Transcripts For CSPAN Key Capitol Hill Hearings 20240622

It is because we know better is always possible. An economy that works for the middleclass means a country that works for everyone. Not in spite of our differences but because of them. More of both of those things. After 10 years of mr. Harper, so do we. I am in this and i want to be your prime minister. Mr. Wells thank you, mr. Trudeau. This concludes the first debate of the campaign. The whole experiment was a bit of a new experience for everyone concerned and i want to thank the leaders for the faith when participate. Good luck on the campaign trail. On behalf of macleans, i want to thank the viewers for tuning in tonight. Be sure to visit the ma macleans website. Stay tuned. I am paul wells. Good night from toronto. [captions Copyright National cable satellite corp. 2015] live now to the Russell Senate Office Building where the alliance for Health Reform is holding a discussion today on how homelessness impacts the health care of individuals. Ed howard on your screen now giving introductory remarks. There is a connection between health and various social determinants. Be will be looking at the nature and the strength of that connection. In this briefing, and in the subsequent ones in the series. Something you may have seen yesterday, new york city mayor bill de blasio announced at 22 Million Program to connect more Homeless People with Mental Health care. I think just another sign of growing activity at every level to connect the dots. I hope ae will shine lot of light on that topic. Our discussion will center on how housing stability impacts Health Outcomes and health care costs. A look at medicaids role in adjusting the problem. And, how much flex ability to is an federal policy to allow states and communities to meld careing and health streams. Importantly, we want to look at what the obstacles might be the biggest obstacles to making these two Program Areas compatible. We are pleased very much to acknowledge support for todays program by the centene corporation, one of americas operatesnsurers that medicaid and other programs and two dozen states, i believe. Before we get to the program, let me do a little bit of housekeeping. In your packets, there is important information, including speaker biographies, onepage material lists in your kids, and the powerpoint presentations and hardcopy, so you can follow along. There will be a video recording of this briefing available on the alliance website. Allhealth. Org. Probably monday. Followed by a transcript a few days later, along with all of the materials in your kit, along with materials that we think might be helpful to you. At the appropriate time, you can ask our panel a question by filling out one of the green cards that are in your packets, or you can come to the microphones. There is one on either side of the room. You can use the he althandhousing to tweet o tweet generally. If you are watching on cspan, and want to ask a question, you can also tweet a question. At the end of the briefing, there is a blue evaluation form in your packets that i would very much appreciate your filling out, so we can improve these briefings, and target them to the needs of the folks who come and need some guidance. Lets hear from our very well panel. D ba i will give them inadequate introductions, and i will do it aly so we do not disrupt the flow of the discussion. We will start with barbara dipietro, director of policy at the National Healthcare for the Homeless Council. She is also active in the health maryland. Omeless of she has a multilevel perspective on how to deal with these problems. We have asked barbara to highlight the connection between health care and housing in general, white is important, and state,nities on the federal, and local levels to address it. Then, we will hear from jennifer ho, Senior Adviser for housing and services to hide secretary Julian Castro hud secretary Julian Castro. She will describe how her agency and others are collaborating on health and housing issues be a gretchen hammer will be next. She is director of colorados department of Health Care Policy and financing. We have asked gretchen to tell us about colorados efforts to Bridge Health and housing policies, and what gets in the way of those efforts. Our final panelist assister adele osullivan, a family physician, and founder of circle the city, a phoenix nonprofit that brings private and public sectors together to help those experiencing homelessness and illness. Describe thewill innovative model and what gets in the way of this approach. We have come to the part of the program that actually has some substance to it, and that is to say, barbara dipietro. Barbara. Dipietro i appreciate so may people being here today. Shows the importance that housing has on Peoples Health status. The National Healthcare for Homeless Council represents Health Centers and the homeless patients that they serve, about 250 nationally. Over one million patients are being seen in americas Health Centers each year. Of their and breath knees, specifically because of a lack of housing, is really an issue for not only Health Centers, but for the larger Health Care Industry that we are looking to change. One of the things that might not housing ise is how health care. Back in the 1980s, the institute of medicine did a study looking at that impact. They found three major findings. Causesthe core health homelessness. Typically we were seeing a spiral of people with an injury or illness, unable to work. When you are unable to work, of course the work goes away, you get fired or laid off, o and you can no longer bring in income. Soon after that, you cant make rent or mortgage. You move in with friends, pretty soon that doesnt work out, so you slide into a shelter situation or on the street. We also see the congress. Homelessness causes for health poor health. If you can imagine living on the it is or in a shelter, stressful. If you did not have issues before, you tend to develop issues when you are homeless. It is very hard to be on the street and exposed to extremes of weather without getting hospital visits tend to be frequent. High pressure. If you want stress before you must housing, you get stressed out. Develop, orends to depression. Lack ofo think about housing, gives treatment. We are putting billions of dollars into our Health Care Industry every year trillions. None of that funding works well and efficient as Health Care Providers. Nothing we do works well with someone who lives on the street. Every time we turn somebody in recovery only to discharge them to the street, we have complicated, and in fact compromised, the treatment we have just affected. What we discharge people to shelters or the street, the care that we just paid for is compromise. These are the things that are all bundled up together in the intersection of health and housing. We really need to appreciate how that throughy housing. One of the things we are seeing, as again, we represent the nurses, and the workforce that goes behind caring for these patients. Not surprisingly, is very high rates of acute and communicable diseases. Respiratory illnesses. All the things you would expect. Infections from cuts you cant keep clean on the street. Try being diabetic with needles on the street. The rate at which we replace medications is astronomical because of the rate that they are stolen. When you cant keep things safe when you cant keep medications refrigerator, it is very difficult to maintain compliance to your health care. How many times has anyone here got to the doctor and then prescribed medication that requires them to go to the bathroom more often . No need for a show of hands. That is not possible when Homeless People did not have the opportunity to go to the bathroom. Life in ar private public space can be extremely an a decent. What we see is Health Care Providers and their clients come in and say, i did not take that medication because otherwise i would get arrested, or i was afraid of getting arrested, or he had nowhere to go, or my meds were stolen. This is what we hear. We see when we look at the literature, the literature shows that people who are homeless have chronic disease three to six times more than other people. Diabetes,ill asthma, hypertension, high cholesterol, heart disease, and all the rest, but at higher rates. We see a lot of intensive needs to coordinate this care. We see both extremes of a use of a Health Care System. We have the high end user, where we are putting a lot of money into a small number of people that we need to stabilize, but we also see People Living on the outskirts of our society who avoid the Health Care System, but have intensive needs, usually in the Mental Health and Substance Abuse areas. How is it that we reach those people . When we look at a hospital systems, hospitals are really strapped. When you are a hospital, what are you supposed to do when you have no safe discharge option for a client that is ready for discharge. It is illegal to discharge to the street, but as anything else else, what dohing you do for someone who does not have a place to go. These are the real issues that Health Care Officials are struggling with two friday capacity to have safe and ethical treatments for people. Whenso see people that they are ill, it is very difficult to get out of homelessness. When you are fighting an addiction or illness, it is very hard to get off the street. This is just one example of how in a health care population, highers people have rates of just about every disease you can imagine. This brings us to Supportive Housing. When we think about what is Supportive Housing, typically it is helpful to think about in terms of a traditional model that emphasizes recovery first. Traditionally, in our communities, we require people to get clean and sober, enter into treatment, and be successful with that before we give them into a housing unit. If everyone follows the rules, and continue to follow the rules, maybe one day you could be in independent housing. While that works for some, where it didnt work was for people who have really Serious Health care conditions. It is hard to get clean when you are living on the street. Thatrtive housing slips model. It is not timelimited. Frankly, any number one of any of us can go home and have a drink. That is perfectly right in our home. It needs to be an opportunity. We need to work with people where they are in the stabilizing unit of housing, so they have a place to put their medications, to put an appointment card. We have a stable place to visit them. Our outreach workers cant find people when they are shifting around in the street. We need to think about how are we supporting housing in this way. A wide range of teambased way to make this work. When you combine the stability of housing with healthcare helpces, we can really people be stable in a housing. This is mainstream right now for seniors and people with disabilities. My grandmother can have meals care. Med to her, in care think about extending the into this population so we are both supporting the housing and services that people need. Relapseto talk about is part of recovery. These are the kinds of things we need to expect. Recovery and Mental Health and ction does not look like black and white. It looks like a struggle. Can just one slip up jeopardize housing and are you back in the street. It is really important that we are able to work with people and adjust services. Again, there is no requirement to sobriety and the services are voluntary. When we find is that people are very excited when they get into a unit. So many things look possible that didnt before. We have been evaluating the effects of housing for about 25 years now. Consistently, what we find is housing improves health, and it improves health i outcome and lowers the cost of health care. I think this is where we need to be thinking. We are so focused on cost, understandably so, but we need to think about it where is it that we can make inroads and partnerships. You can read this site here. Our consistent findings on all of these issues. Again, we want to focus on how is it that bringing these two sectors together is really bringing out the things that we need. There are a lot of opportunities at both the federal, state, and local level. Your states are working on strategies to end homelessness, and to improve health. We also look at greater determinants of health. What are the things that i think is important, particularly here in d. C. To remember, we need federal support for the housing piece. My colleagues will talk a lot about what they are seeing in their sectors. That are being required by sequestration, if we dont have the Housing Support amount of our Healthcare Services will make this work well. We need these to come together. Another thing that i would really recommend as a second point,t as a takeaway for all of you who are health staffers, get to know each other. You have a lot in common. A lot of times we are not talking together at the federal level it like we asked people to do at the local level. Really, what we are doing at the federal level is that bridge between build that bridge between health care and housing. We are in a rapidly changing environment. A whole is system as changing. We are focused on outcomes and costs, but we also need to focus on really potable people, i getting them what they need. Nothing works well as a Health Care Provider when people are living on the street. We really want to b the orient to housing as a health care intervention. My colleague will talk about how hard they have focused on building this bridge, but really as an illustration of making this model work. Myant to point out that m colleague, matt, if anyone is interested in learning more about this, matt will take your card. Mr. Howard we will turn to jennifer ho. i am jennifer ho, the d secretary. I like to joke saying that im the one person that knows the difference between medicare and medicaid every day. You know what im talking about, dont you . Iy background is actually spent my first 10 years and care in managed care. It was in that way that i was brought to a table to consider link between homelessness and health and the impact that Public Housing would have on health. I have a doing that ever sense for the last 18 years i have been doing that ever since for the last 18 years. I want to assure you that there is an unprecedented level of andaboration between hud hhs. Not just because that is my job, but because it really is the case. Hud is talking to the center for medicaid almost every day. Were talking to folks at , at the and medicare ndministration on children and families almost every day. I know and feel sometimes that housing and health care are miles apart, and no one is talking, by want to promise you that in this administration, there is an unprecedented level of cooperation. Civil fact about how we invest in things federally that Health Care People dont always know. You operate in a world of mandatory budgets and in tyler programs. Iseral Housing Assistance the only benefit that is not an entitlement. When someone becomes eligible for medicaid or medicare, they get it. A voucher forout housing option, you get in line. We ask congress to invest more in housing, they worry about the renewal burden, the fact that this increases our total budget in future years. Something i like to call keeping people in their homes. The conundrum is that hud pays for a lot of services that medicaid could pay for. Medicaid has a lot of financial incentives for there to be more affordable and accessible housing, and the budget environment is such that we are not doing what we know works, and not at the scale that matches the needs. That is why im excited to be here with you today. Your interest in housing could help create the consensus that we need to make the investments that matter. Thanks for being here, and thanks for allowing me to be on this incredible panel. I will talk about how this plays out in three areas aging, disability, and homelessness. Americans are living longer, and the babyboom will test our commitment to the relationship between housing and health. As we go older, we are more likely to live alone, have more Chronic Health conditions, and less of mo mobility, and we go poorer. The number of eligible households for assistance will in 2030. Between 2011 fory, we provide assistance 1. 2 million seniors. One out of every three singers who is income eligible. That means that we would need 900,000 more subsidized Housing Units by 2030 just to keep up with one in three people who need it getting it. We have not made significant new investments in housing for seniors in some time. Think about where you live today , or what your parents or grandparents live. Less than one half of 1 of existing housing is currently accessible to someone who uses a wheelchair. Only 5 o is livable for someone who has mobility impairments. Most american existing Housing Stock is not designed for them to age in place safely. Imagine twentysomething Million People over the age of 80 fall, and they cannot return to their home, or they dont fall, but they just cant afford where they live. Where will they go . How do we have a strategy for aging in place and people will not be able to afford or navigate the place of the call home today. The Healthcare System, i would argue, has a huge stake in needs of an aging america, get there is not consensus that this is an investment that the federal government should be making. A lot of the work that we are doing with hhs has been around disability and the institutionalization. Money follows the person largely through section 11. It forces partnerships between the finance agencies and medicaid agencies. And some places in some places, like colorado, it did not have to be forced, the partnership was there. We have two rounds of funding. 35 states now have money. In the last round we funded hundred 50 million for about 4000 units. Inob in the bucket drop the bucket. The Health Care System, i would argue, has more of a stake for creating options for the not aled, yet there is consensus that this is an investment that the federal government should make each year. I appreciate barbara for covering all the arguments. Sister adele will be the closer on this dear gretchen will provide the state o perspective sister and double wille closer, and gretchen provide the state perspective. I want to add a few things. Supportive housing is a proven intervention to end chronic homelessness. It works for people, it improves health, it reduces unnecessary er visits and hospitalizations. The Health Care System, i would argue, has a huge stake in creating a sufficient supply of housing to end chronic homelessness in america. Yet, there is not consensus that this is an investment of the federal government should be making. It is not in the house or senate budgets. Second, we are learning something from the v. A. Here there has been consensus on assistance. We have seen a one third reduction in veteran homelessness between 2010 and 2014, and we are on a path to effectively and veteran homelessness. Imagine if we could get an investment in support of housing and support of housing in line with medicaid for those who have lived on our streets and shelters for years, sometimes decades. My focus has been to work with cms to think about ways in which we can better online housing and medicaid. Im thrilled with the new information on Housing Related Services that they have published. I think there is a link to it in the documents in your packets. Increasingly, state directors, like gretchen, understand if they are going to meet the goals of Health Reform, they will need to deal with housing instability and homelessness. They have a new best friend, the ouser. This document brings clarity to something that has been unclear. Of housing is over here, and health care over here, there is a whole lot in the middle. For,can medicaid pay for whom, and when . I believe is medicaid were paying for all the services that it could pay for, we would have Better Outcomes for seniors, Better Outcomes for people with disabilities, and we could end chronic homelessness. I believe that medicaid became a major player in housing, we could create the consensus needed for the level of investments necessary for seniors to age in a home that they can navigate and afford. People would have more choices of where to live, and more would make their Housing Available because they valued the service partnership. The conundrum is today hard hud pays fory is housing that medicaid could pay for. Medicaid has financial incentives for there to be more affordable and accessible housing and the budget environment is such that we cannot do what we know works. That is why im excited to be here because your interest in housing, your understanding of the relationship between housing forhealth, your advocacy more targeted investments in Supportive Housing for older americans, individuals with disabilities, including false with disabilities living on the streets, could help create the consensus we need to make the investments that will matter. Thank you. Thank you jennifer. Before we go on, if i cant, let me ask you a clarifying question. You were talking about the services that medicaid could pay for in Supportive Housing. I wonder if you could be a little more explicit and say a couple of words about what is stopping that from happening now. Example, and are homeless assistance program, we spent over 400 million a year on services. We only need to under 65 million to create more Supportive Housing and end chronic homelessness, but we are spending 400 million on services. That is everything from the things that medicaid cant pay for like employment assistance, but a lot of that is exactly the engagement,each, assistance that is described in the new housing related bolton. The biggest barrier is that states dont know what cms is approved, they dont know what they will asked for. Everybody is afraid that what we are saying is medicaid should pay for housing. We are not saying medicaid should pay for housing. Were saying medicaid should pay for health. We are also paying for services, for Service Coordinators in a senior housing. We pay for Service Coordinators and Public Housing. A lot of that Service Coordination is really Health System navigation and wellness activity so that we dont have an ambulance pulling up every night and we can people can keep people in the homes as long as we can. Mr. Howard we will turn out to gretchen hammer from colorado. Ms. Hammer terrific. Thank you for inviting colorado to participate in this conversation. It is a privilege to be able to share with you some of the things we are doing. First, i would like to provide some context. Everything we do in our State Government at this point in time is really driven by our platform for health. Our bold goal is to be the healthiest day and the nation. We take that goal very seriously. Not only because we have a great place to live, but because we have Health Disparities within archimedes bell holding us back, and we are working very hard to move we have Health Disparities within our andunities holding us back, were working very hard to move those forward. Atbelieve, when we look things holistically, we are able to put the right services, support, and f are in place to make colorado the Healthiest State in the nation. The nature of the health care needing health insurance, most of the time, to Access Services that you need, and making sure that we have the capacity within our Health Care System to meet the citizens of colorado needs. Then, looking at a Health Care System that can have better value for what it provides today. We invest a lot of money across the nation in a Health Care System, and i think we have some opportunities to get better value for the dollars that we investigate some of that requires infrastructure integrated highly care between physical, behavioral services, so we dont have one person with one body going to three different locations to get their Health Care Needs met. Also, look at health care technology. The state of health is a highlevel holistic view of colorado and how we are looking to move our agenda forward. We did expand medicaid in colorado. A coverage and capacity area of focus. In september 2013, prior to the first open Enrollment Period of , we havedable care act less than one million coloradans enrolled and medicaid, now we have about 1. 2 million. Mothers who get coverage through chip. Peoples a diversity of who we cover. Baseddo did some state activity and expanded early for those living below poverty. That is 11,000 per year in income. Be expanded to 10 of poverty or less. And we built on that as we moved into dead way to that of 14. It was an important step for us to understand the needs of most of those primarily Homeless Individuals to understand how to best and with them, how to support them getting access to coverage, and begin to understand what the rest of the Health Care Needs would be, and other types of services. I expansion has been an important piece of our our expansion has been an important our work. Rt there is a specific person working in the Governors Office on the issue of homelessness. Oft are governor was mayor denver, he worked on homelessness, and that has the government should. We have been able to look at the health careour system. What other animations do we need . Colorado is a very nice place to live. I have lived there almost all of my life. It is also very expensive place to live. Given that housing is one of those issues that is directly impacted by the other components of the marketplace that are around him, and other things, it is really a challenge at times and expensive environment overall colorado has one of the hottest real estate markets in the nation at this point in time, to figure out how Affordable Housing can be made available. This dual focus of both a Health Platform and a housing platform to lookus up well at how we can expand the relationship between these two areas. Health and housing has been an important piece of what we have been working on. We having gauged in some discussions that have created this crosswalk, that i think jennifer was referring to, which is how can we be sure that we are using investments appropriately so that medical related supports are being paid for in a way that makes sense, and other Housing Related Services can be leveraged in the same way. We have engaged in a crosswalk study. I wanted to take a moment to talk a little bit about the findings from that. We looked at fiscal year 20132014 which looks at the First Six Months of our full expansion of medicaid. When we look at our data, there were about 30,000 who reported homelessness. 24,000 had reported homelessness throughout the entire year, and them talkedrest of about being homeless at least at some point. I think that is an important piece to call out. When we think about homelessness , just like when we think about coverage, it is a port in many people. It may not be how you exist in the world throughout the world. It is an important piece more like a programming to recognize that variant in peoples lives. But we did analysis, it was about 160 million of services on those people. Through this exercise, we began 37,000 intose deciles. I know we have been talking a and i wouldney, like to believe that we can recognize from that number is that those people were very very ill, and probably didnt feel very good. I think it is important for us to recognize that we have an opportunity to not only potentially save resources if we do this work better, but also help people feel better, and help people have a better existence as they move through the world. This is a very important piece that we are looking at from both a budget perspective and an Overall Health perspective. What we want to be the healthiest in the nation, that is for everybody. It is a very important dolls to alsoat what to spend, and the experience that people have. What we hear about these new opportunities, the clarity that 26 of this june year, it is really a chance for us to have more clarity as we work to see what we can do to , its health and housing not only address these individuals, but put more permanent structures and place overall. To do that, i think we have talked a little bit about services can exist in silos at level. Ernment we have created a cross agency thep that has members of division of housing, the Governors Office. That group meets twice a week. Some of the work we have to do is clarify language. All bureaucratic programs have acronyms that we only understand. You have to step back and say, what do those letters mean . It has been an important and alsog of language, recognizing that if it takes a some time at the agency level two interact with each other, in colorado,nties across theres going to be some confusion and opportunities for better education. That is where we are focusing helping ours now providers both on the housing site and the health care site understand what are the opportunities to be working bring inand how can we alignment and synergy to the funding available to all of us. We also look at waiver authorities made available. There is a re rece document out recent document out that is perhaps appease of the conversation that we havent highlighted, but a piece of how those services can be delivered. Lastly, the technology piece. We have a Homeless Management Information system and a Health Care Information system. Were looking at the opportunity to have a connection between those because we are now in a time where technology could help us if we let it. Bytly, i would conclude circling back on the reality of the people who are at the heart of these efforts. We had a chance and it former life to talk about and learn about the experiences of those living in a ford will housing, their health care expenses. One of the most heartbreaking things about that was the lack of dignity that they felt they were afforded from the Health Care System. Treated as though it was a gift that they had a chance to be there, that if they were smarter, they could navigate are very complicated Health Care System, that i frankly stole to navigate at times. What we concluded and talk to our partners about is it does not cost us any Additional Resources to respect and give dignity to votes. Some basic things that we can do to help improve Peoples Health, their mental wellbeing, and all our societies and communities with some recognition that these are hard issues and those in the middle of them need respect as we work to solve them. You, gretchen. Nk i now turn to dr. Osullivan. Im very happy to be here today. From another perspective, i am a family physician and i have cared for and exclusively Homeless Population. Can you hear me . For an exclusively homeless 1996. Tion since 1 experience every day and trying to give good patient care the trickledown effect of policy and spending decisions in the lives of my patients. Ability to make good policy and spending decisions influences the Health Outcomes a very real people. I come from arizona. Im going to speak to you about our local situation, which, as all of our environments are, is somewhat unique. Arizona is a Medicaid Expansion state, im happy to say. There is, however, a legal challenge pending in the court to that expansion. We have other successes that i would like to tell you about. One is that arizona decreased chronic homelessness by 15 2014. N 2013 and on a note, which i experience began in thee phoenix area, which is a very large and sprawling county with a Homeless Population of approximately 17,000. I started a nonprofit called circle the city. We did that as a community, as a grassroots effort to bring people together, to meet the incredible need of those who to beoo sick, too frail in our streets and honest on our streets and in our shelters. In 2012, we opened a 50 bed facility in the phoenix area. Isrvice for the surface recuperative care for people experiencing homelessness. You can think of it as Bridge Housing with very intensive medical support. Part of been a crucial our ability to provide for the sickest, the frail us, and the most notable. Piece that happen is that the number of supportive Housing Units is going. In Maricopa County, 1600 supportive Housing Units were funded for individuals with a seriously mentally ill designation. Through regional public and private initiative, it was our united way bringing partners together another 1000 units of Supportive Housing were targeted to chronically homeless. Ndividuals in Maricopa County however, the challenge. We still have a Supportive Housing need and resource challenge. We think it would take about 1000 more supportive Housing Units to end chronic. Omelessness in Maricopa County arizona medicaid plan covers a comprehensive bundle of services. Is that ine of that Supportive Housing, those services are only available to persons with the seriously mentally ill designation. Nonprofit participated in a local project with a medical center. Frequent users of system engagement is an acronym for Supportive Housing. A tremendous, active, wonderful partner and try to get supportive Housing Available to us. Project, wet engaged the most frequent and most extensive homeless utilizes of care. We engaged, we offered the services of our medical respite stabilize,rder to and quickly moved to Supportive Housing. The vouchers were donated by several agencies in the community. That Pilot Project realized the a 73 reduction in Emergency Rooms visits and reduction in inpatient utilization after patients are placed in permanent Supportive Housing. Diagnosis is homelessness. These are the patients that we took care of through the fuse pilot. They did not have just one chronic disease. O. Me had tw most had 3, 4, or five. That does not take into account the acut problem Heart Failure exacerbation, the for which people cycle in and out of emergency room care. Why do people cycle in and out of emergency room care . In our population, these are the reasons we probably believe. As you can see, the last one on there is that the primary care system might not be responsive population issues or the multiple issues that barbara talked about earlier that are simply the cooccurring phenomenon of being homeless and living on our streets. I would like to show you just briefly one case study of a patient that was in our fuse pilot. We call him mr. 280. He was well known to the Phoenix Fire Department because he called 911 all the time for transport to hospitals. In adding up all the hospitals, he had 280 visits. In the hospitals that we worked with, he had been to the emergency room 192 times between 2007 and 2013. We engaged him, brought him to the Respite Center for three weeks, and then we discharged him to permanent Supportive Housing. s80 is mr. Two hospital bill. Page 1, 2, three, 4, 5, 6, 7, 8, 9, and 10. Time, he had 192 visits but not one inpatient admission. When we engage mr. 280, we found out that he was living almost in the hospital parking lot. Overal account charge of 300,000 at one hospital. This is a graph of the emergency room visits during that time. As you can see, there are three places there in 12 and 13 when he was not in the emergency room for the month. We can show you three mugshots that correspond to those months when he did not appear in the emergency room. Since being housed, he has been to the emergency room twice both appropriate visits. He has never been admitted to the hospital. He is stably housed, and has remained stably housed over that period of time. He is receiving care at the local new logical institute. He got his food handlers card. He is employed parttime at a local restaurant. What are challenges on the ground . The talkou have heard of care coordination. We can gett what somebody into permanent Supportive Housing because we have the opportunity im going to get that diabetic foot in housing, not on the street or under the bridge. Theeed to coordinate services that we provide. We havent exactly figured out whose responsibility it will be. As another one of those issues where we have to work together. We have to prioritize the support in terms of medical needs. I think, if you have not seen the work done out of boston with mcconnell, are medically vulnerable are dying on the street. We have pretty good data to show that persons with chronic illnesses, who are medically vulnerable, will not survive. And yet, our systems are electronic systems, our silos, if you will, we have to learn how to cross them to privatize the limited resources that we have to the persons who need them the most. One thing that we are really interested in is developing new and innovative models for delivering primary health care efficiently. Once we get people there, how do we deliver the care and the most efficient way possible . Do we take the services to them . Do we provided transportation and the followup . All of those impossibilities. We know it is important to place people immediately. They will get sick, for one thing. The second thing is what we can locate the person that needs the housing, we need to try and put them there. Plugld like to put in a for medical respite care for the homeless, and the growing of these programs as pivotal points ille patients, who are too sometimes for direct placement without the stabilization of the illness can use medical respite as Bridge Housing. My recommendation housing is health care. If we could increase availability of those permanent supportive Housing Units, we need the vouchers, and we need the services. Anything we can do to incentivize are states our states to cover the array of competence of services in medicaid isusing, wonderful, but medicare alone cannot do it. We need the support from our Mental Health providers. We need hud. We need housing. When we can get those wraparound services, those positive outcomes that people think are possible, im here to tell you that they are possible. Thank you. Mr. Howard that is terrific. Thank you, sister adele. We are now at a point where we would love to hear your questions. Fill out and hold up a green card, and someone will come forward, or you can tweet it, and we can go from there. Let me start with sister adele, if i can. I would welcome other panelists to chime in as well. Can you talk about the kinds of pockets you were able to pick to put together what looks like an incredibly of housing with services that have allowed you to make such progress . Osullivan as far as housing is concerned, through care, and theof united way, we were able to put together some funds from the department of housing, the state department of housing, from a couple of the cities in the metropolitan Maricopa County area, and from philanthropy. Those are the vouchers. Ho Health Care Officials might be confused about the continuum of care. Programsess assistance are delivered into communities through loose Community Collaborations that we call continuums of care. That is confusing for the Healthcare System, i wish we would have called it something else, especially because we are not advocating for a continuum of care. When she is saying money that is probably better assistance¿ assistance. Mr. Howard ok. Observation. Your if you would identify yourself, and keep the question as brief as you can, we would very much appreciate it. Thank you. , a. M. Media. What experience do any of you have with those who have gone on medicaid as a result of ,xperiencing a Natural Disaster and losing the housing they had before . Ho i would love to talk observed in new orleans. It is timely with the anniversary of Hurricane Katrina and rita. One of the things tragic. The number of people who lost their homes was devastating. What happened to that committee was devastating. What they did in the rebuild is amazing. Ofause there was a lot flexible Disaster Recovery money, they got low Income Housing tax credits, which are the biggest producer of capital dollars for the creation of more housing. Money,t hud block grant which is the most flexible money. They got housing choice vouchers which is rental assistance, and shelter plus care vouchers all with Disaster Recovery money. Amazing thing that they did is they use the Community Development block grant flexible money to pay for services while they created Affordable Housing using the low Income Housing tax credit. But they use a housing choice vouchers and the shelter plus care vouchers to deeply subsidize those units for people experiencing homelessness while they built a medicaid system that would a for those houses and become the triage process and pay for those houses become the triage process for people moving into that housing. I chose a state were the government chose not to expand medicaid, but it shows what is possible when medicaid and housing are used strategically together. I hope that reflects on some of what youre asking. I should call attention to what is on the screen, and that is an Incentive Program of hours, along with our friends at sentine, to get you to fill out the evaluation form. If you do in sufficient that we get a 50 participation rate, the alliance will make a contribution to the city of hope which addresses homelessness and health care on the ground in dce so, dont leave without in. C. So, dont leave without filling out your form. This panel is a great example of social medicine. , i am not hearing a focus on standards of care that we would expect all hospitals and Health Care Providers to be aware of. Mr. 280 that sister sullivan introduced us to, to me, is an example of hospitals taking advantage of the medicaid to extract as much money as they can from it rather than identify the sources of this mans needs and making recommendations for addressing whether through the resources of the hospital or the resources of that you community. I think that the colorado story is interesting because they want to be the Healthiest State. That means not just the Healthiest State for homeless Healthiest State for all people. Where are the recommendations on how the Health Care System into the integrated social determinants of health, with housing being an example here . Shouldnt we require, through regulatory authority, standards of health when Health Care Providers identify should be the socialdentify causes of the problems they are expected to treat . I think this is a great opportunity to raise those issues so that we can have some Generic Solutions and not just be proud of reducing homelessness for a certain segment of the population. I will start. I completely agree and i appreciate your passion behind as issue. I think what we are trying to do is get our Healthcare System to the place you have just described. That is not just for special populations. That is for all of us. What we are all looking for is an outcome driven how are we, as individual human beings, and as our communities at Population Health getting healthier . How can we put the resources of our Health Care System behind that . I mean an actual, integrated system that has information and resources to deliver the kind of resources and care that we envision here. We are trying to build the capacity in our communities to get there, and a lot of that has to do with the partnerships that have been described among people who are in charge of the social determinants of health, so not limited to housing, but good nutrition, good education, good jobs, stability and health as well as stability in life. I think when we talk about investments in housing and talking about the partnerships we need to have, it is informed by recognizing this man does not have housing, and that is what is contributing to 280 emergency room visits. So, how does this Hospital Partner with his outpatient primary care provider in the intonity to get him housing . That means identifying the Housing Resources that are woefully insufficient in just about every community in this country. So, i envision and applaud what you are describing as well. We have to get there. That also means investments of the federal level that we need to be serious and honest about. Does that answer your question . It addresses it beautifully. I would add that one of the ways we are seeing movement on this issue is well, one, i think there has been a broader recognition of the impact of the circumstances of someones life on their ability to achieve health potential, but through our physical Health Services, we have regional entities that have Key Performance indicators that they get Additional Resources to achieve. Some of those we pick very strategically to begin. Those were thirtyday readmissions to the hospital, ma use of highcost imaging. So many of the bills that probably mr. 280 had experienced. One likes to have imaging that is not needed or be in a hospital twice if they dont have to be, so it had both components to it. Think very quickly our Health Care Systems who are working toward those Key Performance indicators recognize there may social factors in these individuals lives that, with some in touch and some attention, we can meet these Key Performance indicators. We now have wellchild visits and visits postpartum. We have been talking about homelessness in general terms. Certainly, there are homeless amalies as well families as well. We hope to broaden the indicators to focus on the entire individual and family needs rather than just engagement with the Health Care System. If i could follow up with a point i did not make, which is important. This population was largely ineligible for medicaid up until the Affordable Care act extended medicaid. This population was not even part of the system. They were eligible, but probably not enrolled because of how hard it is. Correct. Only if you had a disability. But the vast majority were not eligible for medicaid or any other health insurance. This is the first time we have been able to get them into the system to really comprehensively at their needs. For mr. 280, that was before medicare expansion, so he had no insurance. Great point. Hello, my name is eleanor with the Infectious Diseases society. Thank you for the panel. This has been wonderful. Barbara and sister adele worst beating about Supportive Housing, but one distinction i noticed is that were speaking about Supportive Housing. One distinction i noticed was that sister adele was speaking about permanent housing. Are there mechanisms to help people phase out to stay sane phase out to sustain their own housing and are their metrics to determine if someone is able to phaseout of Supportive Housing . Take that one. O a couple of things. In the world of homelessness, the term Supportive Housing was really creative to distinguish it from what had been the paradigm of the day, transitional housing. What really meant was that it was not timelimited and you could stay as long as you needed to. The ability to stay in one home and not have a clock ticking is supportive of recovery. The stress associated with knowing that you have to have your act together at a certain able to you need to be go someplace else is counterproductive to having stability and working on longterm goals. It is designed to be housing. Obviously, we hear stories every day of people who dont need it anymore and who get a job and want to move out. They make the Space Available for somebody else. I think that is also where our portfolio is a great example. We do Supportive Housing for the elderly. The expectation is not that when grandma turns 90 she should be able to move somewhere else independently. The concept that housing is your home and its where you live, the idea of home is the idea it is a lifechanging event from hopelessness in the street to hope in a future that happens when somebody moves into a home of their own, when somebody moves out of an institution and into a community, into an apartment of their own. Mobility. Support we want to support people being able to move off of hud assistance whenever that is possible. When we are working with people who are aging, people who have severe disabilities, people who have been living on the streets for a long time, i think we need to presume that they are going to need support for a long time, and sometimes for the rest of their lives. Day of stories every people sister adele, i am sure you hear this, of people who get off the streets who have been on the streets for 25 years, and you afford them the dignity of dying in their own home instead of dying on the streets because they came to you that frail and sick. Sister though those things happen very frequently. I have heard a couple of things that are slightly different among the speakers. Maybe there could be a little bit of dialogue on these questions. One was medicaid should pay for housing. The other, medicaid doesnt need to pay for housing. Medicaid just needs to pay for Housing Services or Services Related to housing. Another is homelessness is a diagnosis. The other says we should target things to people who have relatively severe needs. Requent ed users to resolvey way these contradictions in views . Jennifer i dont think there is a contradiction in what we are saying. When people say medicaid should pay for housing, what they are really saying is that we need more housing and the federal government isnt paying for housing anywhere. Maybe medicaid should be the thing, but medicated statutorily prohibited from paying for housing. I have found it to be an unproductive lobbying strategy. I think medicaid could at least a for the things medicaid does pay for, which are Health Services and home and communitybased support which would allow somebody to move off the street into a home of their own and keep that housing. I dont think those things are at odds at all. I look to my colleagues. In colorado in particular, we have a very dense front range. We have lots of Rural Communities who have individuals who experienced homelessness. To some extent, some of the flexibility of letting local partnerships figure out what kind of resources are available in their community and how to leverage those appropriately as the other piece that does not make them in conflict, but rather, probably reflects the reality of the diversity of our nation and the availability of resources in each of our communities. I am coming from this local perspective where we really had to pull together. You know. Public, private, faithbased, philanthropic. Everybody had to pull together, and it was almost like this cant go on in our community. That we are not providing for the most vulnerable on our streets. I guess thats what we are we just hope is that we can all pull together. I hadd be in heaven if three things. Enough supportive Housing Units, everybody insured, and the support services to surround the person in the housing. Those three things. Thats mine too. Can, i want to just follow up with a question that got raised by the previous question. A formeres administrator of the Health Care Financing administration who runs medicare and medicaid. Thats how former it was. Yes, thats right. Someone had asked him the reasons we ought or ought not to meld the funding streams between housing and medicaid more fully. He said i think the problem with housing or seeking to fund it through medicaid is that medicaid is already under all kinds of political pressure because of suspense. Start to say anything might benefit a medicaid or anything that might benefit of beneficiary are to be covered by medicaid, you start making them more vulnerable to those who want to cut or eliminate it. I am really confident that bruce led it isnt in the room, so i feel comfortable saying i couldnt disagree with that shortsighted perspective more and i think the case studies here uphold that. Perspective that hud, medicaid shouldnt pay for housing because the whole history of medicaid is of doing housing in institutional, horrible ways. Every time medicaid things its doing it better, 10 years later, it is trying to figure out how to downsize and the vested elf of what it thought was a great of what itest itself thought was a great idea 10, 20, 30 years ago. Medicaid does not know how to provide housing. Conveniently, we do. I dont bigots a question of if medicaid should pay for housing. Questiont think its a of if medicaid should pay for housing. I think its a question of our their human benefits on the cost side of the budget to deal with these issues globally, to deal with the aging of america, to deal with institutionalization, to deal with the disabilities of individuals living on the streets. I dont see that as a slippery slope or a black hole. I see that is sound Public Policy to go upstream and fix the problems that are costing sorry. Or mr. 280 i got a little impassioned. Very on federal of me nonfederal of me. In one of our handouts, there is a chart of state initiatives in this area. The state of new york in fact did ask for medicaid money to build housing. And i went and talked to jason before he submitted it and i said why are you asking medicaid to do the very thing it cannot do. He submitted it anyway, medicaid and no. And medicaid said no. What he did not do was include in that same request i hope jasons not here everything medicaid could have paid for, all of the services. Instead, they are paying for it with the state general operating fund. I dont know why they did that. It sounds like some Technical Assistance is in order here. Yes, you have been very patient. Hi, i am from families usa. I appreciate all the focus you guys have put onto homeless issues in regard to housing and health, but i would like to broaden that a little bit. Ms. Ho, you mentioned that the the government collaboration between agencies is unprecedented now. I wonder if there are conversations going on where you are discussing improving Housing Conditions rather than just. Etting people into housing for instance, low income children who have a chronic condition like asthma often are increasingly going to the emergency room because of the mold in their house. I wonder if there is any work going on around that. Jennifer absolutely. Hud iss a ton that hi doing around the area of housing and health. Is there mold . Is there lead . To the production side of the agenda, the stuff i talked about, which we just need more. When we do more, hopefully we do it well. We have an office of lead control and Healthy Homes that specifically on how we do lead abatement and home modification to deal with the causes of asthma. How can we partner with the Health Care System and the public Health System so that we can do that it scale . , think one of the challenges especially with highly mobile families, is that there can be a hesitancy for the Healthcare System to go in and, oh, well, we will completely overhaul this unit, and you dont live there anymore. I would think that would be great because it would mean we have one more healthy unit in the world, but who pays for it . We would love to pay for it if we had the budget dollars to do that and do it at gail, but i think at scale, but i think in the absence of those dollars, we have to figure out how to do partnerships. For example, the partnership we have withdrawns Hopkins University try to do a very targeted we have with johns Hopkins University. We try to do a very targeted strategy. There are things we are doing in california and the Healthcare Work ono do a targeted that. I would add from a state perspective that kind of thinking is great thinking and adds yet another state agency to the mix in our world. The department of Public Health and environment, as art of the guiding health, has a principle around the 10 winnable oftles that include the kind things that from a Public Health perspective we know if we leaned into we could win. Its an important reminder to us , and perhaps we should contemplate adding them to our interagency housing group, but it is a piece that is from a different perspective in a different place in our State Government structure. Health sister agencies who work very closely, it may be another nexus point for us to contemplate. My name is rhonda hamilton. I am a local official who represents local residents, all andhom receive medicaid medicare. In our area, there is a push to break up what is an centered considered concentrated poverty, low income of families, many of whom have mental issues or health factors. That there is push to eliminate the housing, reduce it, create mixed communities. Many of my residents live in fear that they will not have housing. In some cases, they become sick, ill, even die because they are fearful of the future. Question is, how do we secure who arefor those already housed in low Income Housing so that we can work on their Health Issues and they dont continue to become ill because they are afraid they are going to lose their social ties and their connections to their communities . Its a terrific question and thank you for asking it. Have learned a lot at hud about Community Redevelopment over the course of the last five decades. , we kicked it poorly everybody out of the building, tore it down, dealt mixed income communities, and then we didnt who where the people were had been sent away. I had an opportunity last year to visit the community in atlanta created by the community purposenprofit called built that just blew me away. It had been a Public Housing project, old. It was in horrible shape. Who lived there had horrible Unemployment Rates. The neighboring school was one of the worst schools in atlanta if not the state of georgia. Had one of the highest crime rates, and there was almost like a demarcation zone around it, because it had a downward pull singlefamily homes and other communities around it. But working with the residents, which i think was probably a threeyear process at the front end, due to that engagement in a ,eaningful, Sustainable Way they, building by building, unit more, movedlt people out of the old, into the new. To theed people community. The community is beautiful. They built a school. It is now one of the highest performing schools in the atlanta area. People of all incomes want to move their kids to this neighborhood so they can go to that school. They opened a charter school. They have a ywca. They are dealing with health and fitness. I have never been in a place where i saw Young Children of color in the hallways of School Learning with such pride in a community that is the envy of atlanta. We can do this. We can do this. But, you know, the old ways, we didnt do it well, and people have a right to be afraid. Could take your community down to see this community and atlanta. It is a testament to what happens when we do it right. Thank you. In terms of innovation and telehealth introduce yourself . I am daryn. I work for congressman alcee hastings. At providingg overh over the internet, tablets and smartphones, keeping people from traveling very far if they are in rural areas or underserved areas. Its sort of a new service to help provide quality care for people. I guess my question is, do you see this playing a role in saving atelehealth and like, mr. 280 . , these several trips. Telehealth usually prevents people from going to the hospital. 70 of the time they dont need to go to the hospital. Isone thing i can address telehealth is absolutely an emerging model that i think has a lot of promise and is being implemented in a lot of places. I think we are seeing more opportunities to implement that, in rural areas in her ticket her. I think it gives us ruralunities to access areas in particular. I think it gives us access specialo care when Public Transportation is not adequate or even feasible. Is an intriguing idea on how we can implement this where we can, but i think thatght be overlooking there are lots of reasons why mr. 280 and patience go to the hospital, and its not always medical out of necessity. Many of the clients we see are acutely ill, no doubt, but because there is a lack of stability, sometimes the nurses there know these folks by name. Its because of a social connection that they are looking be in a care environment where people actually touch you. I think we shouldnt overlook of care that institutions provide from a compassion perspective. I know sister adele can speak to of ourts that very few clients are touched by anyone except in violence or anger. When you have a Health Care Provider put their hands on you in a loving, caring way for the that cane in 25 years, be lifechanging. So yes, i am excited about telehealth, but i think for our clients, the social connection of being together with people israel important. I will look to sister to add onto that. Adele i agree. I know that for rural areas and people who have no access, what , ay really needed specialist, is wonderful. But i have that same concern , you know, just to go back to mr. 280. We had him for three weeks in the Respite Center. That he has a traumatic brain injury and he had poor impulse control. ,ut every time he felt unsafe he would say to us, ive got to go to the hospital. No, youre fine. Really, because it was safe, it was clean, it was sheltered, and he needed a human contact to tell him it was all right. Can we do that with telehealth . Aboutd be careful implementing it, but i think it certainly has its place. Our clients need a group hug, really. That you aren that. G here is born of its an intense need for all of us. I think we have time for one more question. I will try to make it a good one. I am curious to get your thoughts about Housing Navigation services, given that medicaid doesnt pay for housing and shouldnt pay for housing. Is there a role for Housing Navigation services in the Health System when you think about how difficult it is for vulnerable, low income individuals, particularly homeless and formerly homeless, to even think about how to find a home, whether it is permanent housing or some other kind of affordable unit . Take a look at what is it that states use their money to pay for. What was the biggest challenge associated with that . Cns itation from understands that building a network of landlords, Housing Navigation, pretenancy support you cannot just write a prescription for housing, hand it to somebody and done. Especially given the affordable market. Can pay for sod much more than medicaid has paid for for all of these populations , large and small, and i really we are making good headway on that. If i sat heremiss today and failed to say that we also need more Affordable Housing. There is a cut to the had Affordable Housing program, which is the best engine we have four the creation of more Affordable House have for the creation of more Affordable Housing. If we believe that the connection between housing and health is a matter of achieving the triple aim, and that you are going to need the Health Care System is going to need Housing Units that are available to the people they are targeting, we are going to need to create more Affordable Housing. Make a plug for the National Housing trust fund, that also needs to be it is authorized but not funded. We need to prevent people from coming into homelessness. It would be great to get ahead of the curve. Management for medical conditions, or navigating your eligibility for medicaid or other public located, shouldnt be closer to the houses themselves. That may be the opposite side of the question you asked, but one we are certainly thinking through. For individuals that do have Housing Available to them, the coordinators or whoever else in those facilities are often the first people when they open the mail from our state department which, we are working hard to make mail more understandable, because even those of us who are sometimes like what does that mean that is the first place they would have to potentially ask the question. I just got this. What does this mean . I think i lost my eligibility. How do i get back and rolled . That may be an effective mechanism for us to contemplate as well. Quick word . Wrap up . I would thank you for coming attention tour this message, and really, for whatever you can do to try to provide the collaborative effort us to provide services to the vulnerable. Thank you. Thank you all. Let me do a little bit here at the end. First of all, jennifer has the senate mark. It reminds me of something you said earlier that we would like to endorse heartily. If you are the health l. A. , talk to housing l. A. , appropriations l. A. , and may be veterans l. A. About these issues and try to knowsure that each of you what is going on in the others dominion. You can see that the evaluation form is still up there. The contribution to community of hope is still dangling in your hands. Please fill it out before you leave. They are doing amazing work. There you go. Of organizational privilege, if i could take 30 more slide have one to show you, and that is the thank you slide to the interns who have done such a great job for us this summer. Molly and katie. I see one here. I dont know where molly is, but thank you very much. Its been great. The selection of materials, largely in mollys hands in this briefing. My apologies to those of you who wrote very good questions that i was hoping to get to on cards and wasnt able to even a tweet or two. Thanks to you for staying with us. This is not an easy topic. There are lots of good things to be done on a friday afternoon in august in washington, and you stuck with us, and we very much appreciate it. [applause] forks to our colleagues helping tort of and point us to some good folks for this program of exceptional , which rings me to my final point, which is to ask you to help me thanks is excellent panel for discussion of a very multifaceted and important topic. [applause] [captions Copyright National cable satellite corp. 2015] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] any of thisssed discussion today, it will be available on our website, cspan. Org. Congress is on break until next month. Nebraskas representative took a trip to the middle east this week and sent this tweet today. Ohio senator rob portman is at the state fair today, tweeting california congresswoman mimi walters is also in her home state. She visited and or a radio today in santa monica. She said it would Pandora Radio today in santa monica. She said it was great to two or the facility and learn more about the radio industry. Held steadyrate last month. The Labor Department reporting that u. S. Employers added 215,000 jobs while the Unemployment Rate held at 5. 3 for the second month straight. The number of people seeking benefits remains near a 15 year low. This weekend on the cspan networks, politics, books, and american history. Saturday night at 8 00 p. M. Eastern on cspan, congressional profiles with four freshmen. Embers sunday night at 9 00, with elections coming in october, we will show you a debate among four National Party leaders in canada. On book tvs afterwards, Charles Murray argues that through the use of technology, we can rein in the power of the federal government. Sunday at 7 00, a talk about the city and people of negative nae, japan not a sake japan. This weekend, we commemorate the 70th anniversary of the bombings of hiroshima and not gasaki. Begin with a conversation with Harry Trumans grandson. Later, we will visit the atomic. Omb exhibit sunday morning at 10 00, our coverage continues with the 2000 documentary on the making of the atomic bomb. Later, interviews with two bomb survivors. Get our complete schedule at cspan. Org. Two food justice advocates discuss access to healthy food right. Sic human they spoke at a conference sponsored by the Harvard Law Society and food literacy project in cambridge, massachusetts. This is about an hour and a half. Hi, welcome. Were so glad youre all here today. My name is ona. Im a staff attorney at the food law and policy clinic here at harvard law school. For those of you who dont know, clinic provide action based learning opportunitys for law students to get real lawyer experience and our students are working with nonprofit organizations, advocacy groups to improve the food system in their community. We have an excellent panel of experts here today to talk about how recovering nutritious food that would go to waste is a key strategy to achieving fod food justice. To my left is emily broadleaf she is my boss. She is the director of the harvard food law and policy clinic. In addition to teaching and writing about food law policy issues, she is recognized as a National Leader in the legal and policy efforts to reduce food waste. Doug rowe is the former president of trader joes. He has gained National Attention for his much anticipated store, the daily table, which will be opening in boston next month. Doug has been a long term client of our clinic and we are proud to be supporting his innovative effort in food recovery. Sasha is the executive director of food for free am cambridge based nonprofit that recovers fresh food to distribute those in need. In 2013 they recovered 1. 5 Million Pounds of food and served 25,000 individuals. Food for free has begun an Exciting Partnership with harvard university. We will hopefully hear more about that today. My role is to briefly help us understand the scope of this problem. In the United States between 33 and 40 of the food we produce here goes to landfills. This problem is only getting worse. Between the 1970s and today food waste has increased in the United States by 50 . Why is this a problem . Well, first, one sixth americans are food insecure. Meaning they cant afford the type of nutritious food that would enable them to live a healthy life. We know that the commonly wasted food are fruits, vegetable, seafood. Exactly the type of nutritious foods that are sometimes hard to afford for low income families. Food is also the largest component of municipal solid waste. Its the largest part of what goes into our landfill. As it breaks down, it produces 23 of u. S. Methane emission. We dedicate 25 of fresh water in the United States to producing food that we never actually eat. Not to mention significant amount of petroleum and pesticides and other chemicals. Climate change will dis proportionately affect poor communities. All of these environmental repercussions are very directly connected to food justice as well. I now going to turn it over to our panelist. Were going to describe their innovative effort to increase food recovery. We will leave ample time for questions and have a thoughtful debate. Im executive director of food for free. Food for free is a nonprofit based in central square. For over 34 years we go around to retail stores, wholesalers, Farmers Market, we collect a lot of really good healthy edible food that would go to waste. We bring it to the folks who most need not just food but access to healthy food. We bring it to food pantries, shelters, Youth Programs serving over 25,000 people. Food waste is bad. Its not good to waste food and where we can control it we should control it. One of the places to control it is at the consumer level. A shocking percentage, which i dont have food waste that comes to the consumer level. I would like suggest that at scale, at other levels, surplus foods that can go to waste is inevitable. I want to talk about a couple of scenarios. First let me start with the farm. I will talk about a small new england farm. Thats what i have experience on. If a farmer sends three of his staff out to pick beans for an hour and they come back and the numbers will be wrong here, say they have 100 pounds of beans. He takes those to market and sells those and makes enough money to pay the labor for collecting those beans as well as some profit. The next week he sends three staff back out to the beans. In an hour they come back with 80 pounds. Maybe next week its 60 pounds. At some point, it doesnt make sense for him to send people out to pick every last bean because at some point, the money hes spending on the labor will be less than the money he earns be on a small amount of food theyre collecting. It is inevitable that on small farms in new england, theres going to be food left in the fields. What is not inevitable is that doesnt have to become food waste. Theres a group called gleensers that can go out to farms after the harvest, and they pick every last bean and they bring it to for three or to a food pantry or shelter. The farmer isnt going to be able to do everything to run a business. He doesnt have to pick every last bean. But it doesnt have to be food waste. If we look at super markets. Whole foods is our largest retail food donor. We go to four wholesale food stores. They also are a business and they have to make a profit. To make a profit they have to satisfy their clients. Their client have certain expectations and demands for example when i go to whole foods, i want to get when be when anybody goes, typically in this country, we expect to get what we want when we want it. It maybe a tomato in january. If i go in, i expect lettuce. If i go to weeks in a row and there is no lettuce, i will stop going to whole foods. Whole food has to have a lot of lettuce. I dont want to go in and see one head of lettuce. That is a turn off to a purchaser. With my husband, we would have this huge pile of beautiful bunches of orange carrots. In two hours all of but one bunch would sale. Sell. Ll next foursixthe hours, that last bunch of carrots would never sell, because people dont want to buy the last bunch of carrots. People want to pick what they want. They dont want the bruised apple or lettuce. Additionally if i purchase lettuce from whole food, i want it to last a week. It may not, if it doesnt i may have problems with whole foods. They cant sale me that lettuce if its not good for another five or six or seven days. So whole foods is in a situation where they won two stay in want to stay in business and serve us, the population, they have to make sure they always have everything on their shelves that is full and theyre pulling it off in the next couple of days. That is inevitable to run their stores successfully. What is not inevitable that has to be food waste. Every morning we go to all the whole food stores and they load us up particularly with produce. Produce is parishable. It is one of the most wasted food. Its one of the top foods that folks need. The most expensive food. Its food they cant access in certain neighborhoods. At the farm level and at the retail level, theres produce available. This is a positive thing. It absolutely should be limited because there are costs associated with producing it, but its going to be there. The third example i want to give is a university. As ona mentioned, last year we started a partnership with harvard university. There Dining Services serve 14 dining halls and i believe its about 138,000 meals a week to students. Buffet style. If any of you ever had a large thanksgiving dinner, theres typically left overs. Its hard to know exactly how much food to make. Just like at thanksgiving, if youre serving it and youre bringing in a bunch of people, you dont want people scraping the last bit of mash potato off that plate. If im harvard and i have students paid to eat, there cant be two french fries and half soup, they expect to eat whatever folks ate earlier in the day. They have done a tremendous job at predicting and understanding how much food to prepare but it is inevitable that theyre going to have extra food at the end of each meal. Of that 138,000 meals, we pick up approximately 2000 meals a week. Thats the small percentage of waste. However that is enough to feed about 100 people three meals a day for an entire week. Thats fantastic. We take that food and get it to folks who live in motels and do not have access to kitchens on or who are homeless. There are a lot of people out there who are about getting nutrition to folks who need it. Its produce. Theyve got to cook it. In many cases they cant do that. Now we have this harvard surplus food. The point im trying to make is, surplus food is inevitable. Theres something called food waste and that is bad. I am not advocating over cooking meals, making too much food intentionally. What i am saying is that theres a reality to running a society at the scale in which we run this one. Theres going to be surplus foods at these larger scale institutions. That doesnt have to be a problem. That doesnt have to be food waste. Thats actuallial solution. This isnt solving the core issues of food and security, Food Insecurity which has to do with poverty and jobs. Those things need to be addressed. People should be in a situation where they can buy their food. But the reality is, many people are not. 45 of the children in Cambridge Schools are on free and reduced lunch. Thats almost half the kids. The reality is theyre not. In the meantime, we have to this incredible solution. Its not only preventing a problem which is food waste but its creating a solution. Last thing i want to bring up and well pass it over to doug. When i was working with my husband on his farm, he was trying to create a farm and make a living in new england. That is not an easy thing to do. Sometimes at the Farmers Market people would comment on the price of his tomatoes. He would get frustrated. Because this is the cost of food. I saw this tension between need to grow local food system and to pay farmers a fair wage. And the issue of food access, because i care deep billion our local food system and about hunger. All i saw was tension. When i joined food for free, it was fantastic. I discovered there doesnt have to be tension. One of the things we do in the summer is visit 11 Farmers Market at the end of each market. Say my husband breaks his back harvesting, brings everything to sells, loads it so it and its raining, and nobody comes to the market. At the end of a long day, hes not too happy and hes got a lot of greens and that one bunch of carrot left. He knows he can load it back up, hes going to have to load it up and drive it home and its either going to go to pigs or chicken or compose. Compost. Maybe a few neighbors. Hes going to eat a lot of kale. Instead he can give that to food for free as do many of the farmers. It helps them in terms of ensuring their food doesnt become food waste but becomes a solution. It helps them they dont have to load up this food that dont add that now does not have value to them. Helps them build up the food system and contribute to the issue of Food Insecurity with some of the freshest, most atrocious food that people can eat. Nutritious food that people can eat. Thank you. [applause]. Thank you sasha. First thanks to emily and harvard for this opportunity to discuss this critical issue. I promise not to do death by powerpoint a picture is worth a death by powerpoint, but because a picture is worth a thousand words, i want to give some pictorial context to some of the issues. To me, first thing i learned in my awakening about this, spent 35 years in the food industry, 31 years with trader joes. 14 as president. I saw food throughout the chain being wasted whether its on farms, manufacturers or retail or wherever it was. When i graduated from trader joes, i had the opportunity to do fellowship here at harvard. I was looking at getting the mail from pd america i think they mailed things four times a day to my house, that one in six people in america are hungry. Theyre hungry. Its like, how can this potentially be. Were the richest nation in the world. Food is now a third less expensive when i started at trader joes in the mid 1970s. Even though food is cheap in america now, its really cheap compared to what it was in the 1970s. Now, it is not a surprise that when something is ubiquitous and inexpensive, we tend no the to value it as much. The first thing is whats the real nature the problem. You got to understand the problem. There is nothing worse than trying to answer the wrong question. I thought hunger was a shortage calories. It definitely is what part of with part of the population. Much the population that sasha was talking about is in desperate need of services that shes providing and the food banks and soup kitchens around america are providing. Thats not just what food for free does. They do a lot of other things too. What i want to say is that im very aware that there are people in america whom shortage of calories is a reality. The one in six are mentioned as being hungry, food insecure, vast majority of those actually get enough calories. Thats not the issue. The next big awakening was to come to this. You heard about one in six americans. This is the part that gets interesting. You can get all of this from usda and data. Peoplefood insecure are that make the wrong nutritional decisions due to economics. If bill gates wants to eat poorly, he is not food insecure, just to be clear. But if someone has to give their kid sugar water, liquid candy, or chip and other junk, thats the only way to get the calories they can afford, thats the type of Food Insecurity. What we discovered is that i think it was 39 . These are people that struggle with missing meals during the month at some time. It doesnt mean that 39 of people everyday dont have it. If you go on the website and read the definition, during the month at some point did you go , without food. Any of us ever gone without food for a day know that even a day is tough. In particular for a kid. Here are the things i want to talk about food justice thats really important. First is that, when you talk about black and hispanic, more than one in four, 26 or 27 . One in four is food insecure. Of that, one in three, thats 34. 8 of low income. Now you got a third of low income families that are food insecure. This is to me a chart i i stole this from jonathan bloom, many of you know this is hung inner america. Hunger in america. This is the evolution of man in america and hunger. It turns out hunger isnt a shortage of calories. Its a shortage of nutrients. When you know that, then the solution of majority of those one in six are getting plenty of calories. The problem is theyre getting the wrong calories. They are getting empty calories. They can only afford to eat things that have been stripped of nutrition. Heres, again, youve seen those obesity maps. If not you can google it on cdcs obesity maps. Not now, that would be rude. It goes by year from 1985. I will give you the punchline. This is 2010. 1985, 25 years earlier not a state in the nation was yellow or light orange or dark orange. Not any state, louisiana, mississippi, alabama, texas was more than 14 obese. Now were looking at obesity rates higher than 30 in one generation. This one in six that are food insecure, hunger and obesity coexist in the same community and same person. I was on a panel last year in gentleman who the runs the largest food offered in the United States, he had this slide. He said this is something