Administering Housing Law as Health Care: Attorneys as Healthcare Providers
By
By
Frank Griffin, M.D., J.D.
Housing stability and quality play a critical role in human health and healthcare outcomes.[1] Properly applied housing law, therefore, can provide an important dose of medicine to address health ailments that afflict many vulnerable Americans.[2] This paper explores ways that housing attorneys, largely overlooked in the current system, should be recognized as important healthcare providers to improve Americans’ health, improve healthcare treatment outcomes, and lower overall healthcare spending in the United States.
Housing stability is an important ingredient required for achieving good health.[3] First, lack of housing, or homelessness, is particularly devastating to health.[4] Over 550,000 Americans are homeless every day, with many negative health impacts addressed below.[5] Second, housing instability can have dramatic health consequences. Over 38 million households are housing “cost-burdened”—spending over 30% of their income on housing—leaving limited funds to address health needs, basic necessities, and medical care.[6] Healthy housing not only provides shelter but also ensures enough money is left over to provide for food, utilities, medical care, and other items necessary for good health. [7] Eviction also causes housing instability.[8] The rising cost of rent is rapidly outpacing most individuals’ income growth.[9] Eviction affects approximately 6,300 people every day—leading to damaged credit and severed social ties that can further impact health in addition to potential homelessness.[10]
Housing quality is another important ingredient necessary for good health.[11] Over 30 million housing units may have “significant physical or health hazards” with many in violation of current laws, and these violations disproportionately affect people with disabilities and chronic medical conditions—further adding to the costs of their medical care.[12] Serious health issues like asthma, respiratory infections, lead poisoning, and others can be caused by “[e]xposure to poor indoor air quality, mold, lead, and rodent and cockroach infestations.”[13] Asthma, caused by dampness and mold exposure in homes, alone, affects over 4.6 million people and costs over $3.5 billion in national healthcare costs annually.[14] Housing quality issues like “structural hazards and unsafe conditions” such as those found in dilapidated buildings with leaking roofs, heating or cooling problems, electrical deficiencies, plumbing problems, pest infestations, etc. can also lead to physical injuries, mental stress, and illness resulting in poor health and increased medical expenses.[15] Discrimination also plays a role in housing quality with many people facing “housing discrimination based on disability,” which limits the availability of quality housing among some vulnerable populations.[16]
Housing attorneys functioning as healthcare providers in the American healthcare system can help address a core need for human health—a stable and safe home. This paper explores (1) the far-reaching effects of housing on health, (2) how neglecting housing needs is costing the American healthcare system, (3) ways attorneys can help address this important issue, and (4) how the healthcare system can better incorporate legal services.
Housing directly affects health and health outcomes.[17] Failure to address housing issues negatively impacts hospitals’ financial and reputational performance.[18]
Housing is a basic human need that affects health.[19] Homelessness, unstable housing, substandard housing, and inaccessible housing all have significant effects on health and healthcare outcomes.[20]
First, homelessness negatively impacts health and healthcare outcomes in a significant portion of the population.[21] Without a home, sick people generally cannot take care of their basic health needs—leading to further health complications and costs.[22] Homeless people often experience the “extremes of elements (e.g., freezing temperatures, extreme heat, sun exposure, and rain)” that can have significant effects on medical conditions.[23] Chronic medical conditions in the homeless are worsened due to “lack places to wash, urinate, and defecate, . . . lack [of]. . . refrigeration (for food and medications) or cooking facilities,” “lack of a place to lie without undue pressure on the skin,” etc.[24] Homelessness is associated with a higher rate of chronic medical conditions (e.g., high blood pressure, diabetes, HIV/AIDS) and complications from those conditions.[25] Besides, homeless people are more likely to be “expos[ed] to violence,” “victimize[d],” or both, leading to a higher risk for “serious traumatic injuries.”[26] Further, homeless people may be at higher risk for psychiatric problems such as anxiety and depression due to “lack of a place for social interaction,” “lack of privacy,” lack of a place to “host[] family members or visitors.”[27] One expert observed, “Providing a house for someone who’s struggling through health issues is one of the first and foremost aspects of getting them back to that place where they’re able to participate in society productively.”[28] The program’s director said, “[T]he stability of having housing allows people the mind space to begin to think about managing their lives,” so that they can see their doctors regularly, take their medications, and use other preventive health measures.[29] Additionally, they can apply for social security benefits or look for a job—both of which can positively impact health and diminish healthcare costs.[30]
Communication with healthcare providers is also compromised because homeless individuals lack a stable address to receive (1) mail, (2) notice of doctors’ appointments or test results, (3) private healthcare services like physical therapy, and (4) other items necessary for good health.[31] Thus, healthcare costs for homeless individuals are high “due to the high incidence of chronic illness and lack of regular care.”[32] As a result of all of the above factors, the median life expectancy of chronically homeless individuals is “nearly 30 years shorter than the average US life expectancy,” and homeless adults have over triple the risk of death compared to the general population.[33] Even with shorter lives, the overall excessive associated healthcare costs can negatively impact the entire system as discussed below due to overutilization of unnecessary care.[34]
Second, unstable housing impacts health and healthcare outcomes.[35] Lack of affordability, eviction, unexpected illness, etc can all result in housing instability. Housing is considered unaffordable when “it costs more than 30 percent of a household’s income.”[36] Approximately 23 million Americans live in households that pay “more than half their income for rent, often forgoing necessities, like food or medicine, to keep a roof over their heads.”[37] Forgoing necessities like food and medicine can have serious health impacts, especially on vulnerable populations; of those 23 million people in households paying over half their income for housing, 32% were children, 18% were disabled, and 12% were seniors.[38] In addition to obvious health risks associated with skipping food (e.g., malnutrition) and medication (e.g., medical complications from noncompliance), unstable housing has been linked not only to depression, anxiety, hypertension, and kidney disease among adults, but also to “diminished functioning” and increased risk of hospitalization among children.[39]
Third, substandard housing impacts health and healthcare outcomes.[40] Because people—especially vulnerable populations like the elderly, disabled, and children of low-income families—usually spend more time in their homes than other locations, substandard housing can obviously lead to health issues.[41] Research shows household triggers in substandard housing like “poor insulation, . . . cockroach and rodent infestation, dust mites, hyper- and hypothermia, . . . and dangerous levels of lead in soil and household paint” are associated with diseases like “asthma, neurological damage, malnutrition, stunted growth, accidents, and injury.” [42] Further, substandard housing can worsen ailments like respiratory disease, neurological disorders, psychological and behavioral dysfunction leading to costly hospital readmissions.[43] Further, health conditions like asthma, developmental delay, injury, infectious diseases, behavioral pathology, and elevated lead levels have been connected to substandard housing.[44] Similarly, anxiety and depression have been linked to substandard living conditions like “inadequate heat, dampness, noise, and disrepair.”[45]
Substandard housing can also be related to overcrowding, lack of utilities—like running water, heat, and air conditioning—or both.[46] Overcrowding and poor-quality housing have been associated with poor mental health, heart disease, and developmental delay.[47] Moreover, overcrowding “negatively affects children’s ability to cope with stress, maintain healthy social relationships, and sleep.”[48]
Similarly, lack of utilities can create health issues related to substandard living conditions.[49] According to the Centers for Disease Control and Prevention (CDC), “basic water and sanitation services are important to overall health” with “in-home running water and flush toilets” helping to promote health and reduce “the spread of infectious diseases.”[50] Individuals without running water are at an increased risk for respiratory illnesses, skin infections, severe bacterial infections (including sepsis and meningitis), and dental cavities.[51] Likewise, heated homes are important. Excessively cold homes are associated with increased risks of heart attacks, pneumonia, social isolation, mental illness, insomnia, stress, and even death,[52] especially among, the elderly, the disabled, children, and people with chronic health conditions.[53] Further, cold housing is associated with common colds and flu, as well as exacerbation of arthritis, which also likely leads to expensive emergency department (ED) visits and hospital admissions.[54] Also, air conditioning is important. When temperatures reach over ninety degrees, vulnerable people (e.g., the elderly and those with pre-existing medical conditions) without air conditioning are more likely to die or get sick—ending up being readmitted to the hospital or emergency room.[55]
Finally, inaccessible housing for people with disabilities affects health and healthcare outcomes.[56] Accessibility barriers like stairs without stairlifts, absence of curb cuts with handicap accessible parking, narrow door widths and halls, inaccessible kitchens and bathrooms, and other barriers create predictable health problems and outcomes.[57] Examples of accessibility-related health issues include (1) inaccessible kitchens limiting meal options causing malnutrition, (2) inaccessible bathrooms limiting personal hygiene causing infection, and (3) lack of curb cuts or necessity of stair use causing falls.[58] Vulnerable people like those with disabilities who have recently experienced hospitalization are particularly affected by inaccessible housing.[59] Readmission to the hospital is more common among individuals with disabilities.[60] Patients with new disabilities affecting activities of daily living are particularly likely to be readmitted, and researchers have recommended that those patients’ “functional needs after discharge should be carefully evaluated and addressed” before sending them home.[61]
What if hospitals routinely failed to deliver basic widely recognized healthcare needs—like prescriptions for medications, crutches, or instructions for medical follow-up—upon discharging the patient to the street? It seems likely that those patients would routinely bounce back to the hospital with the same or worse medical problem leading to unnecessary hospital costs, poor hospital quality measures under government programs, and diminished community reputation. Yet, housing (i.e., a safe and stable place to live upon hospital discharge) is a basic health need as noted above and is frequently overlooked as a medical issue when patients go home from the hospital.[62] Hospitals and the American healthcare system have much to gain by addressing patients’ housing needs prior to hospital discharge—including decreasing costly inefficiencies, reducing hospital financial penalties, and improving hospitals’ community reputation.
First, hospital inefficiencies can be improved by addressing housing needs prior to hospital discharge, which can help hospitals’ financial bottom lines and reduce overall healthcare costs.[63] As one researcher noted, “Encouraging hospitals to work with community partners for the purpose of addressing the housing needs of their patients is consistent with [the goal of decreasing unnecessary hospital utilization].”[64] Homeless individuals “have longer hospitalizations for the same illnesses as housed persons, often because it is simply neither safe nor humane to discharge them to the street when they are still recuperating from the condition that caused them to be hospitalized, even if they are no longer acutely ill.”[65] These longer hospital stays make “the whole system function poorly.”[66] Hospitals are generally not reimbursed for these longer stays, which negatively impacts profitability.[67] Private and government payers pay hospitals based upon diagnosis instead of the number of days the patient spends in the hospital—so when patients stay longer than expected, hospitals often lose money.[68]
Likewise, inefficiencies associated with frequent return visits to hospitals’ emergency departments by homeless individuals cost hospitals (and the healthcare system) financially.[69] For example, the head of the Chicago’s University of Illinois emergency medicine department reported that some patients were “literally living at our hospital system,” visiting the hospital over 100 times in a year, and identified fifty patients costing their hospital system over $100,000 per year each.[70] Homeless people are “more likely than housed persons to use hospital emergency departments for health care and to be admitted to the hospital . . . because their conditions cannot be appropriately cared for without safe and secure housing.”[71] For “crisis-related care,” the ED is often homeless individuals’ only access point for care.[72] In many cases, hospitals are not reimbursed for these ED visits.[73]
Addressing recently discharged patients’ housing needs prior to hospital discharge could reduce these inefficiencies—especially because homeless people often do not self-identify, so routine analysis of the home environment as a healthcare need during hospitalization could have surprising results.[74]
Second, reimbursement for healthcare delivery is moving to “value-based care” that is “evolving from diagnosis and treatment to community-based patient engagement,” which can lead to significant financial penalties for specific hospitals if they fail to address patients’ housing issues.[75] Some of these “value-based” reimbursement programs financially penalize hospitals for “quality measures” that are directly affected by housing issues like hospital readmissions, hospital acquired conditions, and others.[76] For example, the Medicare Hospital Readmission Reduction Program (HRRP) was enacted because “[p]olicymakers view high rates of readmission as indicators of low-quality care during a hospital stay and poor care coordination” (which may include coordination of transitions to a safe and stable home environment),[77] and readmissions are much more expensive than initial admissions.[78] In 2011, “researchers estimate[ed] that unnecessary readmissions and complications led to $25–45 billion of wasteful spending.” [79] Policymakers estimate that for Medicare alone “reducing avoidable readmissions by 10% could achieve an annual savings of $1 billion or more.”[80]
Under the HRRP, hospitals are penalized for readmissions because Medicare reduces the hospital’s reimbursement rates for all Medicare patients by up to 3% if the particular hospital has “higher-than-expected readmission rates for a key set of conditions common in the Medicare population.”[81] Each hospital is assigned an annual penalty based upon the hospital’s rate of excess readmissions with higher readmission rates being associated with more severe penalties.[82]
Housing is an important component in reducing hospital readmissions. Homeless patients have “strikingly high 30-day hospital readmission rates,” so hospitals discharging homeless patients are more likely to be penalized under the HRRP.[83] Specifically, 70% of homeless hospitalized individuals either are readmitted to the hospital or return to the ED within thirty days of being discharged from the hospital.[84] Patients facing housing instability likewise have higher readmission risks, with a recent study of 93,606 hospital admissions showing a readmission risk of 25% for patients living in unstable housing.[85] Substandard housing also affects readmission risks. For example, approximately 4.6 million asthma patients’ symptoms are due to “dampness and mold exposure in their homes” costing a national total of around $3.5 billion in unnecessary annual costs—including readmissions.[86] Additional examples are discussed below in later sections of this paper.
The HRRP penalties are significant. Eighty percent of hospitals analyzed in one study were expected to face HRRP penalties in 2018 with the Centers for Medicare and Medicaid Services (CMS) withholding over $564 million in payments for an average penalty of approximately $219,199 per hospital penalized.[87] Hospitals treating higher proportions of poor individuals were almost twice as likely to be penalized compared to hospitals with the fewest proportions of poor patients, and housing issues likely contribute to these disparities.[88]
Another Medicare program that penalizes hospitals for failing to address housing issues is the Hospital Acquired Conditions Reduction Program (HACRP), which penalizes hospitals with the worst performance “a flat 1% of their total inpatient Medicare revenues.”[89] Homelessness and substandard housing likely make patients more susceptible to hospital-acquired conditions. For example, methicillin-resistant Staphylococcus aureus (MRSA) infections are often attributed to hospitals, and “homeless individuals face an elevated risk of methicillin-resistant Staphylococcus aureus infection.”[90] The risk of MRSA is increased in patients who were recently discharged, transient, or failed to shower daily—all of which can relate to housing.[91] Likewise, homeless people are more likely to be diabetic which increases their risk of surgical site infections by 70%.[92]
Above are just two examples, HRRP and HACRP, of value-based performance programs where hospitals are penalized for issues related to housing. As population-oriented, value-based quality measures continue to emerge, many more examples are likely to become apparent. Hospitals hoping to perform well under emerging payment models should embrace a community and population-based approach to patient discharge that includes helping patients address housing factors.
Third, hospitals may also gain market share where publicly reported “quality measures” reflect unaddressed housing issues, and “patients are increasingly able to make competitive marketplace decisions based upon” these measures.[93] Internet-savvy patients needing profitable elective surgeries and using other profitable hospital services may select their hospitals using data that is affected by housing, and hospitals that recognize and help address their patients’ housing needs are likely to perform better among market savvy patients than those that fail to do so.
Surprisingly, relatively few hospitals seem to recognize the potential benefits of addressing housing issues before discharge; “more than 72% of hospitals [are without] a dedicated budget to support population health initiatives,” and “[t]wo-thirds of hospital medical records [are without screening tools] for patients’ social and behavioral needs.”[94] Hospitals that begin to address these issues soon, therefore, have a unique opportunity to become leaders in the healthcare industry by reducing costly financial penalties, making their patient care more efficient, and gain market share.
Attorneys are the most knowledgeable professionals to administer the medication (i.e., federal and state housing laws) needed to treat many housing-related health ailments. Housing laws are complex and constantly changing, so attorney assistance for vulnerable patients at the time of hospital discharge could significantly impact patients’ success rate in obtaining needed assistance or enforcement of appropriate laws. Hospital- or health-system-based attorneys can serve as individual patient housing advocates using current laws and as community healthy housing policy advocates for future laws to help drive down the costs of unnecessary health care and improve the health of many patients. In this section, the ways that attorneys can specifically help decrease bad outcomes by treating homelessness and unstable housing are explored, along with a similar analysis regarding options to help with substandard and inaccessible housing.
Attorneys can play a key role in obtaining assistance for patients who might otherwise develop housing-related healthcare complications. In this section, a few specific examples will be explored including ways attorneys can (1) help patients obtain public housing or housing assistance, (2) help prevent eviction or foreclosure of patients’ recovering from medical issues, and (3) act as community advocates to help policymakers recognize housing needs and associated healthcare costs. This section provides only a few specific examples of ways attorneys can help and is not an all-inclusive list.
Attorneys can help vulnerable patients obtain available housing assistance. “Key barriers” obstructing qualified individuals’ use of federal resources include “lack of knowledge of the program’s existence,” “challenging application forms and procedures,” “complex and conflicting eligibility standards and requirements,” and “lack of staff dedicated to assist individuals in navigating” the application process. [95] Because of these barriers and potential attorney fees charged to patients, many qualified patients are unlikely to maximize the benefits of available laws, which leads to unnecessary health complications and costs.
The Department of Housing and Urban Development (HUD) administers funds under the United States Housing Act of 1937 (42 USC 1437) “to approximately 3,300 public housing agencies (PHAs) to house eligible low-income tenants,” and approximately 1 million public housing units are available today.[96] To qualify for public housing, individuals must have low income or be in low-income families—so they are unlikely to be able to afford to seek legal help on their own.[97] Specifically, “public housing residents must have incomes below 80% of the Area Median Income (AMI),” and almost two-thirds are considered “extremely low income” with incomes below 30% of AMI and with an average annual income of only $14,605. [98] In addition, public housing households are more likely to include seniors (31%) or people with disabilities (30%).[99] Given their extremely low incomes and the likelihood of being elderly or disabled and the complex nature of understanding and applying for public housing, it seems likely that many patients who end up homeless, in substandard housing, or in unstable housing might have qualified for public housing with some assistance from knowledgeable attorneys.
In addition to public housing, attorneys can help patients avoid poor health outcomes related to homelessness or unstable housing by helping them navigate the complexities necessary to obtain federal housing assistance using other programs. For example, Section 8 Housing Choice Vouchers may be available to help some patients find housing on the private market.[100] Once the local Public Housing Authority (PHA) approves a voucher for an applicant, the “applicant must find a unit on the private market.”[101] The unit owner then “enters into a Housing Assistance Payment Contract with the PHA and signs a lease with the tenant.” [102] “Rental units must meet minimum standards of health and safety, as determined by the PHA.”[103] “Each PHA has the discretion to establish local preferences to reflect the housing needs and priorities of its particular community.” [104] The “housing subsidy is paid to the landlord directly by the PHA on behalf of the [recipient],” and the recipient then “pays the difference between the actual rent charged by the landlord and the amount subsidized by the program.” [105] Therefore, the process involves knowledge of the program and a complicated application, as well as negotiation of a contract and signing of a lease—all of which an attorney could facilitate.[106]
Similarly, in other examples, attorneys can help decrease homelessness and unstable housing (1) by helping patients and communities with project-based housing options (e.g., project-based vouchers[107] and project-based rental assistance),[108] (2) by educating and facilitating patients in obtaining low-income housing tax credits through the Low Income Housing Tax Credit (LIHTC) program administered by the IRS,[109] and (3) by helping patients find other sources of federal, state, and private housing assistance.[110] Also, some states may provide additional funding opportunities.
Further, attorneys can help patients with filing complaints when public housing laws are not followed. Filing a complaint with HUD’s Office of Fair Housing and Equal Opportunity (FHEO) may include “residents or applicants of public housing, affordable housing, and voucher programs; . . . residents of homelessness programs; etc.”[111]
As another example, attorneys can help prevent homelessness by advocating for patients in eviction proceedings related to their medical conditions. Almost half of evicted families end up in homeless shelters in some cities.[112] Attorneys may help protect patients’ due process rights, which frequently are trampled as plaintiffs are often without an attorney in eviction proceedings.[113] For example, in Chicago, only 5% of tenants are represented by an attorney, and the average duration of eviction proceedings is less than two minutes.[114] Evicted tenants are digitally blackballed such that future landlords are unlikely to rent to evictees, and some find that “it is simply impossible to secure housing following an eviction proceeding and they are forced into homelessness.”[115] The power imbalance associated with pro se tenants versus lawyered landlords leads to situations where substandard housing goes unreported and leads to predictably poor health outcomes negatively impacting the entire healthcare system.[116]
The frequency of eviction proceedings is significant and likely has health impacts as patients become homeless or move into situations involving overcrowding, unstable housing, or substandard housing. For example, Chicago courts deal with 31,000 eviction cases annually, Milwaukee evicts over 16,000 people annually, and New York City courts handle up to 400 eviction decisions each day.[117] Given the large number of evictions, a significant number of patients recently discharged from the hospital and other health-vulnerable populations are likely affected.
Attorneys working inside the healthcare system can function as community patient advocates to help policymakers reach more educated decisions regarding the relationship between public healthcare costs and housing needs or funding. The overall costs to society of providing housing solutions for patients may be less than the costs associated with housing-related healthcare issues without such housing—meaning that policymakers may be able to reduce government spending (and taxes) by taking advantage of overlooked cost benefits of housing programs. For example, a recent RAND study revealed the societal value of housing support for “patients with complex medical and behavioral health issues who were experiencing homelessness.”[118] Researchers found that after receiving permanent supportive housing assistance, “the associated costs for public services consumed” in the following year “declined by close to 60%” from $38,146 to $15,358; and after taking into account the costs of the housing assistance, “RAND observed a 20-percent net cost savings, suggesting a potential cost benefit of the program.”[119] Specifically, patients’ “use of medical and mental health services, dropped substantially, including emergency room visits and inpatient care,” and “costs, correspondingly, also decreased” after enrollment in the supportive housing program.[120] The study found that patients visited the ED 1.64 fewer times per year and spent four fewer inpatient hospital days per year when they used a stepped approach from respite care to interim housing to permanent supportive housing.[121] In addition, the 890 participants “received less financial aid, were arrested less, spent fewer days in jail, and used fewer mental health services.”[122]
Attorneys working within the system could also advocate more specifically for local needs addressed by policymakers. For example, Public Housing Authorities (PHA) administer the Section 8 Housing Choice voucher program locally and have a “set number of vouchers they are authorized to use each year” based on funds appropriated annually by Congress.[123] Congress might be able to administer the funds more effectively with improved knowledge and understanding of the complex relationship between housing and health care if attorney advocates were more acutely involved in local health-related housing advocacy. Housing stability issues that affect readmission rates “are not evenly distributed between hospitals”—so this is particularly true at some vulnerable, often safety-net, hospitals.[124] For example, “advocacy to preserve units” for project-based rental assistance and preserve annually allocated funds for Section 8 Housing Choice vouchers is crucial for some hospitals. [125] Similarly, knowledgeable local attorneys could encourage “state and local governments [to] adopt policies to encourage landlords in low-poverty areas to accept housing vouchers,” help “[e]nact state or local laws prohibiting discrimination against voucher holders,” “[p]rovide mobility counseling to help families move to and remain in high-opportunity neighborhoods,” and “[e]xpand access to cars to help families to use vouchers in low-poverty areas.”[126] With more educated advocacy, the overall financial costs (and corresponding taxes) to the governments and society might actually decrease due to a reduction in health-related expenditures outweighing the costs of supportive housing.
Similarly, attorneys can play a key role in preventing housing-related healthcare complications by helping patients with substandard and inaccessible housing. A few examples discussed in this section include the application of landlord-tenant laws, help with ordinance enforcement, advocacy for compliance with disability laws, etc. This section provides only a few specific examples and is not an all-inclusive list.
Attorneys can act as healthcare providers by assisting with the enforcement of ordinances and by applying landlord-tenant laws to substandard housing in ways that help improve patients’ health outcomes.[127] Substandard housing has been “shown to contribute to asthma, developmental and behavioral pathology, elevated lead levels, injury, transmission of infectious disease,” and exacerbation of new or pre-existing symptoms.[128] One researcher found that “the density of housing code violations in census tracts is associated with population-level asthma morbidity and predicted hospitalized patients’ risk of subsequent morbidity.”[129]
Attorneys have already proven the value of legal assistance with landlord-tenant laws and housing ordinances in improving health outcomes. Legal assistance with addressing violations—such as “fixing leaks, exterminating pests, or providing a different apartment”—are “highly effective” “in decreasing the number of emergency department visits and hospital admissions, as well as decreasing the need for systemic steroids, of adult asthma patients in sub-standard housing.”[130] For example, a Medical-Legal Partnership (MLP) helped a group of tenants in substandard housing by identifying unaddressed pest infestations and water damage affecting the tenants’ health by citing outstanding violations of city code and ordinance in the buildings, helping organize the tenants into a tenant organization, and “help[ing] tenants work with the [landlord] . . . to identify and prioritize repairs [to] respond to city code standards.”[131]
In another example, the American Academy of Pediatrics recognized the importance of physicians and lawyers working together in a case involving three asthmatic children facing eviction due to their need to use window air conditioning units, noting that “the children’s health improved once the asthma triggers were addressed,” and that “[i]t is doubtful this would have happened without physicians and lawyers working together to address the root cause of the children’s health problem.”[132] The same researcher found that attorneys in an MLP were successful in enforcing ordinances in Cincinnati “to make improvements in a large cluster of pest-infested apartments.”[133] In New York, another researcher found improved medical outcomes among inner-city asthmatic adults linked to an “MLP’s work compelling New York landlords to provide better living conditions”—including “improved breathing,” “reduced dependence on steroids,” and “a 91 percent reduction in ED visits and hospital admissions.” [134]
In addition to ordinances, attorneys may use state law to help patients because most states have a “warranty of habitability” that is violated “by factors that worsen asthma severity like contamination of the home with mold, cockroaches, rodents, and dust.”[135] Further, the National Housing Law Project estimates that “public housing units nationwide need a combined $45 billion (and rising) in repairs.”[136] Some of these necessary repairs undoubtedly affect health and health outcomes—so attorney involvement to find solutions could help.
Attorneys can act as healthcare providers preventing further injuries by making sure that stakeholders follow laws that protect disabled patients—especially patients being discharged from the hospital with a new disability—from the dangers of living in an inaccessible home. The largest percentage of U.S. housing discrimination complaints are made on the basis of disability with 55% of all housing discrimination complaints in 2016 involving disability discrimination, and 91% of those complaints occurring during rental transactions.[137] Treating disabled persons with the same policy as nondisabled persons can lead to discrimination.[138] Failure to grant requests for reasonable modifications and accommodations may prevent some patients from returning home, prolong their hospital stay, lead to further injuries or complications, and result in patients having to live in expensive nursing homes.[139] Attorneys can help remind landlords about federal and state antidiscrimination laws protecting patients with disabilities.
For example, the Fair Housing Act (FHA) “prohibits discrimination in the sale, rental, and financing of dwellings, and in other housing-related transactions, based on . . . handicap (disability)” and covers most types of housing. [140] Under the FHA, “Housing providers must make reasonable accommodations and allow reasonable modifications that may be necessary to allow persons with disabilities to enjoy their housing.”[141] Accommodations or modifications are deemed necessary “when there is an identifiable relationship, or nexus, between the requested accommodation or modification and the individual’s disability.”[142] Under the FHA, reasonable accommodation is “a change, exception, or adjustment to a rule, policy, practice, or service.”[143] A reasonable modification is “a structural change made to existing premises, occupied or to be occupied by a person with a disability, in order to afford such person full enjoyment of the premises” and may include changes to “interiors and exteriors of dwellings and to common and public use areas.”[144] Examples of reasonable modifications for a person with a disability may include “installation of a ramp into a building, lowering the entry threshold of a unit, or installation of grab bars in a bathroom.”[145] Such modifications may prevent a patient from requiring a hospital readmission or an expensive return visit to the emergency room due to an injury caused by inaccessibility and should be included in discharge planning during hospitalization.
Under the FHA, landlords cannot, on the basis of disability, legally (1) refuse to rent or sell housing, (2) refuse to negotiate for housing, (3) set different terms or conditions or privileges, (4) falsely deny that housing is available, (5) indicate any preference or discrimination in advertisement of housing, (6) impose different sale prices or rental charges, (6) use different qualification criteria or applications, (7) harass, evict a tenant or tenant’s guest, (8) delay maintenance or repairs, (9) limit privileges or services, (10) discourage purchase or rental, or (11) otherwise discriminate.[146] In addition to the FHA, most states have their own Fair Housing laws, which typically “mirror the protections found in the FHA, but often add additional protections.”[147]
Many landlords “make overt discriminatory comments or refuse outright to make reasonable accommodations or modifications for people with disabilities, as required under the Fair Housing Act,” and “large numbers of multi-family properties continue to be constructed that do not meet the design and construction requirements under the Fair Housing Act that serve to make more housing opportunities accessible to persons with disabilities.”[148] Therefore, attorneys could potentially make a considerable difference for patients facing overt violations of FHA. Attorneys can help patients file FHA complaints with HUD’s Office of Fair Housing and Equal Opportunity (FHEO).[149] FHEO “enforces many civil rights laws that apply to public entities, including state and local government agencies, as well as recipients of federal financial assistance.”[150]
Numerous other federal laws protecting disabled patients may come into play as well.[151] For example, Title II of the Americans with Disabilities Act (ADA) “prohibits discrimination based on disability in programs, services, and activities provided or made available by public entities,” and is enforced by HUD.[152] The ADA prohibits “discrimination on the basis of disability in all programs, services, and activities of public entities and by private entities that own, operate, or lease places of public accommodation.”[153] Under Titles II and III of the ADA, public entities are required to “make reasonable modifications to policies, practices, or procedures to avoid [disability] discrimination” unless they “can demonstrate that the modifications would fundamentally alter the nature of its service, program or activity” or “making the modifications would fundamentally alter the nature of the goods, services, facilities, privileges, advantages or accommodations.”[154]
Similarly, Section 504 of the Rehab Act provides protections for patients with disabilities.[155] Section 504, unlike the FHA, “does not distinguish between reasonable accommodations and reasonable modifications,” but instead applies the term “reasonable accommodations” to “any changes that may be necessary to provide equal opportunity to participate in any federally-assisted program or activity.”[156] Reasonable accommodations include structural changes, as well as “a change, adaptation or modification to a policy, program, service, facility, or workplace which will allow a qualified person with a disability to participate fully in a program, take advantage of a service, live in housing, or perform a job,” and these changes may include changes to public and common use spaces.[157]
Under Section 504, the housing provider is responsible for paying for reasonable accommodations “unless it amounts to an undue financial and administrative burden or a fundamental alteration of the program.”[158] Examples of reasonable accommodations under Section 504 may include (1) “Assigning an accessible parking space for a person with a mobility impairment,” (2) “Permitting a tenant to transfer to a ground-floor unit,” (3) “Adjusting a rent payment schedule to accommodate when an individual receives income assistance,” (4) “Adding a grab bar to a tenant’s bathroom,” (5) “Permitting an applicant to submit a housing application via a different means,” and (6) “Permitting an assistance animal in a ‘no pets’ building for a person who is deaf, blind, has seizures, or has a mental disability.”[159] These types of accommodations can make a significant difference in a patients’ recovery from illness or injury, prevent a future illness or injury, or both. “Under Section 504 and the ADA, public housing agencies, other federally-assisted housing providers, and state or local government entities are required to provide and pay for structural modifications as reasonable accommodations/modifications.”[160]
Other examples of laws that may come into play include the Age Discrimination Act,[161] HUD Section 202 and Section 811 programs,[162] and many similar state laws,[163] among others.
Attorneys are already trying to address these issues in some isolated cases.[164] Private fair housing organizations and DOJ “have brought legal action against developers and owners of properties that did not meet the requirements of the Fair Housing Act.”[165] For example, NHFA filed a housing discrimination lawsuit against Ovation Development Corporation in 2007 alleging discrimination against people with disabilities by “improperly building units that failed to comply with federal accessibility standards” in the Fair Housing Act and in the ADA.[166] Also, in 2007, the National Fair Housing Alliance (NFHA) filed a housing discrimination lawsuit against AG Spanos Companies in Stockton California alleging failure to “comply with federal accessibility standards in design and construction of its properties.”[167] In 2010, NFHA reached a “landmark agreement” with AG Spanos Companies to “increase housing accessibility for people with disabilities,” including “retrofitting [123] properties in multiple states at an estimated cost of $7.4 million.”[168]
In another case, thirty residents “joined a HUD complaint filed against Charter Realty Group, Miami Property Group, and their property manager for discrimination on the basis of disability, familial status, and sex” over a property in Miami that allegedly did not have a “single wheelchair accessible unit,” “no reserved parking spaces for residents with disabilities,” and denial or delay of requests for reasonable accommodations until after some tenants died.[169] If true, the associated healthcare costs of patients denied reasonable accommodations or dealing with inaccessible housing may likely have been significant—especially because some tenants allegedly died while seeking accommodations.[170] So, attorney involvement at the time of hospital discharge and during healthcare delivery could lead to significant decreases in unnecessary healthcare expenditures related to unaccommodated disabilities.
Formal incorporation of housing attorneys into healthcare teams as recognized healthcare providers could improve healthcare outcomes, lower overall healthcare costs, and improve hospitals’ bottom lines. In fact, stable housing has the potential to provide so many cost and health benefits that some hospitals have developed self-funded housing programs for certain patient populations after discharge; these programs “also aim to help hospitals meet payers demands to provide more value-based care for patients and the communities they serve.”[171]
For example, the Better Health Through Housing pilot project at the University of Illinois Hospital in Chicago began in 2015 and “initially provided housing for 25 patients with severe and chronic health problems.”[172] The hospital paid $1,000 per month for housing for each patient, supplementing federal housing subsidies.[173] For those twenty-five patients, healthcare costs fell by 18%, and the program was deemed “so successful” that the hospital decided to “double the housing program’s size” in 2018.[174]
Other hospitals and healthcare systems are also developing innovative, cost-effective programs to supply housing to vulnerable patients. Kaiser Permanente, “the nation’s largest integrated health system,” has committed up to $200 million from its Thriving Communities Fund “to address housing stability and homelessness.”[175] Kaiser has also partnered with U.S. Mayors and CEOs for U.S. Housing Investment to form a “first-of-its-kind coalition comprised of local government officials and business leaders” to address the problem of homelessness by advancing “key federal housing priorities.”[176] In another example, in Portland, Oregon, six health organizations contributed $21.5 million to help build almost 400 supportive housing units in the Central City Concern.[177]
Similarly, insurers and state governments are beginning to recognize the importance of housing in health care.[178] Some insurance companies are addressing housing needs by providing funding for transitional housing services and other crisis services.[179] Medicaid programs also are getting involved. For example, eligible Medicaid members in one Indiana program have spent over 17,000 nights in short-term transitional housing resulting in a 40% decline in inpatient stays.[180] Another insurer found $6,384 per patient in cost savings associated with integrating permanent supportive housing for homeless patients with special needs.[181] Some insurers are also even working to make homes healthier.[182]
Likewise, the federal government is beginning to recognize the importance of housing in health care. Alex Azar, Secretary of Health and Human Services, indicated that CMS is looking for innovative holistic solutions and even included the possibility that government programs might “pay a beneficiary’s rent if they were in unstable housing.”[183] Azar noted that government healthcare programs may realize significant savings by including housing solutions because there is “compelling evidence that [on a state level] a combined intervention of stable, affordable housing along with supportive services can pay off in reduced utilization of crisis and inpatient services, resulting in better healthcare outcomes for individuals with complex needs who are homeless, and improved management of costs.”[184]
Azar plans to leverage the Medicare Advantage program to address housing issues with Medicare Advantage plans in 2020 being allowed to pay for “home modifications” and other housing related expenses.[185] Azar notes, “Paying for outcomes means paying for the right inputs—whether they are healthcare services or not.”[186] Paying for housing attorneys’ services makes sense to help address housing needs clearly linkable to healthcare outcomes. The Center for Medicare and Medicaid Innovation (CMMI) has launched the Accountable Health Communities payment model to screen high healthcare utilizers for housing needs (along with other social determinants of health) during their doctors’ visits.[187]
What has largely been overlooked is the role that attorneys can play in direct and individualized patient care and the value that housing-related legal services bring to the table if incorporated more formally into the provision of health care. If it makes sense for hospitals to pay for housing for some patients, then surely it makes more sense to hire attorneys to make sure that patients benefit from appropriate federal and state housing subsidies and that housing laws are followed when violations lead to increased healthcare expenditures. As noted above, some hospitals and payors are already finding that paying for housing may be more cost-effective than paying for the health consequences of housing insecurity and homelessness, so hiring attorneys (instead of paying for housing outright) to leverage government programs and enforce housing laws may be much more cost-effective.[188]
Housing attorneys should be incorporated into the healthcare system as hospital employees and as independent providers using new payment models for housing-related legal services. Some of this work is already being done on a small scale on a pro bono basis through Medical-Legal Partnerships (MLP).[189] In 2006 the National Center for Medical-Legal Partnerships was founded “to bring doctors and lawyers together to remedy health problems needing legal intervention” with a mission to “improve the health and well-being of people and communities . . . [using] . . . an integrated, upstream approach to combat[] health harming social situations.”[190] The American Bar Association and physician organizations have supported this approach.[191] By 2016 (just ten years later), there were 294 MLPs housed in 155 hospitals, 52 law schools, 139 health centers and 34 health schools.[192] They are staffed by 126 legal aid agencies and sixty-four pro bono legal partners.[193] Most MLPs are “related to pediatric patients and are associated primarily with children’s hospitals” and can only scratch the surface of addressing the housing-related issues outlined in the paper.[194]
Given the health consequences of failing to address housing as a health issue in all individuals (including adults), relying on the goodwill of attorney organizations to provide pro bono services is not enough. Hospitals, payers, and society as a whole stand to gain by addressing housing issues before patients are discharged to unstable or substandard housing only to bounce back and cost the system and society even more money with resultant, predictable, and expensive hospital readmissions, ED visits, and other medical complications. Further, additional societal benefits are likely. For example, in addition to the health benefits outlined above, participants in one housing program “received less financial aid, were arrested less, spent fewer days in jail, and used fewer mental health services.”[195] Thus, the healthcare system could be improved (1) by recognizing attorneys as healthcare providers employed by healthcare organizations (e.g., by hospitals), (2) by developing payment mechanisms in the healthcare system for independent attorneys to act as healthcare providers, or both.
The hospital, health system, and insurer are logical access points for housing-related legal services because the patient’s changing health situation may be the final straw that qualifies the patient for public housing assistance or the need for disability accommodations if the patient experiences a health-related drop in income, reduced job prospects, or a new disability. It also makes sense financially because failure to address housing issues costs hospitals, health systems, and insurers money.[196] Adding housing attorneys to hospital staffs to monitor changes in the law, educate patients and social workers, and provide direct legal assistance when necessary could lead to improved patient health and better hospital and system financial outcomes.[197] In addition, the fact that “most tenants do not have the resources to hire an attorney to remedy their housing issues” means that hospital or health system assistance might make a considerable difference for renters in unhealthy substandard housing.[198]
Remember the observation mentioned above by one large city ED director that some patients were “literally living at our hospital system,” visiting the hospital over 100 times in a year” with fifty patients costing the hospital over $100,000 per year each annually.[199] Also, recall that under Medicare’s HRRP, hospitals are penalized if they are below average with regard to readmissions compared to other hospitals in their peer group, and that the average penalty is likely around $219,000 annually per hospital—which is more than enough to pay at least one dedicated housing attorney’s salary.[200] As noted earlier, at least one expert has noted that with regards to housing that “[a] health system can take this on, and it can be done in a large scale.”[201]
Employed attorneys could easily be incorporated into the hospital workflow and are the most qualified professionals to help address complex housing law and policy issues. Many homeless people are unwilling to admit homelessness—so hospitals need to use trained screeners.[202] Patient intake and screening by social workers to identify patients with potential housing needs for attorney consultation should be adopted. Attorneys can provide oversight for social workers to develop techniques to detect people who are likely eligible for housing assistance programs available in their area. Attorneys can stay abreast of local housing options and can advocate with the local legislature and housing providers to expand availability when appropriate, which will keep down hospital and healthcare costs. Based on experiences in oncology, onsite specialized housing attorneys will likely prove to be productive patient advocates by forming collaborative relationships with treating physicians, ultimately benefiting the entire healthcare system and especially benefiting patients with improved healthcare outcomes.[203]
Healthcare providers are typically paid using a series of codes placed on forms that are sent to insurance companies and government payers. A code for the diagnosis is necessary, along with a code for the type of service provided. New codes for attorney services should be developed to incorporate paid attorneys into the healthcare system as providers.
Some medical diagnosis codes necessary for billing purposes already exist related to housing. Healthcare billing is done using alphanumerical “codes” that are recognized by insurers and government payors in a kind of shorthand for naming complex medical diseases and services. Medical diseases are coded for billing purposes using the International Classification of Diseases, 10th Revision (ICD-10).[204] For example, the ICD-10 code for osteoarthritis of the right knee is M17.11.[205] Some ICD-10 codes for housing deficiencies already exist. For example, Z59.0 is the code for “homelessness,” Z59.1 for “inadequate housing,” Z59.2 for “discord with . . . landlord,” Z59.8 for “other problems related to housing and economic circumstances,” and Z59.9 for “problem related to housing and economic circumstances, unspecified.”[206]
ICD codes should also be developed to recognize “housing-sensitive conditions,” which are defined as those “that stable housing has an especially important impact on the ability to care for [that] specific condition.”[207] In other words, housing-sensitive conditions are for those “whose course and medical management are more significantly influenced than others by having safe and stable housing.”[208] HIV infection is an example of a housing-sensitive condition.[209] Developing codes for housing-sensitive conditions will make it easier for screeners to recognize when legal services may be needed.
To be paid, the provider must pair the ICD code with a service code for the type of service provided; the service code is called a Current Procedural Terminology (CPT) code and determines how much the provider is paid for the service provided.[210] CMS determines the amount of work required to provide the CPT-coded service using a complex set of determinations using Relative Value Units (RVUs) and sets Medicare rates based upon those determinations.[211] New CPT codes have been recognized as “important complements to the implementation of alternative payment models,” such as emerging value-based payment models.[212]
RVUs could be determined for housing attorney work and paid according to the amount of legal work required. For example, a new CPT code could be assigned for New Patient Housing Attorney Assessment Visit to allow an attorney to be paid for visiting with the patient regarding his or her housing issues; an RVU value could be assigned to this new code. Similarly, a new CPT code could be created for services like Established Patient Housing Attorney Treatment Visit that would include payment for the attorney’s time required to check on an established patient, and additional codes for “Attorney Housing-Related Letter” or “Attorney Completion of Housing-Related Form” could be assigned values as well. This type of payment system mirrors mechanisms already in place to pay other healthcare providers and helps prevent open-ended hourly billing that could create disincentives for efficient and cost-effective handling of healthcare-related housing issues.
CPT codes should be paired with certain ICD codes. For example, attorneys could treat homelessness (i.e., ICD Z59.0) by assisting with government programs (CPT code to be determined), treat substandard housing (i.e., perhaps ICD Z59.1) by dealing with landlord-tenant laws and enforcing housing regulations (CPT codes to be determined), and treat unstable housing (i.e., perhaps ICD Z59.1) by representing patients facing eviction and foreclosure (CPT code to be determined).
In many cases, attorneys’ involvement early in the process may result in little being required legally other than education of the patient regarding his or her rights, the availability of assistance, or both, and perhaps writing an attorney letter to a landlord or other entity to remind the party of the applicable law—so the cost-effectiveness of these interventions might be surprising. Over time, additional attorney CPT housing codes may also be developed.
Housing is an important medication necessary to treat and prevent human illness, and attorneys are the most qualified professionals to help deliver this medication to patients in need. Without housing, patients must fight illness while exposed to elements like cold, heat, and rain and while deprived of basic facilities to maintain hygiene (e.g., showers and lavetories), which often results in predictable and unnecessary readmissions to the hospital and emergency department visits.[213] With unstable housing, patients must choose between buying their medications to comply with the doctors’ orders or keeping a roof over their heads—with either sacrifice leading to costly health consequences.[214] With substandard housing, patients must face pest infestation, mold, leaks, unsanitary conditions, and other conditions that lead to predictable bad health outcomes like exacerbation of chronic illnesses and the development of additional infections, asthma, and other illnesses.[215] With inaccessible housing, people with disabilities experience unnecessary falls, malnutrition (due to inaccessible kitchens), inadequate facilities to maintain hygeine, and other obstacles to proper healing—all of which leads to health and financial costs on the patient and the healthcare system.[216] Some hospitals and insurers have even found the cost of inadequate housing so great that they have discovered it is cheaper to simply pay for housing outright for some patients.[217]
Housing-related legal services should be incorporated into the healthcare system by recognizing housing attorneys as paid healthcare providers when administering housing laws to treat health conditions. Many housing laws and programs are already in place to address housing assistance, unstable housing, substandard housing, and inaccessible housing. Attorneys are the most knowledgeable professionals to treat housing deficiencies by applying current laws and by helping policymakers develop new laws to decrease unnecessary health and financial consequences associated with housing issues. Hospitals, health systems, and insurers should hire attorneys to work directly with patients to treat their housing deficiencies to decrease unnecessary health-related expenditures related to deficient housing. In addition, financial coding mechanisms (including CPT codes and RVU values) should be developed to include attorney consultation for housing deficiencies as a paid service—rather than the system continuing to rely on the goodwill of the legal community in providing free services through Medical-Legal Partnerships alone. These legal services provide significant value to the healthcare system and should be reimbursed alongside other healthcare services.
Without safe and stable homes, many patients will continue to struggle with housing-related health complications and continue to drive up the cost of health care; some of those patients are protected by current laws that attorneys could help administer. Attorneys have a role to play in treating housing-related health conditions and should be recognized as healthcare providers when working in this area in the future.
. Erwin de Leon & Joseph Schilling, Urban Blight and Public Health: Addressing the Impact of Substandard Housing, Abandoned Buildings, and Vacant Lots 1 (2017) (“The quality of housing can contribute to general well-being or cause poor health.”); 2019 Annual Message: Our Homes are Key to Our Health, Robert Wood Johnson Foundation [hereinafter 2019 Annual Message], https://www.rwjf.org/en/library/annual-reports/2019-annual-message.html?i=deeplink-intro-2b#introduction [https://perma.cc/9DLA-UX6K], (“The stability and quality of our housing . . . play a critical role in shaping our health.”); Announcing $200M Impact Investment to Address Housing Crisis, Kaiser Permanente (May 18, 2018) [hereinafter Kaiser Permanente], https://about.kaiserpermanente.org/community-health/news/kaiser-permanente-announces-200-million-impact-investment-partne [https://perma.cc/DR9V-6NLA] (Housing stability is a key factor in a person’s overall health and well-being.”); Lisa Ward, A New Emphasis on Social Factors to Reduce Readmissions, Modern Healthcare (Sept. 2, 2016), http://www.modernhealthcare.com/article/20160902/TRANSFORMATION03/
160839983 [https://perma.cc/A5QS-AH5Y]. ↑
. Kaiser Permanente, supra note 1 (reporting that Kaiser Permanente’s chief community health officer noted, “To improve the health of an entire community we must step beyond the four walls of our hospitals and medical offices to help those most in need”). ↑
. Id. ↑
. Id. (quoting family doctor Bechara Choucai, “I’ve provided medical care to the homeless, and have seen first-hand the impact that living without a home can have on someone’s health”). ↑
. Id. ↑
. 2019 Annual Message, supra note 1 (noting that (1) “38.1 million households are ‘cost-burdened,’ spending more than 30% of their income on housing;” (2) over half of “cost-burdened households pay more than half of their income for housing;” and (3) “[w]hen too much of a paycheck goes toward the rent or mortgage, there’s less money for other essentials including: transportation to work and school, medical care, utilities, food, and savings”). ↑
. de Leon & Schilling, supra note 1. ↑
. Id. at 9. ↑
. 2019 Annual Message, supra note 1. ↑
. Id. ↑
. de Leon & Schilling, supra note 1 (“The quality of housing can contribute to general well-being or cause poor health.”). ↑
. Id. ↑
. Id. ↑
. Id. (“Asthma is often cited as a key outcome of poor housing conditions.”); David Mudarri & William J. Fisk, Public Health and Economic Impact of Dampness and Mold, 17 Indoor Air J. 226, 227 (2007). ↑
. Id. ↑
. de Leon & Schilling, supra note 1 (noting studies show “that poor children, particularly children of color living in dilapidated urban housing, have dangerously high blood lead levels that can lead to irreparable harm to their health and impede their development”); 2019 Annual Message, supra note 1 (observing that 57% of housing discrimination complaints are related to disability, 19% race, 9% familial status, 7% sex, 7% national origin, 1.4% color, and 1.3% religion). ↑
. Id. at 4. ↑
. See Christopher Cheney, How Housing with Supportive Services Can Cut Hospital Utilization, Health Leaders (Oct. 1, 2018), https://www.healthleadersmedia.com/clinical-care/how-housing-supportive-services-can-cut-hospital-utilization [https://perma.cc/Q2ME-BE8B] (explaining research shows stable housing with supportive services reduces expensive medical care). ↑
. Universal Declaration of Human Rights, G.A. Res. 217 (III) A, U.N. Doc. A/RES/217(III), art. 25 (Dec. 10, 1948); see The Nat’l Academies of Sci., Eng’g, and Med., Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness 4, 31 (2018) [hereinafter Permanent Supportive Housing] (“The committee believes that housing in general improves health.”); Michael K. Gusmano et al., Medicare Beneficiaries Living In Housing With Supportive Services Experienced Lower Hospital Use Than Others, 37 Health Affairs 1562, 1562 (2018) (“There is strong evidence that housing conditions affect population health.”). ↑
. Permanent Supportive Housing, supra note 19, at vii. ↑
. Id. at 1 (“In 2017, more than 550,000 people were staying in shelters or in places not intended for human habitation on a single night. That same year 86,962 individuals were considered chronically homeless, nearly 7 in 10 of whom were unsheltered.”); see also Ctr. on Budget & Policy Priorities, United States Federal Rental Assistance Fact Sheet (2019) (observing that approximately “1.3 million American school children lived in shelters, on the street, doubled up with other families, or in hotels or motels during the 2016–17 school year”). ↑
. Bridget M. Kuehn, Hospitals Turn to Housing to Help Homeless Patients, 321 J. Am. Med. Ass’n 815, 822 (2019) (“We’re learning more and more that without a place to live, it’s nearly impossible for a person to take care of their basic health needs.”). ↑
. Permanent Supportive Housing, supra note 19, at 4; Michael Nardone et al., Ctr. for Health Care Strategies, Inc., Medicaid Financed Services in Supportive Housing for High Need Homeless Beneficiaries: The Business 3 (2012) (“Homeless adults, particularly those who are chronically or long-term homeless, are far more likely to suffer from chronic medical conditions, such as HIV/AIDS, hypertension and diabetes and to suffer complications from their illness due to lack of housing stability and regular, uninterrupted treatment.”); Kuehn, supra note 22, at 823 (noting that many of the homeless patients have “multiple comorbid medical conditions, including severe mental illness, substance abuse disorders, and chronic conditions like diabetes or heart failure”). ↑
. Permanent Supportive Housing, supra note 19, at 4. ↑
. Id. at 1 (noting a higher risk of “death due to exposures to extreme heat or cold”); Nardone et al., supra note 18 (“Homeless adults, particularly those who are chronically or long-term homeless, are far more likely to suffer from chronic medical conditions, such as HIV/AIDS, hypertension and diabetes and to suffer complications from their illness due to lack of housing stability and regular, uninterrupted treatment.”). ↑
. Permanent Supportive Housing, supra note 19, at 1, 4. ↑
. Id. at 4. ↑
. Kuehn, supra note 22, at 823. ↑
. Id. at 822. ↑
. Id. (“For example, [people with stable housing] are able to see their primary care and specialist physicians regularly, take medications or preventive health measures that may be impossible while living on the street, apply for social security or other benefits, or look for a job.”). ↑
. See Permanent Supportive Housing, supra note 19, at 4 (noting that those who live on the street do not have addresses to receive services and mail). ↑
. Nardone et al., supra note 23. ↑
. Id.; Kuehn, supra note 22, at 823. ↑
. See Daniel G. Garrett, The Business Case for Ending Homelessness: Having a Home Improves Health, Reduces Healthcare Utilization and Costs, 5 Am. Health & Drug Benefits 17, 17 (2012) (noting that the annual cost for emergency department visits can cost between $18,500 for average users and $44,400 for the most frequent users). ↑
. See id. ↑
. Ctr. on Budget & Policy Priorities, supra note 21. ↑
. Id. (emphasis added). ↑
. Id. ↑
. Am.’s Health Ins. Plans, Safe & Affordable Housing: Social Determinants of Health 2 (2018) [hereinafter AHIP Issue Brief] (noting that young children living in low-income, unstable housing have “nearly a 20% increased risk of hospitalization”); Allyson Gold, No Home for Justice: How Eviction Perpetuated Health Inequity Among Low-Income and Minority Tenants, 24 Geo. J. on Poverty L. & Pol’y 59, 73 (2016); Frank Griffin, Improving Health Outcomes and Lowering Costs: Attorneys as Proactive, Paid Providers Treating Social Determinants of Health, 71 Rutgers U. L. Rev. 795, 815 (2019). ↑
. See, e.g., Samiya A. Bashir, Home Is Where the Harm Is: Inadequate Housing as a Public Health Crisis, 92 Am. J. Pub. Health 733, 733 (2002) (noting the connection between health problems and poor housing is on the rise and well documented); Andrew F. Beck et al., Identifying and Treating a Substandard Housing Cluster Using a Medico-Legal Partnership, 130 Pediatrics 831, 834 (2012) (stating health disparities among children are exacerbated by poor-quality housing); Gold, supra note 32 (arguing that the consequences of poor housing go beyond just physical health outcomes); Joshua Sharfstein et al., Is Child Health at Risk While Families Wait for Housing Vouchers?, 91 Am. J. Pub. Health 1191, 1191 (2001) (identifying that the link between poor health and poor housing has been recognized for over a century). ↑
. Bashir, supra note 40 (“[O]ften life-threatening ailments disproportionately affect children of color and children from low-income families. . . . The culture of isolation ensures that the persons who are most vulnerable to these diseases—infants, children, the elderly, the chronically ill, and the immuno-compromised—are also those who spend the most time indoors and alone.”); see Gold, supra note 39, at 72 (arguing that the burden of unhealthy housing falls disproportionately on low-income people of color). ↑
. Bashir, supra note 40; Beck et al., supra note 40, at 832 (observing that substandard housing can cause health problems due to pest infestation, mold, overcrowding, etc.); Gold, supra note 32, at 71 (noting that “poor ventilation, dirty carpets and pest infestation” lead to conditions that can worsen asthma and that 44.4% of asthma among children and adolescents is attributable to such residential risk factors). ↑
. Bashir, supra note 40 (“Substandard and deteriorating housing contributes to a variety of ailments, from respiratory disease and neurological disorders to psychological and behavioral dysfunction. . . . Significant research demonstrates the harmful association of asthma, neurological damage, malnutrition, stunted growth, accidents, and injury with household triggers like poor insulation, combustion appliances, cockroach and rodent infestation, dust mites, hyper- and hypothermia, unaffordable rent, and dangerous levels of lead in soil and household paint.”). ↑
. Id.; Beck et al., supra note 40, at 832; Sharfstein, supra note 40. ↑
. Gold, supra note 39, at 73. ↑
. Beck et al., supra note 40, at 836. ↑
. Bashir, supra note 40 (noting disrepair, inadequate heat, noise, and dampness in homes is associated with anxiety and depression). ↑
. Gold, supra note 39, at 73. ↑
. See Water and Sanitation, Ctrs. for Disease Control & Prevention (Apr. 1, 2011), https://www.cdc.gov/ncezid/dpei/aip/water-sanitation.html [https://perma.cc/J9VU-EUA4]. ↑
. Id. ↑
. Id. ↑
. Cold Homes and Health, Centre for Sustainable Energy, https://www.cse.org.uk/advice/advice-and-support/heat-and-health [https://perma.cc/BNG3-BCBR]; see also Marmot Review Team, The Health Impacts of Cold Homes and Fuel Poverty 9, 23, 26, 35 (2011) (discussing Excess Winter Deaths (EWD) and noting that cold housing negatively impacts mental health and that Excess Winter Deaths (EWDs) due to low indoor temperatures lead to cold temperatures that cause 40% of EWDs secondary to cardiovascular disease and 33% of EWDs due to respiratory illness). ↑
. Centre for Sustainable Energy, supra note 52. ↑
. Marmot Review Team, supra note 52, at 9. ↑
. Juliet Eilperin, Study: Home Air Conditioning Cut Premature Deaths on Hot Days 80 Percent Since 1960, Wash. Post (Dec. 22, 2012), https://www.washingtonpost.com/national/
health-science/study-home-air-conditioning-cut-premature-deaths-on-hot-days-80-percent-since-1960/2012/12/22/5b57f3ac-4abf-11e2-b709-667035ff9029_story.html?noredirect=on&
utm_term=.44f2e6769e09 [https://perma.cc/64JU-FJXW] (pointing to a study projecting that the rate of premature deaths has decreased by 80% since the advent of home air conditioning in 1960). ↑
. Pei-Shu Ho et al., Health and Housing Among Low-Income Adults with Physical Disabilities, 18 J. Health Care for Poor & Underserved 902, 903 (2007). ↑
. Nat’l Fair Hous. All., The Case for Fair Housing: 2017 Fair Housing Trends Report 27 (2017). ↑
. Id.; see also Ho et al., supra note 56, at 908, 909, 912 (noting inaccessible living environments for the disabled can prevent them from living independently, having mobility, and maintaining personal hygiene). ↑
. See Ho et al., supra note 56, at 903 (noting that inaccessible living environments can result in injuries to the disabled). ↑
. Kenneth J. Ottenbacher et al., Length of Stay and Hospital Readmission for Persons with Disabilities, 90 Am. J. Pub. Health 1920, 1920 (2000) (“[An] increase in hospital readmission were found across all impairment groups (P<.001). Readmission increases ranged from 6.7% for amputations to 1.4% for orthopedic conditions. LOS was longer (2.1 days) for readmitted patients (P<.01).”). ↑
. Glen DePalma et al., Hospital Readmission Among Older Adults Who Return Home With Unmet Need for ADL Disability, 53 Gerontologist 454, 454 (2012) (“Many older patients are discharged from the hospital with ADL disability,” and those with unmet needs related to new ADL disabilities are “particularly vulnerable to readmission.”). ↑
. See Stewart Fleishman et al., The Attorney as the Newest Member of the Cancer Treatment Team, 24 J. Clinical Oncology 2123, 2123 (2006) (“In a recent survey of cancer patients . . . nearly half of the individuals surveyed said that non-medical issues relating to their cancer were unmet by their oncologists, including 35% who said nonmedical issues were wholly unaddressed and another 14% who said they believed their oncologists wanted to assist with nonmedical issues but did not have enough information or experience to do so.”); Ara Ohanian, The ROI of Addressing Social Determinants of Health, Ajmc.com (Jan. 11, 2018), http://www.ajmc.com/contributor/ara-ohanian/2018/01/the-roi-of-addressing-social-determinants-of-health [https://perma.cc/6GQM-TWDW] (“Two-thirds of hospital electronic medical records do not screen for patient’s social and behavioral needs.”). ↑
. See Cheney, supra note 18. ↑
. Id. ↑
. Permanent Supportive Housing, supra note 19, at 1. ↑
. Kuehn, supra note 22, at 823. ↑
. Id. ↑
. See Ctrs. for Medicare & Medicaid Servs., Design and Development of the Diagnosis Related Group (DRG) 1 (2016) (“Prospective payment rates based on Diagnosis Groups (DRGs) have been established at the basis of Medicare’s hospital reimbursement system.”). ↑
. Kuehn, supra note 22, at 823. ↑
. Id. ↑
. Permanent Supportive Housing, supra note 19, at 1. ↑
. Griffin, supra note 39, at 814 (“For the homeless, the expensive emergency department (ED) tends to be their usual and sometimes only source of care.”); Nardone et al., supra note 18 (citing several studies revealing excessive ED use by homeless people); see AHIP Issue Brief, supra note 39, at 1 (“Hospitalization rates and emergency room use can be up to three to four times higher for those without a home.”). ↑
. See Maureen Groppe, Who Pays When Someone Without Insurance Shows up in the ER?, USA Today (July 3, 2017), https://www.usatoday.com/story/news/
politics/2017/07/03/who-pays-when-someone-without-insurance-shows-up-er/445756001/ [https://perma.cc/T287-JTTX] (noting the fact that “every uninsured person costs local hospitals $900 in uncompensated care costs each year. . . . [i]s not a trivial thing for a hospital to deal with.”). ↑
. See Kuehn, supra note 22 (giving the example of one hospital that identified over 4,600 patients who were likely homeless, but not identifying themselves as homeless to hospital staff, and noting that “[s]ome patients do not admit to being homeless,” but the hospital can use patient addresses and other information to identify homeless individuals). ↑
. Griffin, supra note 39, at 803 (quoting Ohanian, supra note 50). ↑
. Id. at 803; see, e.g., Hillary Mull et al., Association of Postoperative Readmissions with Surgical Quality Using a Delphi Consensus Process to Identify Relevant Diagnosis Codes, 153 J. Am. Med. Ass’n 728, 728 (2018) (noting that almost half of gall bladder surgery (i.e., cholecystectomy (47%)) readmissions were unrelated to surgical quality, and that overall “one-third of postoperative readmissions are unlikely to reflect problems with surgical quality”); see also, Deborah Bachrach et al., Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment 3 (2014) (“Changes in the health care landscape are catapulting social determinants of health from an academic topic to an on-the-ground reality for providers, with public and private payers holding providers accountable for patients’ health and health care costs and linking payments to outcomes.”). ↑
. Griffin, supra note 39, at 804 (“The Medicare Hospital Readmission Reduction Program (HRRP) applies to most acute care hospitals and was created as part of the Affordable Care Act (ACA).”); see Nat’l Quality Forum, NQF Report on 2017 activities to Congress and the Secretary of the Department of Health and Human Services 26 (2018) (“High rates of readmissions are costly to the healthcare system and can indicate low-quality care during a hospital stay and poor-quality care coordination.”); U.S. Dept. of Health & Human Servs., Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs 68, 70 (2016) (explaining program places penalties on hospitals if they have higher-than-expected readmission rates for conditions common in the Medicare population); see also Patient Protection & Affordable Care Act, 42 U.S.C. § 300gg-17(a)(1)(B) (2012) (providing for implementation of activities to reduce readmissions through education and counseling); 42 C.F.R. § 412.152 (2018) (defining readmission as a return to the same or a different hospital within thirty days form discharge). ↑
. Griffin, supra note 39, at 804 (“Readmissions are more costly than initial admissions for all payors—specifically, 30% higher for Medicaid and privately insured patients, 11% higher for uninsured patients, and 5% higher for Medicare.”); Nat’l Quality Forum, All-Cause Admissions and Readmissions 2017, Technical Report 7 (2017). ↑
. Griffin, supra note 39, at 804 (citing Nat’l Quality Forum, supra note 78). ↑
. Griffin, supra note 39, at 804 (quoting Nat’l Quality Forum, supra note 77, at 27); see Ottenbacher, supra note 60 (“Hospital readmission costs have been identified as a major component of health care spending in the United States and account for approximately 24% of Medicare spending.”). ↑
. Cristina Boccuti & Giselle Casillas, Henry J. Kaiser Family Found., Aiming for Fewer Hospital U-Turns: The Medicare Hospital Readmission Reduction Program 2 (2017) (“The HRRP was established by a provision in the Affordable Care Act (ACA) requiring Medicare to reduce payments to hospitals with relatively high readmission rates for patients in traditional Medicare.”); Griffin, supra note 39, at 804–05 (“The HRRP is especially punitive because ‘hospitals with readmission rates that exceed the national average are penalized by a reduction in payments across all of their Medicare admissions—not just those which resulted in readmissions.’”) (quoting Boccuti & Casillas); see U.S. Dept. of Health & Human Servs., supra note 77 (noting the maximum penalty was set at 3% in 2015, “where it will remain”); Hospital Readmissions Reduction Program (HRRP), Centers for Medicare & Medicaid Servs., https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html [https://perma.cc/3HRS-JJWC] (more specifically, CMS uses excess readmission ratios to measure performance in thirty-day unplanned readmissions for conditions like chronic lung disease, heart attacks, pneumonia, and coronary artery bypass surgery). ↑
. Griffin, supra note 82, at 805 (“After some adjustments, each hospital is annually assigned a penalty for the upcoming year based on CMS’s calculation of that hospital’s rate of excess readmissions . . . ‘the greater each hospital’s rate of excess readmissions, the higher its penalty.’ The hospital’s penalty is posted in the Federal Register and listed on the Medicare website.”) (quoting Boccuti & Casillas, supra note 65). ↑
. Kelly M. Doran et al., The Revolving Hospital Door: Hospital Readmissions Among Patients Who Are Homeless, 51 Medical Care 767, 767 (2013) (also observing in its abstract that homelessness is an independent risk factor for readmission of patients with heart disease and that hospital “discharge to the streets or shelter versus other living situations [is] associated with increased risk for readmission”); Griffin, supra note 39, at 814 (“[H]omeless patients . . . have high hospital readmission rates and poor health outcomes.”). ↑
. Doran et al., supra note 83; Griffin, supra note 39, at 806 (quoting Doran, supra note 83) (“For example, homeless patients have ‘strikingly high 30-day hospital readmission rates’ with half of hospitalizations of homeless individuals resulting in hospital inpatient readmission and over 70% resulting in ‘either an inpatient readmission, observation status stay, or emergency department visit within 30 days of hospital discharge.’”). ↑
. Amol S. Navathe et al., Hospital Readmission and Social Risk Factors Identified from Physician Notes, 53 Health Srvs. Res. 1111, at 1123–24, 1123 tbl.4 (2018). ↑
. de Leon & Schilling, supra note 1 (citing Mudarri & Fisk, supra note 14, at 227 (2007)) (noting that experts “estimate that about 20 percent (4.6 million) of the 21.8 million people reported to have asthma in the United States can attribute their condition to dampness and mold exposure in their homes” and “calculate the national annual costs of asthma due to dampness and mold exposure in the home to be $3.5 billion”). ↑
. Griffin, supra note 39, at 805 (calculating the per hospital average penalty); 2,573 Hospitals Will Face Readmission Penalties This Year. Is Yours One of Them?, Advisory Bd. (Aug. 7, 2017), https://www.advisory.com/daily-briefing/2017/08/07/hospital-penalties [https://perma.cc/CU7H-DH39]. ↑
. Griffin, supra note 39, at 805 (noting that 70% of hospitals with the most poor beneficiaries are penalized versus only 40% of those with the fewest poor beneficiaries); see U.S. Dep’t of Health & Human Servs., supra note 77, at 71 (explaining “hospitals with higher proportions of poor and minority beneficiaries have higher readmission rates,” and “beneficiaries and hospitals in high-poverty communities have higher readmission rates”). ↑
. U.S. Dep’t of Health & Human Servs., supra note 77, at 100. ↑
. Jessica H. Leibler et al., Prevalence and Risk Factors for MRSA Nasal Colonization Among Persons Experiencing Homelessness in Boston, MA, 66 J. Med. Microbiology 1183, 1183 (2017). ↑
. Id. ↑
. Griffin, supra note 39, at 809; see also U.S. Dep’t of Health & Hum. Servs., supra note 77, at 102. ↑
. Griffin, supra note 39, at 803; see, e.g., Hospital Compare, Medicare.gov, https://www.medicare.gov/hospitalcompare/search.html [https://perma.cc/3YDY-6H4J] (stating that hospitals are given star ratings based on a “variety of quality measures,” some of which are undoubtedly influenced by housing); see also Bachrach, supra note 60, at 3 (noting that “new models are creating economic incentives for providers to incorporate social interventions into their approach to care” and that “[i]nvesting in these interventions can enhance patient satisfaction and loyalty, as well as satisfaction and productivity among providers”). ↑
. Ohanian, supra note 62. ↑
. Raul Preciado Mendez, Nat’l Policy Consensus Ctr., Underutilization of Federal Benefits in Oregon: Programs and Strategies 1 (2017). ↑
. Public Housing, Nat’l Hous. Law Project, https://www.nhlp.org/resource-center/public-housing/ [https://perma.cc/LUA8-8FWL] (noting that “[t]he United States Housing Act of 1937 (42 USCA § 1437) established the public housing program, which produced nearly 1.4 million units nationwide,” and approximately 1 million units remain in the public housing program after dispositions, demolitions, and other changes). ↑
. Id. (“Public housing is limited to low-income families and individuals.”). ↑
. Id. ↑
. Id. (“Additionally, 31% of public housing residents are seniors (> 62 years old), 30% of public housing households include a non-elderly family member who experiences a disability, and 3.3 million children live in public housing.”). ↑
. Barbara Sard & Douglas Rice, Ctr. on Budget & Policy Priorities, Realizing the Housing Voucher Program’s Potential to Enable Families to Move to Better Neighborhoods 1, 6 (2016) (explaining that the Housing Choice Voucher (HCV) program is “federally funded and run by a network of more than 2,200 state and local housing agencies,” and it helps “nearly 2.2 million low-income households pay for modestly priced, decent quality homes in the private market”—minor children are present in nearly half of these households) (citing Ctr. on Budget & Policy Priorities, The Housing Choice Voucher Program 1–2 (2017)); Section 8 Housing Choice Vouchers, Nat’l Hous. Law Project, https://www.nhlp.org/resource-center/section-8-vouchers/ [https://perma.cc/72L6-UMSL] (“The Section 8 Housing Choice Voucher (HCV) Program was enacted in 1974 as Section 8 of the United States Housing Act.”). ↑
. Section 8 Housing Choice Vouchers, supra note 100. ↑
. Id. ↑
. Housing Choice Vouchers Fact Sheet, U.S. Dep’t of Hous. & Urban Dev., https://www.hud.gov/program_offices/public_indian_housing/programs/hcv/about/fact_sheet [https://perma.cc/JX3H-FFXC]; see 24 C.F.R. § 982.401(g)(1) (2018). ↑
. Housing Choice Vouchers Fact Sheet, supra note 103. ↑
. Id. ↑
. Id. ↑
. Project-Based Vouchers, Nat’l Hous. Law Project, https://www.nhlp.org/resource-center/project-based-vouchers/ [https://perma.cc/DF2H-5C39] (explaining that the project-based voucher is a “variation on the Section 8 Housing Choice Voucher” under which “the public housing authority (PHA) uses a portion of its Housing Choice Voucher funds to attach voucher assistance to particular units through Housing Assistance Payment (HAP) contracts with private landlords”). ↑
. Project-Based Rental Assistance, Nat’l Hous. Law Project, https://www.nhlp.org/resource-center/project-based-rental-assistance/ [https://perma.cc/4NCQ-4T58] (noting that, “[w]ith project-based rental assistance, a private for-profit or non-profit owner enters into a contract with HUD to provide affordable units,” and that “[p]roject-based rental assistance” can be paired with other programs to “provide a deeper level of affordability”). ↑
. Low-Income Housing Tax Credits, Nat’l Hous. Law Project, https://www.nhlp.org/resource-center/low-income-housing-tax-credits/ [https://perma.cc/C47C-UFG9] (noting that this program “encourage[s] developers to create affordable housing” by providing tax incentives, and that “[t]here are about 2,000,000 tax credit units today and this number continues to grow by an estimated 100,000 annually”). ↑
. Other examples of federally funded housing possibilities where attorneys’ knowledge and expertise might come into play include the following: HOME, Community Development Block Grants, Sections 202 and 811 Supportive Housing for the Elderly or Persons with Disabilities, USDA Rural Development Sections 514, 515, and 538, and McKinney-Vento Supportive Housing (permanent or transitional) to name a few. See NCH Fact Sheet #16: Federal Housing Assistance Programs, Nat’l Coalition for Homeless, http://www.nationalhomeless.org/publications/facts/federal.html [https://perma.cc/X6YC-HJ9C]; Federal Register Publications, U.S. Dep’t Agric. Rural Dev., https://www.rd.usda.gov/publications/regulations-guidelines/federal-register-publications [https://perma.cc/Z3DF-VN5H]; Mindy Mitchell, Homeless Assistance: McKinney-Vento Homeless Assistance Programs, 4 Advoc. Guide 65 (2019). ↑
. Non-Discrimination in Housing and Community Development Programs, U.S. Dep’t of Hous. & Urban Dev., https://www.hud.gov/program_offices/fair_housing_
equal_opp/non_discrimination_housing_and_community_development_0 [https://perma.cc/8LRZ-NBCK] (“FHEO has civil rights authority over the housing-related programs, services, and regulatory activities of state and local governments and recipients and subrecipients of financial assistance from HUD, including private businesses.”). ↑
. Gold, supra note 39, at 69 (citing Stout Risius Ross, Inc., The Financial Cost and Benefits of Establishing a Right to Counsel in Eviction Proceedings Under Intro 214–A, at 3–4 (2016)) (“An estimated 47% of all families in New York City homeless shelters are homeless as a result of eviction.”). ↑
. Id. at 60, 63–64 (discussing unprotected due process rights). ↑
. Id. at 64 (citing Karen Doran et al., Lawyer’s Comm. for Better Hous., No Time for Justice: A Study of Chicago’s Eviction Court 4 (2003)). ↑
. Id. at 63, 69. ↑
. Cf. id. at 68 (highlighting the limited power of tenants). “My landlord has a very bad reputation. He will sue you for anything. I don’t want to do anything if it means I won’t be able to find a good place to live after this.” Id. ↑
. Id. at 62. ↑
. Sarah B. Hunter et al., RAND Corp., Evaluation of Housing for Health Permanent Supportive Housing Program, and iii (2017). ↑
. Id. at viii. ↑
. Id. ↑
. Id. ↑
. Kuehn, supra note 22, at 823. ↑
. Section 8 Housing Choice Vouchers, supra note 100 (“On the federal level, the Department of Housing and Urban Development (HUD) administers the program and locally, vouchers are administered by public housing agencies (PHAs).”). ↑
. U.S. Dep’t of Health & Human Servs., supra note 77, at 70. ↑
. Project-Based Rental Assistance, supra note 108 (“This is particularly true in rapidly gentrifying areas, where the loss of project-based rental assistance would likely result in the displacement of low-income families.”); see Section 8 Housing Choice Vouchers, supra note 100. ↑
. Sard & Rice, supra note 100, at 15–17. ↑
. See Beck et al., supra note 40, at 831. ↑
. Id. at 832. ↑
. Dayna Bowen Matthew, Ctr. for Health Policy at Brookings, The Law as Healer: How Paying for Medical-Legal Partnerships Saves Lives and Money 19 (2017). ↑
. Griffin, supra note 39, at 830; M.M. O’Sullivan et al., Environmental Improvements Brought by the Legal Interventions in the Homes of Poorly Controlled Inner-City Adult Asthmatic Patients: A Proof-of-Concept Study, 49 J. Asthma 911, 911 (2012). ↑
. Beck et al., supra note 40, at 831; Griffin, supra note 32, at 830. ↑
. Susan M. Scott, Medical-Legal Partnerships Address Social Issues Affecting Patient Health, AAP News (Feb. 5, 2018), https://www.aappublications.org/news/
2018/02/05/law020518 [https://perma.cc/JTZ3-A767]. ↑
. Matthew, supra note 129, at 19. ↑
. Id. ↑
. Griffin, supra note 39, at 135; O’Sullivan, supra note 113, at 911. ↑
. Public Housing, supra note 96. ↑
. Nat’l Fair Hous. All., supra note 57, at 7, 26–27 (observing, “[i]n the early 2000s, housing discrimination complaints on the basis of disability became the greatest percentage of all complaints filed in the U.S,” and in 2016, 55% of 28,181 housing discrimination complaints were filed on the basis of disability, and 91.5% of all housing discrimination occurred during rental transactions). ↑
. Reasonable Accommodations and Modifications, HUD.GOV, https://www.hud.gov/program_offices/fair_housing_equal_opp/reasonable_accommodations_and_modifications [https://perma.cc/2ZB3-6ADD] (“Since rules, policies, practices, and services may have a different effect on persons with disabilities than on other persons, treating persons with disabilities exactly the same as others will sometimes deny persons with disabilities an equal opportunity to enjoy a dwelling or participate in the program.”). ↑
. Id. ↑
. Fair Housing Laws, Complaints, and Lawsuits, FindLaw, https://realestate.findlaw.com/landlord-tenant-law/fair-housing-laws-complaints-and-lawsuits.html [https://perma.cc/EA8Y-QHME]; see also 42 U.S.C. §§ 3601–3608 (2012); Disability Overview, HUD.GOV, https://www.hud.gov/program_offices/fair_housing_equal_
opp/disability_overview [https://perma.cc/97L3-2V87]; Housing Discrimination Under the Fair Housing Act, HUD.GOV, https://www.hud.gov/program_offices/fair_housing_equal_
opp/fair_housing_act_overview [https://perma.cc/GVB9-223F] (noting the FHA “prohibits discrimination in housing because of: race, color, national origin, religion, sex, familial status, and disability” and that the FHA “protects people from discrimination when they are renting or buying a home, getting a mortgage, seeking housing assistance, or engaging in other housing-related activities”); Non-Discrimination in Housing and Community Development Programs, supra note 94 (noting that non-discrimination “obligations extend to recipients of HUD financial assistance, including subrecipients, as well as the operations of state and local governments and their agencies, and certain private organizations operating housing and community development services, programs, or activities”). ↑
. Housing Discrimination Under the Fair Housing Act, supra note 140. ↑
. Reasonable Accommodations and Modifications, supra note 138 (“A provider is entitled to obtain information that is necessary to evaluate if a requested reasonable accommodation or modification may be necessary because of a disability.”). ↑
. Id. (“The Fair Housing Act makes it unlawful to refuse to make reasonable accommodations to rules, policies, practices, or services when such accommodations may be necessary to afford persons with disabilities an equal opportunity to use and enjoy a dwelling and public and common use areas.”). ↑
. Id.; 42 U.S.C. § 3604(f)(3) (2012). ↑
. Reasonable Accommodations and Modifications, supra note 138 (“Under the Fair Housing Act, prohibited discrimination includes a refusal to permit, at the expense of the person with a disability, reasonable modifications of existing premises occupied or to be occupied by such person if such modifications may be necessary to afford such person full enjoyment of the premises.”). ↑
. Housing Discrimination Under the Fair Housing Act, supra note 140. ↑
. Fair Housing Laws, Complaints, and Lawsuits, supra note 140. ↑
. Nat’l Fair Hous. All., supra note 57, at 27. ↑
. Reasonable Accommodations and Modifications, supra note 138 (“When a person with a disability believes that he or she has been subjected to a discriminatory housing practice, including a provider’s wrongful denial of a request for reasonable accommodation, he or she may file a complaint with FHEO. If the individual who was denied an accommodation files a complaint with FHEO to challenge that decision, then HUD (or the state or local agency receiving the complaint) will review the evidence in light of applicable law and assess whether the housing provider violated that law.”). ↑
. Non-Discrimination in Housing and Community Development Programs, supra note 111. ↑
. Reasonable Accommodations and Modifications, supra note 138 (“Various federal laws require housing providers to make reasonable accommodations and reasonable modifications for individuals with disabilities. . . . These laws also prohibit housing providers from refusing residency to persons with disabilities, or placing conditions on their residency, because they require reasonable accommodations or modifications.”). ↑
. Fair Housing Laws, Complaints, and Lawsuits, supra note 140 (“HUD enforces Title II when it relates to state and local public housing, housing assistance and housing referrals.”). ↑
. Disability, HUD.GOV, https://www.hud.gov/program_offices/fair_housing_e
qual_opp/disability_main [https://perma.cc/W2PW-MQY5]. ↑
. Reasonable Accommodations and Modifications, supra note 138. ↑
. Disability, supra note 153 (“These protections apply in most private housing, state and local government housing, public housing and any other federally-assisted housing programs and activities. . . . Section 504 of the Rehabilitation Act prohibits discrimination on the basis of disability in any program or activity receiving federal financial assistance.”). ↑
. Reasonable Accommodations and Modifications, supra note 138 (“Unlike the Fair Housing Act, Section 504 does not distinguish between reasonable accommodations and reasonable modifications. Instead, both are captured by the term ‘reasonable accommodations.’”). ↑
. Id. ↑
. Id. ↑
. Id.; see also 42 U.S.C. § 3602(h)(1) (2012). ↑
. Reasonable Accommodations and Modifications, supra note 138. ↑
. Fair Housing Laws, Complaints, and Lawsuits, supra note 140 (noting that the Age Discrimination Act “prohibits discrimination on the basis of age in programs or activities receiving federal financial assistance”). ↑
. Section 202 and Section 811 Programs for the Elderly or Persons with Disabilities, Nat’l Hous. Law Project, https://www.nhlp.org/resource-center/section-202-section-811-programs-for-the-elderly-or-persons-with-disabilities/ [https://perma.cc/VY7H-E6X9] (“The HUD Section 202 and Section 811 programs provide critical affordable housing to our nation’s elderly and persons who experience disabilities.”). ↑
. Fair Housing Laws, Complaints, and Lawsuits, supra note 140 (“[M]any state[s] have enacted similar fair housing laws and legislation.”). ↑
. Nat’l Fair Hous. All., supra note 57, at 27. ↑
. Id. ↑
. Id. ↑
. Id. at 28. ↑
. Id. ↑
. Id. at 57. ↑
. Id. (“In some cases, tenants died awaiting reasonable accommodation requests.”). ↑
. Kuehn, supra note 22, at 822. ↑
. Id. ↑
. Id. (noting also that a local nonprofit organization provided a case manager to help patients coordinate their health care and provided additional supportive services). ↑
. Id. ↑
. Kaiser Permanente, supra note 1 (noting that Kaiser focuses on “preventing displacement or homelessness of lower- and middle-income households . . . reducing homelessness by ensuring access to supportive housing; and making affordable homes healthier”). ↑
. Id. ↑
. Kuehn, supra note 22, at 823. ↑
. AHIP Issue Brief, supra note 39, at 8 (“Health insurance providers understand the direct connection between housing and overall health.”). ↑
. See generally id. at 5–8 (providing examples like AmeriHealth Caritas District of Columbia, Anthem Indiana Medicaid, CareOregon, and others). ↑
. Id. at 6 (referencing Anthem Indiana Medicaid’s Blue Triangle Program). ↑
. Id. at 7–8 (pointing to UPMC Health Plan’s integration of permanent supportive housing for homeless special needs patients). ↑
. See generally id. at 5–8 (mentioning the efforts of Kaiser Permanente and others). ↑
. Steven Porter, Azar Outlines HHS Ambition on Social Determinants of Health: 5 Takeaways, HealthLeaders (Nov. 14, 2018), https://www.healthleadersmedia.com/
innovation/azar-outlines-hhs-ambition-social-determinants-health-5-takeaways [https://perma.cc/WN5H-YQCL] (noting also that the government is “actively exploring how we could experiment with actually paying for non-health services, like housing and nutrition—an integrated, individually driven approach to health and human services on a scale that has never before been tried in the United States”). ↑
. Nardone et al., supra note 23, at 11. ↑
. Alex M. Azar II, Sec’y U.S. Dep’t Health & Human Servs., Keynote Address at the Hatch Center Policy Symposium: The Root of the Issue: America’s Social Determinants of Health (Nov. 14, 2018), https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/the-root-of-the-problem-americas-social-determinants-of-health.html [https://perma.cc/AK5L-KZ87]. ↑
. Id. ↑
. Id. ↑
. Hunter et al., supra note 118, at viii. ↑
. Scott, supra note 132. ↑
. Id. ↑
. Id. ↑
. Id. ↑
. Id. ↑
. Id. ↑
. Kuehn, supra note 22, at 823. ↑
. Id. (“Hospitals are desperate now because they’re responsible for readmission rates [and] care coordination, . . . [along with] value-based payments and reducing lengths of stay.”). ↑
. AHIP Issue Brief, supra note 39, at 8 (“Health insurance providers recognize that the social determinants of health must be addressed in order to prevent and treat health care conditions. Housing remains one of the most complicated determinants to address.”). ↑
. O’Sullivan, supra note 130, at 911. ↑
. Kuehn, supra note 22, at 822. ↑
. Griffin, supra note 39, at 805; CMS, New Stratified Methodology Hospital Level Impact File User Guide 6 (2017). ↑
. Kuehn, supra note 22, at 823. ↑
. Id. at 822. ↑
. Fleishman et al., supra note 62, at 2126 (“As oncology care is evermore provided in an ambulatory setting, oncology treatment teams are forced to confront family and financial issues that may expedite or impede patient treatment. An on-site, specialized attorney can intervene to address these issues before a crisis develops that interferes with cancer treatment.”). ↑
. Dep’t Health & Hum. Servs., ICD-10-CM Official Guidelines for Coding & Reporting: FY 2019, at 1 (2019), https://www.cms.gov/Medicare/Coding/ICD10/
Downloads/2019-ICD10-Coding-Guidelines-.pdf [https://perma.cc/F9GC-WBPH]; Intro to CPT Coding, Med. Billing & Coding, https://www.medicalbillingandcoding.org/intro-to-cpt/ [https://perma.cc/2ZHW-EHZU]; ICD-10 Z Codes for Social Determinants of Health, Health Info. Tech., Evaluation, & Quality Ctr. 1 (June 2017) [hereinafter HITEQ], http://hiteqcenter.org/About/The-Triple-Aim/icd-10-z-codes-for-social-determinants-of-health-1 [https://perma.cc/CEK3-Y8U7]. ↑
. Id. ↑
. Osteoarthritis of the Knee M17, ICD10Data.com, https://www.icd10data.com/ICD10CM/Codes/M00-M99/M15-M19/M17- [https://perma.cc/8NWA-DYGK]. ↑
. Dep’t Health & Hum. Servs., supra note 204, at 20; Problems Related to Housing & Economic Circumstances Z59, ICD10Data.com, https://www.icd10data.com/ICD10CM/
Codes/Z00-Z99/Z55-Z65/Z59- [https://perma.cc/4K24-5T4S]; HITEQ, supra note 204. ↑
. Permanent Supportive Housing, supra note 15, at 5. ↑
. Id. at 129. ↑
. Intro to CPT Coding, supra note 204. ↑
. Nat’l Health Policy Forum, The Basics: Relative Value Unites (RVUs) 1 (2015). ↑
. Joshua M. Liao et al., Medicare’s Approach to Paying for Services That Promote Coordinated Care, 321 J. Am. Med. Ass’n 147, 148 (2019). ↑
. Permanent Supportive Housing, supra note 19, at 4. ↑
. de Leon & Schilling, supra note 1. ↑
. Id. ↑
. Nardone et al., supra note 23, at 4. ↑
. See, e.g., Nat’l Hous. Law Project, supra note 96. ↑
Frank Griffin, M.D., J.D.