Under a waiver program, states can test new ways to offer Medicaid services. For Oregon, that means some people on the Oregon Health Plan can get help with housing costs.
Oregon is the first in the nation to roll out rental assistance as a statewide Medicaid benefit for eligible OHP members, according to the Oregon Health Authority.
People would need to have a qualifying risk factor to be eligible for the aid, which could include rental assistance for up to six months and help paying utility bills.
Steph Jarem is the 1115 waiver policy director for OHA. Andrea Bell is the executive director of Oregon Housing and Community Services. They join us with details of the program and what it means for Oregonians.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. According to the Oregon Health Authority, Oregon just became the first state in the nation to roll out rental assistance as a statewide Medicaid benefit for eligible Oregon Health Plan members. It means that people with qualifying risk factors can now get things like six months of rental assistance or help paying utility bills. The state wants to prove that it can boost health outcomes by using federal healthcare dollars to keep people in their homes.
Steph Jarem is the 1115 waiver policy director for the Oregon Health Authority. Andrea Bell is the executive director of Oregon Housing and Community Services. They both join us now. It’s great to have both of you on Think Out Loud.
Steph Jarem: Good to be with you.
Andrea Bell: Thank you.
Miller: Steph, first. I mentioned that you’re the state’s 1115 waiver policy director. What are these waivers?
Jarem: Great, thank you. Thanks for inviting us today. All states in the country are required to follow a certain set of rules for how they deliver Medicaid services. Those rules are set up by the federal government. States that are interested in testing out new or innovative approaches can enter into something called an 1115 waiver agreement. When we do that, we get to say, hey, there are all these innovative ways that we think that we could deliver healthcare and get better outcomes at about the same cost. Can we do that? And so we enter into a negotiation and the federal government allows us to test out new ideas.
Miller: Am I right that these last for five years?
Jarem: Correct.
Miller: And it’s close to a billion dollars in federal money that we’re talking about, then there’s a state match as well. Is that money that you’d be getting either way, or is it new money that the feds are giving you to try out these new ways to leverage healthcare dollars?
Jarem: These are new dollars. We have $1.1 billion that are coming into the state, specifically for testing out what we call health-related social needs. And it supports us being able to improve healthcare by understanding and connecting with sectors that are outside of the medical environment.
Miller: Are there states that don’t actually apply for these and miss out on billions of dollars of aid?
Jarem: Yes. Many.
Miller: OK, that’s a separate conversation, but it’s surprising in its own right.
How did you decide that housing was, if not the best use, then a really good use for a big chunk of this money, hundreds of millions of federal dollars?
Jarem: We looked at where our state is in terms of our housing crisis. There’s a reason that this is a priority of the governor and our current leadership in our state. I think Director Bell could tell you quite a bit about where we’re at with housing and our needs in the state. This, in particular, is something that our state partners and our state agencies have been working on for over a decade, to really think about how to bring these systems together, often serving the same people with complicated, difficult systems. And so using the waiver is one approach to tackle a piece of the puzzle to really serve these people in a more coordinated fashion.
Miller: Andrea, what’s the connection between housing and health?
Bell: Yeah, well, it’s really interesting because we know that that term has been around for a lot of time: health and housing, housing and health. But the reality is the primary portion of a person’s health, our health, actually takes place outside of the healthcare delivery system. So things like nutrition, social support, community support, and for the sake of today’s conversation, housing. So it is a critical determinant of health, but also think about all of the investments that we put into a person’s health and then oftentime their housing isn’t stable. So we’ve been making this case to the federal government. And for the first time, we actually have resources to do something about it, not only use it as a colloquial term in terms of health and housing, and its importance to make life better for people.
Miller: Nevertheless, Steph, I can imagine someone just saying, all right, but we’re talking about health and healthcare here. Let me look at the leading causes of death in Oregon: cancer, and heart disease or cardiovascular health. If you have a billion dollars from the feds to use, but then, let’s put that towards even more mammograms, cancer screenings and help for people who are pre-diabetic. Why not do that? Why not say to the feds, we have new ideas we still want to experiment, but we want to focus on the leading killers themselves?
Jarem: We do some of that work anyway, as part of our program. I think in Oregon in particular, we really have an energy around constant transformation. So you’ll see throughout the state a lot of efforts to improve on those chronic diseases that you’re talking about. I think when you add in the aspects of housing … I mean, trying to treat a kidney infection when you live in a tent in the cold is not something that is going to be easily done.
So bringing together the important factors of how you keep someone stable enough, especially when they’re crossing multiple systems. A lot of our waiver has focused on people who are exiting carceral facilities, or people who are aging out of foster care, people who are needing to navigate many systems at the same time. It’s really difficult. And so that is the support that we are testing with the federal government is to really say, how do you bring those together in a way that makes it easier for the patient to navigate. And then also actually improves their outcomes in multiple systems.
Miller: Let’s get to some of the specifics here, in terms of how this will work. In addition to income requirements and being a renter for something, say, like rental assistance, OHP members have to fall into at least one of these categories: They have to have a complex physical or behavioral health condition; have a developmental or intellectual disability; difficulty with self-care or daily activities; experience of abuse or neglect. They have to be 65 years or older, or under the age of six; be pregnant or have given birth in the last 12 months; or repeated use of emergency room or crisis services.
Steph, it’s a pretty extensive list. And when you add all those populations together, I imagine it’s actually a good chunk of people. Do you have an estimate for the percentage of current enrollees who will somehow qualify?
Jarem: Great question. It is a large number of people. We have estimated around 130,000 – between 100,000 and 150,000 – households in the state are likely going to be eligible in some form.
Miller: And the household could be one to two to five people?
Jarem: Correct.
Miller: OK, so we’re talking about, I don’t know, a ballpark figure, maybe half a million Oregonians.
Jarem: I think that when you then add on layers of whether or not they have those qualifying conditions that you just stated, as well as the actual burden of rent, they also have to have an income that is 30% of the area median income. So there are a number of layers. As we’ve talked about, we’re really bringing together a healthcare system, so you hear those clinical aspects. And then you’re also bringing together a housing aspect, and so that looks at the income and the rent burden. But it is a large chunk of people and we see the system ramping up to be able to prepare for that.
Miller: Well, let’s talk about that. Andrea, this is where you come in, your agency even more so. Can you just give us a broad sense for the organizational challenges of doing work like this that I guess on this statewide level has never been done before, not just in this state but anywhere? So, where do you start?
Bell: That’s right. So it’s really interesting because this particular innovation is happening when one of two other things are happening. One, housing is on the hearts and minds of so many people. We need to boost affordable housing. It’s also coming at a time where Oregon is building like it has never built before. Now, we still need to do more so people can feel that in their day-to-day lives, but just if we look back from 2019 till now, over 28,000 affordable homes were built across the state. We need more of that.
Miller: Can I interrupt you? Is it true that we’re building like we never before, or building like we haven’t been building in recent years?
Bell: I think both.
Miller: Really? That’s truly surprising to me. I thought that in the ‘70s and ‘80s, or ‘50s and ‘60s, I just would have assumed that the rate of home construction would have far outstripped where we are right now. So I’m surprised and happy to hear that you’re saying there actually are currently historic levels of housing production.
Bell: There are historic levels of housing production here in Oregon. So just for example, we made a goal … we, as a state, said in 2019, we want to test to see if in five years we can bring on 25,000 new units of affordable housing. Now, if we think about that, 25,000 units, it’s a lot, but it’s still not proportional to what the need is. But we had never built that much affordable housing in five years and now we’re over 28,000 units of affordable housing being built. I say that for two reasons: one, because it can’t be the watermark of our progress by any stretch of the imagination. But what it also has done is it has changed the conversation about what is possible in terms of government being able to help facilitate local progress, but also making the case that people’s lives are impacted. And every single moment that someone doesn’t have housing, there’s a real impact to that.
So with this waiver and with this new benefit, what we have the ability to do is to help stabilize people while they are getting their healthcare needs met. When we think about implementation, it really has been how we can invest in localized solutions. And much of what has brought us here today are community-driven solutions that have helped build us out so that it works for each community in their own nuance.
Miller: OK, let’s get to the specifics though. How is somebody who is technically eligible going to find out that they are?
Bell: Yeah, so I would say the first way is many OHP members now are actively working with their local community-based organization to get other services. Now, what this means is there is enhanced and an additional benefit. If someone goes in to get care [and] they identify and communicate that there is a housing need and they might need rental assistance, there’s actually additional resources under this benefit to do something about it.
Miller: So if somebody goes in, say, for a checkup, it’s policy now that they would be asked, “Do you have housing insecurity? Are you able to pay your rent?” And are those questions going to be asked so that the answers could actually be heard?
Jarem: There are many healthcare providers who currently ask those types of questions, but we haven’t really had an opportunity for them to then refer out or connect to those services. And so getting that information is great, but then what is that provider to do? So, we are doing a lot of work. Again, we’re 15 days in, so we’re doing a lot of work to work with our local providers on the healthcare side, to make sure that they know where to refer. Then there’s a lot of other spaces in which people are able to connect with systems, whether it’s schools or the Department of Human Services, that they can walk in and say, “I’m having these challenges, I need support,” that they’re able to connect.
Miller: Andrea, one of the issues that we’ve talked about when it comes to a variety of state or federal social services in recent years is a sort of double-edged sword. On the one hand, I think everybody understands why there needs to be accountability and there needs to be requirements that are met if public funding is going to go to help somebody. On the other, sometimes the hoops themselves can be so onerous that they can actually either discourage people from applying or just make it hard for someone to get a loan or whatever. I mean, it’s not just about social services, it’s about SBA stuff, too.
Bell: Yeah.
Miller: There’s a long list. So. How much is somebody going to have to prove to actually get access to this money?
Bell: Well, you were right in that a lot of times we’ve seen where there’s been new resources and then people have to go through what feels like Olympic-sized hoops to get to them. And then oftentimes feel discouraged and just say “oh forget it, I’m gonna keep moving on.” One of the areas that is more technical and probably not exciting, but I think really important in terms of service delivery and access, is thinking about the different forms, the different ways in which people can identify that they’re eligible. If you have to prove your income, sure it could be through some traditional means like your pay stubs or other forms, but maybe it’s other things like attestations, maybe it’s other things like getting something from your landlord verifying that you’re behind rent. This is about not screening people out, particularly at the moment when they need it the most, and I think there’s a lot of people that probably think that the government needs to do a better job of that.
Miller: Steph, I want to turn to current politics right now because it’s on a lot of folks' minds. As a candidate, Donald Trump promised to renew some expiring tax cuts, and he needs some way to pay for that. If cuts to Social Security and Medicare are off the table, is Medicaid a likely target?
Jarem: It’s a great question. I think whenever there’s a change in the federal administration, we anticipate that there are going to be changes that then impact healthcare policy in particular. As a state, it’s something that we’re watching quite closely and monitoring. I would say that on the whole, Oregon Health Authority is focused on our current work and continues to be really driving towards the missions that we have, and we don’t have a plan to change that.
Miller: Does the new administration, does any administration have the legal power to change either the way an already-approved waiver is handled or the money that is sent out? I mean, could the Trump administration say we don’t think that this is a good experiment. We think there’s a better use of federal money for healthcare, and we’re going to turn the spigot off midstream in the middle of these current five years?
Jarem: I think that would be difficult. I think that we’re going to look forward to having those conversations with the incoming administration. There’s a lot of evidence about the links between health and housing, and the importance of this work. I think that stands on its own as well, regardless of the administration. There’s a lot of this work that’s pretty bipartisan.
Miller: What about the next waiver? Which I imagine you’re in the middle of applying for right now, even as you’re administering the current one. It doesn’t seem outlandish to assume that the Trump administration would look at a blue state’s sort of liberal expansion of connecting housing and health and say, “no, we don’t think this is a good use of money going forward.” You’ve been very careful and I appreciate it [laughter]. But let me put it this way, would you think your chances of a new similar waiver would be better under a Harris administration than they are going to be under the Trump administration you’re getting?
Jarem: I think that the Harris administration would have likely stayed the same course in terms of pushing this forward. We do not anticipate getting additional federal dollars in the next waiver, regardless of the administration. I think this is a very specific mechanism that some administrations have used and then it’s gone away and it’s come back. So we were able to really take advantage of the opportunity to get in the door there …
Miller: When you say you don’t expect additional money, you’re saying that regardless of the next administration, you wouldn’t expect to get another billion dollars waiver like this at all. So this is a kind of five-year experiment that you’re seeing as a one and done.
Jarem: Yes. We will build these benefits into our program going forward, and that’s what we anticipate doing. But at that point, we’ll have made the investments in the state infrastructure to really have capacity to be able to link these systems going forward.
Miller: Well then that gets to what you’re hoping to be able to prove and how you’ll prove it. It seems like there’s so many variables here. What are you going to be focusing on to show efficacy?
Jarem: There are a lot of short-term measures that we’re looking at that have to do with utilization – both on the healthcare side and with the new benefits – to be able to really see, what is the impact of a family that gets rent when a parent lost their job, and whether or not that child is also staying in the school district and not having to move throughout the state? There are a lot of these small type case studies that we’ll be examining. We also have a mandatory third party evaluation that’ll be done that looks at some of the longer term impacts to things like emergency department use and other factors that we know link that health outcome with our housing benefit.
Miller: Steph Jarem and Andrea Bell, thanks very much.
Bell: Thanks for having us.
Jarem: Thank you.
Miller: Steph Jarem is the 1115 waiver policy director with OHA. Andrea Bell is the executive director of Oregon Housing Community Services. And Andrea, I hope we’ll talk soon and much more deeply about housing in the state, since there’s a lot more to talk about.
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