you will get in line. When we asked congress to invest in more affordable for Supportive Housing they worry about the renewal burden, the fact that this increases our total legend in future years something i like to call pete keeping people in their homes. The conundrum is today medicaid could pay for, medicaid is a lot of financial incentives for there to be more affordable accessible in Supportive Housing in the budget environment is such that we are not doing what we know works and not doing anything at scale that matches thats why im excited to be here with you today because sure interest in housing could help create the consensus we need to make the investment that will matter. So thanks for being here and thanks for allowing me to be on this incredible panel. I will talk about how this plays out in three areas aging disability and homelessness. Americans are living longer and the aging ab boom is going to test our commitment to the relationship doing housing and health. Age is a great equalizer. As we grow older we are more likely to live alone have more Chronic Health conditions less mobility and we grow poorer. Sorry for that down over lunch. Studies project a number of older households eligible for rental assistance will increase by 2. 6 Million People between 2011 and 2030. Today at hud we provide rental assistance for 1. 2 million seniors. Thats one out of every three seniors who is income eligible. That means we would need 900,000 more subsidized Housing Units by 2030 just to keep up with one in three people who needed and are getting it. Yet we have not made significant investments in more hud assistance and housing for seniors for some time. Think about where you live today or where your parents or grandparents live. Less than 1 2 of 1 of existing housing is currently accessible to someone in a wheelchair. Only 5 is livable for someone who has mobility impairment and only 40 is modifiable. Most americans existing Housing Stock is not designed for them to age safely. Imagine a 20something Million People the age of 84 and they can return to their homes or they dont fall but they just cant afford where they live. Where will they go . How do we have a strategy for aging in place that people will not be able to a wart or navigate the place of that call home today . The Health Care System i would argue has a huge stake in meeting the affordability and accessibility needs of an aging america if there is not consensus that this is an investment of federal government should be making. A lot of work we are doing his rant disability and institutionalization. Largely through new and improved program called section 811 Supportive Housing or individuals with disabilities. 811 forces partnerships between the state finance agency and the state medicaid agency. In some places like colorado the partnership as they are pretty leverages sources of funding creates integrated housing were medicaid provides communitybased services in a unit that is a deep breath substitute your hud. We have rounds of funding. 35 states have this money and the last around 30,180,000,000 for 4511 units. A drop in the bucket but at least we have made investments. The Health Care System i would argue has a huge stake in creating more integrated Housing Options for individuals with disabilities who would otherwise be an institutional setting yet there is not consensus this is an investment that federal norman should be making a cheer. Each year. H year. I came to washington to help with chronic homelessness. I appreciate barbara covering all the chronic arguments. I want to add a couple things. First, the president s budget request last year and this year have included investments to create a sufficient supply of Supportive Housing to end chronic homelessness in america. In 2016 he requested 255 million to hundred 55 million to create 25500 Additional Units of Supportive Housing but leverage the creation of many more. So Supportive Housing is proven to help homelessness people. It improves health and reduces er visits. The Healthcare System, i would argue, has a huge stake in our creating a sufficient supply of Supportive Housing to end homelessness in america. Yet there is not consensus that this is an investment the federal government should be making. Second we are learning something in the work that we are doing with the veterans affairs. Here there has been confessing this consensus. We have had a one third reduction in homelessness between 2010 and 2013 and we are on a path to end their homelessness. Imagine if we could get this aligned with medicaid to repeat this with individuals with disabilities who have lived on our streets and in our shelters for years. My my focus has been to work with cns to find ways we can better align housing and medicaid. Im really thrilled with the Housing Related Services report they just published. There there is a link to it in the documents and all of the information you have in your packet. Im increasingly meeting state medicaid directors who understand that if they are going to achieve the goals of health reform, bend the curve, they will need to deal with housing and homelessness and they have a new best friend who is a house. This new document brings clarity to something that was pretty unclear. If housing is over here and health care is over here, there is a a whole lot in the middle. What cannot medicaid do to pay for for whom and when . If medicaid were were paying for all the services in support of housing that it can pay for, we would have better Health Outcomes for seniors, individuals with disabilities and we could end chronic homelessness. I believe if medicaid became a major player in Supportive Housing we could build the consensus needed to make the level of investments necessary to help seniors age in a home they can navigate and afford. Individuals with disabilities who have a right to to live in an integrated setting have more choices of where to live and there would be more Housing Available because they value and service partnership. Let me finish right started. The conundrum is, hud pays for a lot of services in housing that medicaid could pay for. Medicaid has a lot of financial incentive for there to be a lot more affordable, accessible and Supportive Housing and the budget environment is such that were not going to do what we know works and were not doing anything at scale. That is why i am excited to be here. Your interest in housing, your understanding of the relationship between housing and health, your advocacy for Supportive Housing for older americans, individuals with disabilities, including folks with disabilities living on the street, could help create the consensus we need to make the investments we need to make the investments that will matter. Thank you. Thank you jennifer. Before we we go on, if i can, lets clarify, you are talking about the kind of services that medicaid could pay for in Supportive Housing. I wonder if if you could be a little more explicit and say a couple words about what is stopping that from happening now. For example, in our homeless assistance programs we spent over 400 million per year on services. We only need 265 million to create more Supportive Housing to end chronic homelessness but were spending 400 million Million Dollars a year on services. Thats everything for things medicaid cant pay for but a lot of that is exactly the type of and reach, engagement, assistance that is described in the new housing related bulletin. The the biggest barrier is that states dont know what will be approved and what to ask for, everybody is afraid that what we are saying is medicaid should pay for housing. Thats not what were saying. Were saying medicaid should pay for health and these services that we are doing naturally now, keep grandma out of the nursing home or keep someone not of an institution, we just need to extend that. Were also paying for services for Service Coordinators in our senior housing, we pay for Service Corps nadirs and Public Housing and a lot of that Service Coordination is really Health System navigation and wellness activity so we dont have an ambulance pulling up every night and we can keep people in their homes longer. Okay, very good. Letsxd turn to gretchen from colorado. Thank you all for inviting colorado to participate in this very interesting conversation. As jennifer mention, colorado is working very diligently on this issue and its a privilege to be able to share with you some of the things we are doing. First i would like to provide a little context. Everything we do within our State Government at this point in time is really driven by our governors platform for health. That is the state of health. Our very bold goal is to be the Healthiest State in the nation. We take that goal very seriously not only because we have a great place to leave live, but we have Health Disparity in our community that are holding us back. We are we are working very hard to move those forward. It really is around this interconnected nature of health for our economic growth, social conditions, for Health Care System to work more effectively than it does today, to help healthier people and to create a healthier bid business environment. We believe when we look at those things holistically we are able to put the right services, support and finances in place. If anyone anyone is familiar with the triple aim, the best care for the best value and that is our translation of that very important concept. That is a commitment to starting with prevention and wellness, which is a lot of what we talk about when we talk about the issues were discussing today. The nature of the Healthcare System needing Health Insurance most of time to access the services you need and making sure we have the capacity within our Healthcare System to meet the needs of the residents of colorado. We invest a lot of money in across the nation in our Healthcare System and we have some opportunities to get better value for the dollars we invest. Some of that requires infrastructure investments, things like healthcare capacity, primary primary care medical homes, having integrated care between various types of healthcare so we dont have one person with one body going to three different places to get their healthcare needs met. It is our highlevel, holistic view of colorado and how were looking to move our agenda forward. We did expand medicaid in colorado. One of those buckets, as you remember, is a coverage remember, is a coverage and capacity area of focus. Prior to september, or in september 2013, prior to the first day of enrollment in the Affordable Care act we had many residents and now we are up to 1. 2 million covered by medicaid. You can see in the breakdown there is a dive