New York Debates Whether Housing Counts As Health Care

Standing outside her sixth-floor apartment in the Bronx, Lissette Encarnacion says she sometimes forgets the place belongs to her.

"I'm thinking I'm at somebody else's [house]," she says. "I'm ringing my own doorbell."

Encarnacion used to have a career in banking, and lived in a real home with her son and husband. Then one night everything changed, she says, when her husband came home drunk and angry, and threw her off a balcony.

"He came home, pulled me from the hair, and just started beating the hell out of me," she says. She was seven months pregnant with her second child, a boy.

Encarnacion suffered traumatic brain injury and was never the same. She and her sons moved in with her sister, but Encarnacion often wandered off.

Eventually she became homeless, she tells NPR affiliate WNYC, and remained that way for a decade. She suffered from epileptic seizures, and was frequently picked up by paramedics and taken to emergency rooms.

Then two years ago, she moved into The Brook, an apartment complex that provides supportive housing to its residents — more than half of whom are formerly homeless.

Now Encarnacion lives in a studio apartment, which she has decorated with stuffed animals and Christmas lights. And though the place is small, she likes to think of it as her "penthouse" apartment.

Brenda Rosen, the director of Common Ground, the organization that manages the building, says The Brook offers a full range of services to keep its residents healthy: social workers, security, a doctor and even an event planner.

And while these services don't come without a cost — an apartment at The Brook runs at about $24,000 a year — Rosen says they are cheaper than the estimated $56,000 per year that the city spends on the emergency room visits and stays at shelters and jails, where many people with severe mental illness end up.

"You know, we as a society are paying for somebody to be on the streets," says Rosen.

Few people would dispute that Lissette Encarnacion is better off in her studio apartment than she was when she was living under the bridge. And it's far cheaper if she has a doctor downstairs than if she has to show up regularly in the ER.

The question is, who pays for this kind of housing?

New York now has about 47,000 supportive housing units, and the state intends to invest $260 million Medicaid dollars over the next two years. But the federal government won't match it.

At the crux of this debate is the question of whether housing qualifies as health care.

This past December, the outgoing New York State commissioner of health argued in an article in The New England Journal of Medicine that housing is health care. Providing housing to the chronically homeless saves health care money, he argues, so Medicaid should help pay capital costs.

New York State Medicaid Director Jason Helgerson went further, arguing that federal Medicaid money already pays for housing, through long stays in nursing homes and hospitals.

But Bruce Vladeck, who formerly administered Medicaid and Medicare in the Clinton administration, says federal Medicaid dollars can't and shouldn't be used to pay for housing — it's not cost-effective.

"Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem," says Vladeck.

Instead, Vladeck argues that housing programs should be paid by housing agencies.

"As a society, both in the private sector and the public sector, we are really cheap and niggling and resentful about paying for social services, and we are much more generous when it comes to paying for health services," he says.

At the moment there is not enough housing money to go around for all the people who need it — people like Encarnacion, who are done living on the streets but still need support. For her, The Brook offers a place in between.

"I stuck it out, and it's good," she says. "And God's been real good to me. And the people that work here have been very good to me — and patient, because I am not easy. I am not easy."

To hear and read more about The Brook and other innovative initiatives in health care reform in New York, check out WNYC's series Prescription for the Bronx.

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