Transcripts For CSPAN2 Key Capitol Hill Hearings 20240622

He takes some risk with fat as well. We have more forest fires now in california than anybody has ever seen and now messing of the traffic which is sacrilegious by yet it goes up one day then goes down the next. The people say it is a big issue, paying attention. But it will be interesting to see. He understands this issue and he wants to the of the bright side. In an interesting moment for my point of view. But with the popes visit i am learning about how much it cost to travel to a country so with that financial burden to talk so much the impact of this message so food takes charge of that . The cost is the United States will be different than the cost of cameron because washington d. C. In particular and new york are two cities that are very used to do handily enormous events so in terms of cost there is always a security cost and you can go to Capitol Police and the secret service to see how much has been spent then they bring in the occupancy taxes with the department of revenue to read the compare similar events to get us sense of what money is coming in and and what is going out of there was the economy of scale it would be different if you look from that perspective to see a big difference there. What could be an interesting topic is the lobbying q the right before he comes here come the day do not have the infrastructure, were talking about super bowl cities her capable to absorber incredible demand to with the infrastructure to guarantee safety. Q but is different with a direct contrast between water redoing and then the next couple of days inn in new york or philadelphia or washington as a fascinating story. We focused on the popes visit to congress but it he is a listing other places added is the entry points for stories. In philadelphia he will go to a prison and he is rather outspoken on forgiveness and care of prisoners and social and criminal justice is a great opening on the day from the back of our system and reminded me we have one of the highest incarceration rates in this country of developed nations. This is a good entry point some even if you cannot get access, there are so many other Access Points to allow a journalist to find a really great story strike if we see a picture of him carrying his own bags i would like to see it. Any questions . The question i have is for my own purposes and but the policy issues, the cultural issue of a huge gathering of people. Them like the day after the super bowl with an empty stadium. So where do we go as a journalist . What do we tell in the wake of the visit . And all the is issues the next thing is whether or not he has the impact. Did he break in the consciousness . So that is a great thing to follow up to keep track of the issues that he addresses of there is movement in the congress. They appear to have lost the religious survey but if there is a surge in membership or even something so simple as having a Catholic Church but then one week after they see if the pews are filled to see if that had any of course, it is anecdotal not based on scientific evidence, but you get a feel if there is impact with those color stories sam policy followups. You can come after words about planet change. I cannot remember one but that is the good question. But a lot of people for the singular event but that is to look bad before and after who will introduce legislation . Check out that member of congress find out their issues to address the policy expertise. If they will capitalize on that. The panel was day ready made the list with before and after the visit that will dominate some peoples thinking of what they want to hear and have not been able to. Dont pay a lot of attention to the internal politics there is colonel sam bishops that do not think the pope is headed in the right direction and a great source of that is there is a catholic newspaper called the catholic reporter and they have some great story ideas to get as well lots of questions. Were they going to do about the language and if he gives speeches in spanish. So how are your organizations preparing for that . There is a lot of french and german speakers so we are in pretty a good shape that way. We do think there will be a great deal available spare mcfadyen is the idea to cover different ethnic groups. And hit it is growing among the hispanics are immigrant groups and look at where the church is a growing angelou the pope will try to send the message to. But maybe he will speak spanish to connect that makes for a great story. I will address this to the experienced the reporters on the panel. But to be there in the crowd . What equipment do you bring . How do you file your story . Etc. A crowd like this faith is not a problem. So the volume as restated earlier in the day the recorder but those are more likely and it has been easy and it is a shared a moment. Filing could be a bit of a problem if youre out on the mall obviously. You might want to preplan a coffeehouse of where you expect for that place to file. If you Cover Congress i would not bank on running outside and look for a place you can file even if it is against the wall early to avoid the tunnel of death. Just get to the mall early with as little as toughish possibly can. With the most recent inauguration was the cellphone tower overloaded you could not even been tweet something so you should be prepared for that. I had both my pad and phone with me when i was working in one that was not. But i never thought that i would say of the national mall. But it is something to think about. Even if you catch a disposable phone for that event. And whats a fair ratings . That is horrible. M a have a crowd like this with the march on washington i have never seen such a collection of umbrellas standing alongside his should prepare for that when the paper gets wet remember japan wont work some of the proponent to have a pencil with a little sharpener like did your schoolbag. Keep your eyes peeled for any mannerisms. Lake the parent and child but it is to take your eyes off and then what . What we want to accomplish is to let him as a multi dimensional human being an addition underneath all these trappings. What is he like . Along the lines of what to bring it is as much as you can and still be professional with comfortable shoes and clothing because if you spend time in washington is a temper it can be absolutely gorgeous or horrible you never know what you will get. You have to prepare for raid or sunshine or the cold blast. You dont want to be miserable. Hot were lucky he is coming in september instead of a january when one reporter got frostbite on her feet in 2009 inauguration. So be prepared with your own personal comfort. You may be required to be held for several hours or all day long. And it is a sport i i did not plan but a cat on a bicycle and i got to my office about 530 in the morning and i got to the hill, by 6 00 and i just waited then i went outside and started to interview people and i was out and tell the time that the president stopped speaking. That is how i planned for a larger defense as the all day in denver. There is no lastminute go here or go here. But to let them know what cannot be done logistically. Then they will say we heard there was of family can you go find them . [laughter] it isnt always that easy. Just to make that clear. I hate to say this but as a disaster reporter think through of a contingency plan if something bad happens and theres all kinds of bad from the stampede to a weather even and like last night in chicago where and a tent blew down and. How much a kid yourself, how are you thinking it through . And will be different depending upon your organization is to mix the have people coming in to town and to give them guidance. Has anybody seen the traffic map . It is road closures or anything around the mall. Probably not until it gets closer that is probably still being worked out. As you know, because with the d. C. Government sometimes they dont share the same idea of what is worthy to be closed so im sure there is negotiations going on about that. You expect inauguration type of closures . Yes. We knew those one week before. Find seats and we will try to get started here. My name is ed howard. I am with the alliance for Health Reform. I want to welcome you on behalf of the board of directors. I want to welcome you to the program on health and housing with an emphasis on the relationship between medicaid policy at the Community Level at the state level and the federal level as well. This is actually a first in a threepart series and we will explore the intersection of social policy over the next couple months. In october, i believe its october 9, you will be looking at how well Health Services correlate with nonmedical home and unity based services. Then in december we will examine some of the emerging issues in connection between health and incarceration, which is is a growing area of concern and activity. There is a connection between health and various determinants and we will look at the strength of that connection during this briefing and the subsequent ones in the theory. You may have seen yesterday the new york city mayor bellagio announced a milliondollar 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 that link Better Health and better housing. I hope that will bring a lot of light on that topic. Our discussion will center on how housing stability affects Health Outcomes and healthcare costs. They will look at the role in addressing this program and how much flexibility there is in federal policy to allow states and communities to meld those together. We want to look at what the obstacles might be. What are the biggest obstacles. We are pleased very much to acknowledge the centime corporation. One of americas largest private insurers. They operate in two dozen states. Before we get to the program let me do a little bit of housekeeping. In your packets there is Important Information including speaker biography one page materials and the Powerpoint Presentation in hard copy so you can follow along. There will be a recording of this briefing available on the website on monday followed by a transcript a few days later along with all of the materials in your kit and links to more materials we think would be helpful to you. At the appropriate time you can ask our Panel Questions by filling out one of the green cards in your packet or you can come to the microphones there is one on either side of the room. You can use the health and housing to tweet us questions and if youre watching on cspan to want to ask a question, you can also tweet a question. We will be keeping an eye on that and having them brought to the panel to respond. And at the end of the briefing there is a blue evaluation form in your packet 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 the guidance. So, enough of that. That. Lets hear from our very wellinformed panelists. We gave them in adequate introductions and ill do it so i wont disrupt the flow of the discussion as we go along. He is the director of policy at the National Healthcare for the Homeless Council. He is also on the healthcare counsel for marilyn. He has a perspective on how to connect and address these problems. Why its important and the opportunities from the state federal and local levels to address it. Then we will hear from the Senior Advisor for housing and services and she will explain the current activities and describe how her agency and others are collaborating health and housing issues. Gretchen will be next. She is director of colorados department of Public Policy and financing and that is colorados medicaid and chip programs. She is going to tell us about the bridge and what gets in the way of those efforts. Our final panelists is a family physician and she is founder of a phoenix nonprofit that brings private and public sectors together to help those experiencing homelessness. They will describe the Innovative Housing model and what gets in the way of this approach. So weve arrived to the part of the program that also has some substance to it. Heres barbara. I really appreciate so many people being here today. I think it really is important about the growing awareness of how healthcare is changing the country and in particular the impact that housing has on health status. The National Healthcare for the Homeless Council represent many Healthcare Facilities and the Homeless Individuals they serve. Over 1 million patients are being seen in these facilities each year. The lack of housing is really an issue not only for the Health Centers but the larger Healthcare System that we are looking to change. One one of the things that might not be intuitive is how housing affects health care. Back in the 80s the institute of medicine did a study looking at that very impact and they found three major relationships. Poor health causes homelessness. Typically what we would see as a spiral of people who had an illness, were unable unable to work and when youre unable to work and you get fired or laid off and you can no longer bring in money. You cant make rent or mortgage so you move in with family and friends and that doesnt work out so you go to a shelter or live on the street. You also hear that homelessness causes poor health. Living on the street or in a shelter is stressful and you are exposed to other illnesses. Without getting hospitalization or Emergency Care that tends to be very high. High blood blood pressure, Mental Health issues alcoholism depression all tend to develop. If you didnt have them before you tend to develop them afterward or they get exasperated. You also think about how lack of housing complicates treatment. We are putting billions of dollars into our Healthcare Industry every year. 2 trillion. None of that funding works well. Nothing that we do as Healthcare Providers works well when someone is living on the seat. Street. Every time we turn someone to a 90 Day Treatment Program it is only to discharge them to the street we have complicated and probably compromise the treatment we just invested. When we discharge from hospital to the street the wound care that we just paid for is now compromise. These are the things that are really bundled up together in health and housing. We need to appreciate how we can rectify that through housing. One of of the things we are seeing, as again we represent the doctors in nurses and addiction counselors and the workforce that goes beyond caring for these patients, and what we see, not surprisingly, is very high rates of acute and communicable diseases. Respiratory illnesses, infections from cuts that you cant keep clean diabetics on the street, the rate in which we replace medication is astronomical because of the rate they are stolen. When you cant keep your medication safe or refrigerated its hard to maintain compliance with your healthcare. How many times as anybody here gone to the doctor and had a prescription given to them that may cause them to visit the bathroom more often . Thats just not possible. No need for show hands. [laughter] thats just not possible when Public Places dont allow homeless to use the public restroom. We have local ordinances increasingly that criminalize that activity so really what we see as Healthcare Providers, our client come in and say i didnt take that medication because otherwise id get arrested or i was afraid of getting arrested or i didnt have any place to go or made meds were stolen or my needles were stolen or its not safe for me to have needles. This is what we hear. We see when we look at the literature it shows people who are homeless get diseases at three to six times the rate everyone else does. Theres still asthma and diabetes and hypertension and high cholesterol and Heart Disease that everybody else has but it still in higher rates. We see a lot of intensive needs and we see both extremes of use of the Healthcare System. We are getting a lot of attention in the frequent user of very high end user were putting a lot of money into a small number of people that we need to stabilize, but we also see people who are living on the outskirts of our society who avoid our Healthcare System that have intensive needs, usually in the Mental Health and Substance Abuse treatment area. How is it that were reaching those people were very fragile and in need of care . Will look at our hospital systems, they are really stressed. They really get it when you are a hospital and you have no safe discharge option for a client that is ready for discharge. It is illegal to discharge to the street but as with anything else we get discharged for rest and recuperation. What do you do for someone who doesnt have any place to go . These are these are the real issue that local Healthcare Systems are facing. What can we do to provide safe and ethical treatment for people question what we see a lot of people wear when they are ill, its difficult to get back out of homelessness. Working on housing and getting a job, if youre fighting an addiction or Mental Health and not in treatment, its very hard to get out of the shelter or off the street. Just one example of in a healthcares situation, people who are homeless have disproportionate high rates of every disease you can imagine. That brings us to support of housing. When we think about what is Supportive Housing, its typically helpful to think about in terms of a traditional model that emphasizes recovery first. Traditionally, in our communities, we required people to get clean and sober. Weve required them to enter into treatment and be successful with that before we get them into a housing unit. Is everyone follows the rules and you continue to follow the rules then maybe one day you can be in independent housing. While while that certainly works for some it doesnt work for people have really serious Healthcare System. Its hard to get clean when youre living on the street. The Supportive Housing slips that model. Its not not timelimited. Its the same lease as anybody in the community. Frankly any one of us can go home tonight and have a drink and its perfectly all right to do in our home. It needs to be an opportunity as well. We need to work with people where they are in the stabilizing unit of housing so weve got that stability. So people have a place for have a place for the medication, they have a place to put an appointment card and keep track of them. Our outreach people people cant find people when theyre shifting around on the street and encampments change a lot. We need to think about how are we supporting housing in this way. A wide range of teambased services is really the key to making this work. When you combine this biz untrans the ability of housing with Healthcare Services, we can can help people be stable in their housing. This is mainstream right now for seniors and people with disabilities. My grandmother has meals delivered to her peerage and have in care help to help her bathe and keep the house clean. All of these things im taking for granted. Speaking about extending that into this population so we are supporting the housing and the services that people need really isnt keeping up with that same theme. I want to talk about our relapses part of recovery. These are things we need to expect. Recovery in Mental Health and addiction doesnt look like black and white and yes and no. It looks like a struggle. When we have we have people who are in zero tolerance housing, even that one slip up advertises your housing and you could be back on the street. Its really important that we are able to work with people and adjust services if they need that. Again. Again theres no requirement for sobriety and the services are voluntary, but what we have find found his people are very excited when they get into a unit that now so many things were possible that didnt seem possible before. We been evaluating the effects in the peerreviewed literature for about 25 years and consistently, what we find is that housing improves health and it improves Health Outcome and lowers the total cost of healthcare. I think this is really where we need to be in rethinking housing because we are so focused on cost right now, understandably so. We need to think about where is it we can be making a partnership. You can read the slide here. There are consistent findings over all of these issues but again you really want to focus on how is it bringing these two sectors together is really bringing us the things that we need. There is a lot of opportunities at both the federal, state and local level. All of of your states are working on studies to end homelessness and improve health. Were looking at greater determinants of health. One thing that is important in d. C. To remember is we need federal support for the housing piece that goes along to making this work. My colleagues here well talk a lot about what they are seeing in their sectors but again the cuts that are required by sequestration if we dont have the Housing Support to put people in, no amount of our Healthcare Services are going to make this work well. We need these to come together. Another thing i would really recommend are the take away points, for all of you who are health staffers and those of you who are housing staffers, get to know each other because you have a lot in common. A lot of times we are not working together at the federal level like we are asking them to do at the local level. That would. That would be a lot of things i would recommend. What we are doing at the local level is to try to bridge that gap. We are in a rapidly changing environment including medicaid but the system as a whole is changing. We are focused on outcomes and cost we also need to be focused on Vulnerable People and getting them what they need. Nothing works well as a Healthcare Provider if theyre living on the street. We really want to focus on housing as a healthcare intervention. My colleagues will talk about how hard they focus on building this bridge from housing to health is an illustration of how we are trying to Work Together to make this model work and achieve the outcomes we are looking to achieve. I want to point out, my colleague matt warfield, he can take your car to get back to you if you are looking interested in looking into this further. We we really appreciate you being here. Thank you barbara. I am jennifer. I like to joke that means i am the one person that knows the difference between medicare and medicaid every day. You know what im talking about, dont you . My background, actually i spent the first ten years in my career in managed care. Largely medicaid and medicare managed care. It was in that work that i was first brought to the table to consider the relationship between homelessness and health in the impact that the board of housing would have on both Health Outcomes and spending. I have been doing that ever cents for the last 18 years. I want to assure you that there l of collaboration happening today between hud and hhs. Not just because of my job but because it really is the case. Hud is trying to talk with medicaid almost every day. Were talking to folks at many different organizations. Were no it feels that housing and healthcare are miles apart and no ones talking, but i want to promise you, in this administration, there is an unprecedented level of collaboration. There is a simple fact about how we invest in housing federally that a lot of people dont know because you operate in a world of mandatory budgets. Federal Housing Assistance is not an entitlement. When someone becomes eligible for medicaid or medicare, they get it. If you fill out an application for housing, you get in line. When we asked congress to invest in more affordable or Supportive Housing they worry about the renewal burden. The fact that this increases our total budget in future years something i like to say keeping people in their homes. The conundrum is today, hud pays for a lot of services and housing that medicaid could pay for medicaid has a lot of financial incentives for there to be a lot more affordable, accessible and Supportive Housing and the budget environment is such that were not doing what we know works and not doing anything at the scale that matches the need. That is that is why im excited to be here with you today because your interest in housing could help create the consensus that we need to make the investment that will matter. Thanks for being here and thanks for allowing me to be on this incredible panel. I want to talk about how this plays out in three areas, aging, disability and homelessness. Americans are living longer and the age of 81 will test our commitment between the relationship of housing and health. The ages and equalizer we will be more likely to live alone have Chronic Health issues, less mobility and we grow poorer. Studies project that the number of older households eligible for rental assistance will increase by 2. 6 Million People between 2011 and 2030. Today at hud we provide rental assistance for 1. 2 million seniors. That is one out of every three seniors who has become eligible for it. That means we would need 900,000 more subsidized Housing Units by 2030 just to keep up with one in three people to need getting it. We have not made significant new investment for seniors for some time. I think about where you live today or where your grandparents live. Less than one half of 1 of existing housing is currently assessable to someone who uses a wheelchair. Only 5 is livable for someone who has mobility impairments and only 40 of it is modifiable. Most americans is not designed for them to age in their existing place imagine 20 Million People who cant return to their home and cant afford where they live. Where will they go . How do we have a strategy for aging in place of people will not be able to afford or navigate the place they call home today . The Health Care System, i would argue, has a huge stake in meeting those needs of aging america yet there is not consensus this is something the federal government should be making. A lot of the work has been focused on disability. There is section 811. 811 forces 811 forces partnership between state housing and state medicaid in some places like colorado it doesnt happen together. They create integrated housing where medicaid provides Homebased Services in a unit that has deep subsidies. We have two rounds of funding 35 states now have this money. The last run we founded funded 4500 units. Thats a drop in the bucket but at least we have made some investment. The Healthcare System, i would argue has a huge stake in creating more integrated Housing Options for individuals with disabilities who would otherwise be in an institutional setting. There is not consensus this is an investment the federal government should make each year. I came to washington to help with chronic homelessness. I appreciate barbara covering all the chronic arguments. I want to add a couple things. First, the president s budget request last year and this year have included investments to create a sufficient supply of Supportive Housing to end chronic homelessness in america. In 2016 he requested 255 million to hundred 55 million to create 25500 Additional Units of Supportive Housing but leverage the creation of many more. So Supportive Housing is proven to help homelessness people. It improves health and reduces er visits. The Healthcare System, i would argue, has a huge stake in our creating a sufficient supply of Supportive Housing to end homelessness in america. Yet there is not consensus that this is an investment the federal government should be making. Second we are learning something in the work that we are doing with the veterans affairs. Here there has been confessing this consensus. We have had a one third reduction in homelessness between 2010 and 2013 and we are on a path to end their homelessness. Imagine if we could get this aligned with medicaid to repeat this with individuals with disabilities who have lived on our streets and in our shelters for years. My my focus has been to work with cns to find ways we can better align housing and medicaid. Im really thrilled with the Housing Related Services report they just published. There there is a link to it in the documents and all of the information you have in your packet. Im increasingly meeting state medicaid directors who understand that if they are going to achieve the goals of Health Reform bend the curve they will need to deal with housing and homelessness and they have a new best friend who is a house. This new document brings clarity to something that was pretty unclear. If housing is over here and health care is over here there is a a whole lot in the middle. What cannot medicaid do to pay for for whom and when . If medicaid were were paying for all the services in support of housing that it can pay for, we would have Better Health outcomes for seniors individuals with disabilities and we could end chronic homelessness. I believe if medicaid became a major player in Supportive Housing we could build the consensus needed to make the level of investments necessary to help seniors age in a home they can navigate and afford. Individuals with disabilities who have a right to to live in an integrated setting have more choices of where to live and there would be more Housing Available because they value and service partnership. Let me finish right started. The conundrum is hud pays for a lot of services in housing that medicaid could pay for. Medicaid has a lot of financial incentive for there to be a lot more affordable accessible and Supportive Housing and the budget environment is such that were not going to do what we know works and were not doing anything at scale. That is why i am excited to be here. Your interest in housing your understanding of the relationship between housing and health, your advocacy for Supportive Housing for older americans, individuals with disabilities, including folks with disabilities living on the street, could help create the consensus we need to make the investments we need to make the investments that will matter. Thank you. Thank you jennifer. Before we we go on, if i can, lets clarify you are talking about the kind of services that medicaid could pay for in Supportive Housing. I wonder if if you could be a little more explicit and say a couple words about what is stopping that from happening now. For example, in our Homeless Assistance Programs we spent over 400 million per year on services. We only need 265 million to create more Supportive Housing to end chronic homelessness but were spending 400 million Million Dollars a year on services. Thats everything for things medicaid cant pay for but a lot of that is exactly the type of and reach, engagement, assistance that is described in the new housing related bulletin. The the biggest barrier is that states dont know what will be approved and what to ask for, everybody is afraid that what we are saying is medicaid should pay for housing. Thats not what were saying. Were saying medicaid should pay for health and these services that we are doing naturally now keep grandma out of the nursing home or keep someone not of an institution, we just need to extend that. Were also paying for services for Service Coordinators in our senior housing, we pay for Service Corps nadirs and Public Housing and a lot of that Service Coordination is really Health System navigation and wellness activity so we dont have an ambulance pulling up every night and we can keep people in their homes longer. Okay, very good. Letsxd turn to gretchen from colorado. Thank you all for inviting colorado to participate in this very interesting conversation. As jennifer mention, colorado is working very diligently on this issue and its a privilege to be able to share with you some of the things we are doing. First i would like to provide a little context. Everything we do within our State Government at this point in time is really driven by our governors platform for health. That is the state of health. Our very bold goal is to be the Healthiest State in the nation. We take that goal very seriously not only because we have a great place to leave live, but we have Health Disparity in our community that are holding us back. We are we are working very hard to move those forward. It really is around this interconnected nature of health for our economic growth, social conditions for Health Care System to work more effectively than it does today, to help healthier people and to create a healthier bid business environment. We believe when we look at those things holistically we are able to put the right Services Support and finances in place. If anyone anyone is familiar with the triple aim, the best care for the best value and that is our translation of that very important concept. That is a commitment to starting with prevention and wellness, which is a lot of what we talk about when we talk about the issues were discussing today. The nature of the Healthcare System needing Health Insurance most of time to access the services you need and making sure we have the capacity within our Healthcare System to meet the needs of the residents of colorado. We invest a lot of money in across the nation in our Healthcare System and we have some opportunities to get better value for the dollars we invest. Some of that requires Infrastructure Investments things like healthcare capacity, primary primary care medical homes, having integrated care between various types of healthcare so we dont have one person with one body going to three different places to get their healthcare needs met. It is our highlevel, holistic view of colorado and how were looking to move our agenda forward. We did expand medicaid in colorado. One of those buckets, as you remember, is a coverage remember, is a coverage and capacity area of focus. Prior to september, or in september 2013, prior to the first day of enrollment in the Affordable Care act we had many residents you can see in the breakdown theres diversity of population that we cover. This housing conversation has been accelerated by at this expansion. Colorado did that faith based activity expanding those living at 10 or less. Let me remind you that is 11,000 a year in income. So we expanded 10 of poverty or less prior to the full expansion of the Affordable Care act and built on that as we move to january 1st, 2014. It was an important step for us to understand the needs of those primarily Homeless Individuals, understand how the best engagement with them and how to get access to coverage and to begin to understand the breadth of their healthcare needs and what other services. Our expansion has been an important piece of our work and coupled with that expansion has been an additional commitment at the Governors Office around permanent Supportive Housing, theres a specific looking at the issues of homelessness when the Current Governor was mayor of the city of denver he had an important platform around homelessness and that has continued on into the administration. A lot of that focus has been around permanent Supportive Housing which you will notice across three of the comments so far and that required us to look at the capacity of the housing system. How can we identify and mobilize existing state resources and what other innovations do we need . Colorado is a very nice place to live. I have lived there almost all my life and is an expensive place to live and given that housing is one of those issues that is directly impacted by the other components of the marketplace that are around areas of Median Income and all those things it is a challenge at times and very expensive environment, housing environment overall, colorado has the hottest realestate markets in the nation at this point to figure out how Affordable Housing can be made available so letting innovation models to be incredibly important so this dual focus of a Health Platform and housing platform has set us up very well to look at how we can begin to expand the relationship between these two areas so health and housing has been an important piece of what we have been working on. We engage in some discussions that have created this crosswalk jennifer was referring to which is how we be sure we are using investments appropriately so that medical related support services are being paid for in a way that makes sense and other Housing Related Services can be leveraged in the same way . We engage in a crosswalk study tonight. I want to talk a little bit about findings from that. We look at fiscal year 1314, july 1st, 2013, to july 30th of 2014 looking at our first months of expansion of medicaid and we look at our data, there are 37,000 enrollees who reported during the year, 24,000 or so supported homelessness in the entire year and others the bulk of those, the rest of them talked about being homeless so that is an important piece the coverages a. Point in time for many people, a period of time in your life you are homeless or you have coverage you pick up that survey or the point in Time Homeless survey and that is where you why. When you look at programming to recognize what is in peoples lives. The analysis of spend on those services about 160 million and through this exercise of the crosswalk we begin to break those 37,000 and the 3700 people who were the most expensive, 97 million and i know we have been talking about money and i would like to believe what we recognize from that number is those people were very ill. And probably didnt feel very good. It is important for us to recognize 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 better existence as well they move through the world so this is an important piece we are looking at from a budget perspective and an Overall Health perspective. When we say we want to be the Healthiest State of the nation that is for everybody and that is an important balance to look at the experience people have. As we hear about the opportunities, the clarity that came in june of this year, june 26th is the date on that memo is a chance to have more clarity as we work to see what we can do to bridge between health and housing to not only address these individuals but put more permanent structures in place and to do that as i think we talked about a little bit, services can also exist in silos at State Government level. We have created agency were groups with members of the department and Health Care Policy and financing, the medicaid industry, division of housing and Governors Office and that is twice a week and the basic work we had to accomplish is clarifying language. All bureaucratic programs and we use acronyms that only we understand and you have to step back and say what are the letters, what do they mean and it has been an important clarifying of language and recognizing it is taking us some time at the agency level to know how to interact with one another. In 64 counties across the state of colorado with the sixth largest land estate in the nation will probably be some confusion and opportunity for better education and that is where we are focusing our energy now, helping all of our providers and the housing side and the health care side understand the opportunities to be working together, how can we begin to bring alignment in and synergy into the funding available to all of us . We are also looking at new waiver authorities that have been made available, recent document out around 1115 waivers related to substance disorder, that is a piece of perhaps this conversation we have highlighted but important piece of how those services can be delivered and lastly some of the technology pieces, we have a Homeless Management Information systems and medical Management Information system and as the state is going to read procurement of those we are looking to see if theres opportunity to have a connection between those of the we are now in the time where technology can help so lastly circling back on the reality of the people at the heart of these efforts we have the chance in my former life in a partnership with some folks to talk about and learn about the experience of those living in Affordable Housing their health care experiences, one of the most heartbreaking things is lack of dignity, and if we were smarter, the complex Health Care System, to navigate at times and what we concluded from that peace and top with partners about is it doesnt cost any Additional Resources, to have respect and supervise dignity. It is important to think through these but there are basic things we can do to help improve Peoples Health and Mental Wellbeing and all of our society and communities with just some recognition that these are hard issues and the folks in the middle of the need support and respect as we work this out. Thank you. Lets turn to dr. Sullivan. Good afternoon, everyone. I am very happy to be here. I speak from another additional perspective. I am the family physician and i have cared for and exclusively Homeless Population. Can you hear me . For an exclusive thely Homeless Population since 1996. The trickledown effect of spending decisions and the lives of my patients. And how our ability to make good policy and spending decisions influences the hilton of very real people. On 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 the Medicaid Expansion stage, i am happy to say. There is still legal challenge pending in the courts to that expansion. We have other 6 ses i would like to tell you about. One is that arizona decrease homelessness by 15 between 2013 and 2014. A note i experienced personally, we began in the phoenix area which is a very large and scrawling county with a Homeless Population of approximately 17,000. I started a nonprofit called circles this city and we did at as a Community Coming as a grassroots effort to bring people together to meet the incredible need of those who were too sick, too frail to be in our streets and on our shelters. In 2012 we opened the 50 bed facility in the phoenix area. A name for the service is called medical respite the respite is somewhat confusing, recuperative care for persons experiencing homelessness. You could think of it as Bridge Housing with very intensive medical support. This has been a crucial part of our ability to provide for the sickest, the for ellis and most vulnerable. The number of supporting Housing Units is growing. 1600 Supportive Housing units were funded for individuals with the seriously mentally ill designation by continuum of care who funded the rental subsidies and medicaid to funds support of the services through a regional public, private initiative it was our united way bringing partners together, another thousand units of Supportive Housing were targeted to chronically Homeless Individuals. However the challenge we still have a need in resources challenges, we think it would take about a thousand more Supportive Housing units to end chronic homelessness. Our arizona medicaid plan covers of a comprehensive bundle of services. The flip side of that is those services are only available to persons with seriously mentally ill designation. Our nonprofits participated in a few Pilot Projects with the local large medical centers. Frequent users of systems engagement is an acronym of the corporation for Supportive Housing. Tremendous, active wonderful partner in getting Supportive Housing available to us. In this Pilot Project, we engage the most frequent the most expensive homeless utlilizers of care. Aljazeera done it by several agencies. That Pilot Project realized the 70 reduction in emergency room visits and 74 reduction in and in patient utilization after patients are placed in permanent Supportive Housing. The diagnosis is homelessness. The patients we took care of, they didnt have just one chronic disease. Some had two most had three, four or five. That doesnt take into account the acute problem the diabetic foot ulcers, the exacerbation the crises for which people cycle in and out of emergency room care. Why do people cycle in and out of Emergency Care reasons we probably believe, as you can see the last one, the primary care system might not be responsive to the population issues or the multiple issues barbara talked about earlier is that are the occurring phenomena and of being homeless and living on our streets so i would like to show you a study of a patient, we call him mr. 280. He was wellknown to the Phoenix Fire Department because he hit 911 all the time for transport to local hospitals and we think between adding all of a hospitals up, with a hospital 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 discharged him to permanent Supportive Housing. This is mr. 280s hospital bill at st. Josephs hospital. Page 1. Page 2. Page 3, page 4, page 5, page 6, page 7, page 8, page 9, page 10. During that period of time he had 192 visits to the Emergency Department but not one in patient admission. I can tell you when we actually engaged mr. 280 we found out he was living almost a hospital parking lot. Total account charges of 358,417 at one hospital. This is a graph of the emergency room visits during that period of time. You can see there are three places there in 1213, when he wasnt in the emergency room and we can show you three mug shots that correspond to those months when he didnt appear in the emergency room. So since being halsey has been to the emergency room twice. He has never been admitted to the hospital. He is stable the house and has remained stable the house over that period of time. He is receiving care in the Traumatic Brain Injury Clinic he got his food handlers card and is employed parttime at a local restaurant so what are our challenges on the ground . I think you have heard talk of care coordination. We love when we can get somebody into permanent Supportive Housing because we have that opportunity. I am going to get that diabetic foot ulcers heal. I am not going to get it healed if he is in shelter or under the bridge. We need to coordinate services the we provide. We havent figured out whose responsibilities that is going to be. That is another one of those issues and we have to Work Together. We have to prioritize the support in terms of medical needs. If you have not seen the work by dr. Ocala all about our medically vulnerable or dying in streets, we have pretty good data to show that persons with chronic illnesses were medically vulnerable will not survive and yet our systems are Electronic Systems silos, we have to learn how to cross them to prioritize those limited supportive resources that we have to be persons who need them from most. And one thing we are interested in in this developing new and innovative models for delivering primary health care efficiently in permanent Supportive Housing so once we get people fair how do we deliver care in the most efficient way possible. To we take services to is them . Do we provide transportation and followup to get to fixed sites . All of those are possibilities. We know that is important to place people immediately, dont get sick for one thing. The second at thing is when we can locate the person that needs to housing we need to put them there. Put in a plug for medical respite care for the homeless and the growing of these programs as pivotal points where patients who are too ville for direct placement with out the stabilization of that illness can use medical respite for Bridge Housing. So my recommendations, housing is health care. If we could increase the availability of permanent Supportive Housing units, we need the vouchers and the services. So anything we can do to incentivize our states to cover that array of comprehensive services in permanent Supportive Housing medicaid is wonderful. But medicaid alone cant do it. We need the support of from our Mental Health providers. We need had ud we need housing thank you. Thank you. Let me just, we now are at an point where we would love to hear your questions at one of the microphones with the green card you fill out and hold up and bring forward, tweet it and go from there. Let me start sister at dell and welcome other analysts shining in as well, about the kinds of money, which pockets were you able to pick to put together what looks like an incredibly impressive array of Housing Services that have allowed you to make such progress . As far as the housing is concerned, through our continuum of care also through the united way we were able to put together some funds from the department of housing, state department of housing, from a couple of the cities in metropolitan areas and philanthropy. Those are the vouchers. The health care folks in the room may be confused by the term continue of care and since i want to take credit for that as a hud program i will check in, Homeless Assistance Programs are delivered in communities through this Community Programs we call continuums of care, that is confusing to the Health Care System and i wish we had named it Something Else especially since we are advocating a continuing level of care, that is something, so when she is saying she has money that was probably maybe some Capital Development costs through the hud Homeless Assistance Program which is the same place in the budget we are trying to get the funding to do the Additional Units exactly like you are saying so you can end chronic homelessness, just a little plug for that. Okay. Thank you for your observation of decorum. If you could identify yourself and keep the question as brief as you can we would appreciate it. Al milliken, a. M. Media blitz what experience do any of you have with those who have gone on medicaid as a result of experiencing a Natural Disaster and losing the housing they had before . I would love to talk about what i have observed in new orleans, with the anniversary of hurricanes katrina and rita. Tragic, the number of people who lost their homes was devastating. What happened to the community was devastating but what they did in the rebuilt is amazing and because there was a lot of flexible Disaster Recovery money, they got lowincome housing tax credits which are the biggest producer of capital dollars for the creation of more Affordable Housing and Disaster Recovery money. They got Hud Community block grant money, Disaster Recovery, housing choice vouchers which is hud rental assistance and shelter plus care vouchers which are hud homelessness rentals, Disaster Recovery money, the amazing thing they did is they used Community Development block grant flexible money to pay for services when they created Supportive Housing lowincome tax credit they use the housing julius vouchers and shelter care vouchers to deeply subsidized those units for people experiencing homelessness when they built the medicaid system that would pay for service and support of housing and become the triage process for identifying people who have that vulnerability and need to move them into housing. I say that in a state where the governor has chosen to not expand medicaid, but it shows what is possible when medicaid and housing are used strategically together so i hope that reflect what you are asking for. I should call attention to what is on screen and that is an Incentive Program of hours along with our friends to get used to fill out the. Evaluation form. If you do in sufficient numbers that weve reached a 50 Participation Rate in this exercise the alliance will make a contribution to the community of hope youre in town which deals with some of these problems we have been discussing including homelessness and health care on the ground in d. C. So dont leave without filling out your evaluation form and making sure the person next to you fills out the evaluation form as well. The institute of social medicine and community health, this panel is a great example of social medicine and yet 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 sisters sullivan introduced us to to me is an example of hospitals taking advantage of the Medicaid Program to extract as much money as they can from it rather than identify the sources of this mans needs and making recommendations for addressing them whether through the resources of the hospital or the resources of the generic community. I think the colorados story is interesting because they want to be the Healthiest State. That means not just the Healthiest State for Homeless People but the Healthiest State for all people. Where are the recommendations on how the Health Care System should be integrated into the 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 forced to identify the social causes of the problems that they are expected to treat, this is great opportunity to raise those issues so we can have some Generic Solutions and not just be proud of reducing homelessness for a certain segment of the population. I will start with this. I completely agree and appreciate the passion behind this issue. What we are trying to do is get our Health Care System to the place you have just described and that is not just for special populations but all of us. What we are all looking for is an outcome in trenton, how are we as individual human beings and the in our communities getting healthier and how can we demonstrate at and put the resources of the Health Care System behind that. When i say yes to my mean an actual integrated system that has informed with it and resources to be able to deliver the kinds of care that we envision in the presentations here, trying to build capacity in our communities to get there and a lot of it has joy with partnerships that have been described, with social determinants, not limited to housing but good nutrition, good education, good jobs, stability and health and stability in life so when we talk about investments in housing and talking about the partnerships we need to have informed by recognizing this man does not have housing and that is contributing to 280 emergency room visits. How does this Hospital Partner with outpatient primary care in the community and Housing Providers to get into housing . That means identifying Housing Resources that are woefully insufficient in every community in this country. So i envision and applaud what you are describing as well. We have to get there and that means investments at the federal level that we need to be serious and honest about. Does that answer your question . Addresses it beautifully. I would add one way we are seeing movement on this issue is there has been broader recognition of the impact of social deterrents of someones life circumstances on their ability to achieve their potential but in addition through our medicaid Delivery System through our physical Health Services for Accountable Care collaborative structure where we have regional entities that have Key Performance indicators that they get Additional Resources they achieved and some of those wares picked strategically and those were 30 they readmission to the hospital, the use of highcost imaging so many bills, mr. 280 they experience a high cost and no one likes to have damaging that is not needed in a hospital twice if they dont have to be or waiting so it has both components to it and i think very quickly our Health Care Systems working towards Key Performance indicators recognized there may be underlying social factors that with some attention we could meet these Key Performance indicators so those are transforming overtime. We have visits that we have been talking about homelessness in general terms and there are homeless families as well so we believe all those indicators can broaden the focus on the entire individual familys needs beyond the single engagement with the Health Care System. If i can follow up with the point i did not make but which is important this population largely was ineligible for medicaid until the point of the Affordable Care act extending medicaid and so this population wasnt even part of the system. Saber eligible but not enrolled because of how hard it is. The vast majority of people were single non disabled on elderly adults who 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 comprehensively look at their needs. For mr. 280 that was before Medicaid Expansion so he had no insurance. Very good point. Go right ahead. I am with the Infectious Disease society and hiv medicine association. Thank you so much for the panel. It has been wonderful. You both were speaking of Supportive Housing but one distinction was sister adele referred to permanent Supportive Housing. My question is are there mechanisms in place for Supportive Housing to help individuals phaseout to sustain their own housing and sustain their own medical needs and are there any metrics in place to determine when somebody is able to phase out Supportive Housing if it is meant for them to phase out . I am happy to serve that one. A couple things in the world of homelessness, the term of permanent Supportive Housing was really created distinguish it from the paradigm of the day, transitional housing and what it meant is it wasnt a time limited program and you could stay as long as you needed to and the ability to stay in the same home without a clock ticking is supportive of recovery. Stress associated with having your act together and eastern time end you need to go someplace else is counterproductive to having longterm stability and working on longterm goals so is designed to the housing. Obviously we hear stories every day of people who dont need it anymore and who get a job and want to move out and make the Space Available for someone else but that is where our aging portfolio is a great example. We do Supportive Housing for the elderly and the expectation is and when she turns 90 she should learn some place else, the concept that housing is your home and where you live, that idea of home is the idea, the life changing event from hopelessness in the streets to hope and a future that happens when somebody moves into a home of their own, when someone moves out and institution into a community and an apartment of their own. We want to support mobility and people being able to move off of hud assistance whenever possible, when we arent working, with people age in which people with severe disabilities and people with severe disabilities living on streets for a long time we need to presume they will need support for a long time and sometimes the rest of their lives. We also hear stories everyday of people i am sure you lived at this, and people you get off the streets, you afford the dignity of dying in their own home instead of on the streets because they came to you that frail. Those things happen very frequently. George Washington University a couple scenes among the speakers, maybe there could be a little dialogue on these questions. One was medicaid should pay for housing, medicaid doesnt need to pay for housing, just needs to pay for Housing Services or Services Related to housing. Another is homelessness is the diagnosis. The other is we could target things to people with relatively severe needs, frequent secret mental illness, is there any way to resolve these apparent contradictions . I dont think theres any contradiction at all. When people say medicaid to pay for housing when they are saying is we need more housing and the federal government investing for housing programs need to get somewhere with the health impact, maybe medicaid should be the thing but it is statutory league prohibited from paying for housing so it is an unproductive strategy. As the result medicaid could pay for the things medicaid does pay for which are the Health Services and supports to move off of the streets to the home of their own, i dont thing those things are at odds at all. Look to my colleagues to see if they heard. The other piece that is important is in colorado in particular we have a population dense range from fort collins through denver to Colorado Springs but then we have large swathes of Rural Communities that also have individuals who experience homelessness of the flexibility of letting local partnerships figure out what kinds of resources are available in their community and how to leverage those appropriately is the other piece that doesnt make him in conflict but rather reflect the reality of the diversity of our nation and availability of resources in each of our communities. Coming from a local perspective we really had to pull together Public Private faith based philanthropic. Everybody had to pull together and it was almost this cant go on in our community. We are not providing for the most vulnerable on our streets and that is what we are saying to you. We just hope we can all pull together. I just think i was in heaven if i had three things, support of Housing Units and give everybody was insured and we had a Supportive Services to surround the person those three things. I want to just follow up with a question that got raised, the previous question. It involves a former administrator of financing administration, bruce babbitt. That is how former it was. That is right. Someone asked him about 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 funding housing or seeking to fund it through medicaid is medicaid is already under all kinds of political pressure because of its expense. You start to say anything might benefit of medicaid beneficiaries, if you start to say anything that might benefit a medicaid beneficiary ought to be covered by medicaid you are opening up a Bottomless Pit and making the program even more vulnerable to those who want to cut or eliminate it and i wonder if i could elicit some response. Confident that bruce is not in the rim, i couldnt disagree with the short sighted perspective that represents and the case studies say that but the important thing from our perspective is medicaid shouldnt pay for housing because the whole history of medicaid is about housing in really institutional horrible ways end any time medicaid thinks it is doing it better, ten years later is trying to figure out how to downsize and divest itself of a great idea 10, 20, 30, 40 years ago. Medicate does not know how to provide housing. Conveniently we do. It is not a question of should medicaid pay for housing. Is a question of should the federal government invest in the discretionary side housing programs that have the enormous human benefit and cost on the mandatory side of the budget in order to deal with budget deficit issues globally to deal with the aging of america, deal with the institutional is aging, individual disability is living on the streets. I dont see that as a slippery slope or a black hole, i see that as sound Public Policy to go upstream and fix the problems that are costing 328,000 for mr. 280 when we dont i got a little impaction that there. I know that in one of our hand outs there is a chart of stated initiatives in this area and the state of new york in fact did ask for medicaid money to build housing. I went and talked why are you asking medicaid to do the very thing it cannot do . And he submitted it anyway and medicaid said no and when he didnt do is included in the same request, i hope jason is not here everything medicaid could have paid for, all the services that theyre paying for that on the general operating fund, i dont know why they did that. Sounds like Technical Assistance is in order here . From families usa. On homeless issues, you mentioned at the federal government, collaboration between different agencies are unprecedented. Improving Housing Conditions rather than getting people into housing low income children, like asthma increasing emergency room because of the mold in their house. I wonder if theres any work around that. The environment we live, what is happening in a home is the mold, when we do more, hopefully we do it well. Led Controlling Health the homes that focus on how to do lead abatement home modification dealing with causes of asthma, by the Health Care System and public Health System and one of the challenges with high t Mobile Channel mes completely overhauled this unit. One more healthy and in the world but who pays for it, we love to pay for it if we had the budget dollars to do that. And do some funding in this area but we are trying to figure out how to do partnership. For example the partnership we have with Johns Hopkins university and try to joy targeted strategy in that community and some things we are doing in california, partnering with the Health Care System to figure out a concerted effort on that. That doesnt mean it is not an important part of the work hud and h h s do together. I would add from a state perspective that kind of thinking is great thinking end as yet another state agency to the mix in our world so the department of Public Health and environment as part of the stage of health has a guiding principle around the ten winnable battles that include things like from a Public Health perspective if we leaned into we could win and other things, environmental causes of disease so it is an important reminder to us perhaps we should contemplate Interagency Group but it is a piece that from a different perspective between Health Sister agencies and might be another nexus point to contemplate. I am a local official, representing hundreds of low income residents with medicaid and medicare. In other areas there is a push to put together concentrated policy that is the housing of hundreds of lowincome families that have in some cases many chronic illnesses, Mental Health issues and a number of factors but theres a big push to eliminate housing, to reduce it, create mixed communities, so most of my constituents live in fear that in the next two years they will not have housing, leads them to become sick and joy land in some cases they die. We dont know what would happen in the future because a lot of people dont like to see lowincome residents concentrated in serious throughout the city as we pushed through mixed communities. My question is how do we secure housing for those that are already housed and public Housing Units so the we can work on their health issues. We learned, over the last 5 decades. Week everybody out of the building. And we dont know where people were. It was created by the community. It blew me away. The people have horrible unemployment rates. It had neighboring school is the worst in atlanta. And and the singlefamily homes around it. At working with residents was a three year process on the front end. Do that engagement in a meaningful, sustainable way. Building by building, unit by unit, build more, moved people out of the old gent into the new. The community is beautiful, they built the school it is one of the highest performing schools in the atlanta area. People of all incomes went to move to this neighborhood so kids can go to that school they started as a Charter School k40, ywca doing health and fitness, i have never been in a place where i saw a Young Children of color, such pride, in the end of atlanta. We can do this, the old ways we didnt do well. I wish i could take your community down to see this community in atlanta because it is testament to what happens when we do it right. Thank you. Thank you very much. In terms of innovation, a lot and coming services i am not sure if you are familiar with it. Introduce yourself. Darren. I work for a congressman. We are looking at tell us health teleheaslth providing health over the internet or smart phones, at keeping people from traveling very far if they are in rural areas or underserved areas, sort of the new service to help provide quality care for people. My question is do you see this playing a role in housing . Telehealth . Saving a lot of money on mr. 280, several trips, telehealth usually prevents people from going to the hospital. 70 of it, they dont need to not go to the hospital. Telehealth is an emerging model that has a lot of promise and is being implemented in a lot of places and i think we are seeing more and more opportunities to implement that in rural areas in particular. In a Health Center setting and a Service Provider i think it gives us opportunities to access Specialty Care where it may not be available because of travel time and Public Transportation is not adequate or feasible for a vulnerable population to navigate. This is an intriguing idea on how we can implement this where we can but we might also be overlooking lots of reasons why mr. 280 and a lot of patients go to the hospital and is not always strictly a out of medical necessity. No doubt what we see are acutely ill but because there is lack of stability sometimes the nurses know these folks by name and it is because of a social connections they are looking for to be in necker environment where people touch you. I think we joy and overlook quality of care our Health Care Institutions provide from a compassion perspective. Sister adele can speak to the fact that very few of our clients are touched by anyone else except in violence or a anger. When you have a Health Care Provider put their hands on you in a living caring way the first time in 25 years that can be life changing. I am excited about telehealth but i think for our clients the social connectedness of being together with people is important. Add on to that. I agree. For rural areas and people who have no access when what they really need is a specialist, is wonderful. I have the same concern. Why for three weeks in center and i can tell you, and impulse control. Any time we felt and place. You are flying. They went there and really, it was safe and clean and he needed a human contact to make sure he is all right. Can you do that with telehealth . I would be careful about implementing it. Clients need a group hud so the compassion you are hearing is born out of that realization that that is an intense human need for all of us. The last question. I will try to make it a good one. Janet with the National Housing conference. I am curious to get your thoughts on the panel 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 of how difficult it is for vulnerable, low income individuals, particularly Homeless Individuals to start to think about how to find a home whether it is primitive Supportive Housing or another affordable unit, what will you think that place in comprehensive Care Coordination Services . Take a look at what is it states use their money follows the persons dollars to pay for . And the biggest challenge associated with that . What im excited about it understands building a network of landlords, Housing Navigation supports a package, you cant just write a script for housing and hand it to somebody especially given the affordable markets. I think medicaid can pay for some much more than medicaid has paid for for all these populations abroad and small and i think we are making good head way. I would be remiss if i sat here today and failed we also need more Affordable Housing and in the senate there is a 90 cuts to the hud home investment the best engine we have for the creation of more Affordable Housing and if we believe the connection between housing and health is up matter of achieving that you are going the Health Care System needs Housing Units that are available to the people they are targeting, to create more Affordable Housing. Make a plug for the National Housing trust fund, it needs to be as authorized but not funded a vehicle for creating Affordable Housing so we need to prevent people from becoming into homelessness which would be great at getting ahead of the curve. One thing to contemplate quickly is if Care Management for medical conditions and or medicating other Public Programs shouldnt be located closer to the Housing Units themselves. The opposite side of the question you asked but one that we certainly are thinking from new for individuals who have Housing Available to them, the coordinators or whoever else is in those facilities are often lead first people when they open the mail from the state department which we are working hard to make mail more understandable to rethink because even those of us that is the first place they would have the chance to ask the question. What does this mean . I may have lost my eligibility, at the point where they are house may be an effective mechanism to contemplate as well. You have a quick word . Dont need to take it, that is fine. I would release thank you for coming today, for your attention to this message and really for whatever you can do to provide the collaborative effort to provide services for the vulnerable. Thank you all. Let me do just a little bit at the end. Jennifers mention of the senate reminds me of something you said earlier which we would endorse heartily and that is if you are going to talk to the housing and appropriations, veterans about these issues tried to make sure each of you know what is going on in the others dominion, you can see the evaluation form still up there. Still dangling in your hands, fill it out before you leave. They are doing really amazing work. The point of organizational privilege if i can take 30 seconds. One more slide to show you, thank you slide the interns have done such i s c one here, i dont know where molly is, thank you very much. [applause] it has been great. Selection of materials largely in malis hands. My apologies to those who wrote very good questions i was hoping to get to on cards and wasnt able even a tweet or two, thanks for staying with us. This is not an easy topic, lots of things to be done friday afternoon in washington and you stuck with it and we very much appreciate it. [applause] thanks to our colleagues for their support of and helping to point as to some good folks for this program of exceptional panelists which brings me to the final point which is to ask you to help me there is an excellent panel for discussion of a very multifaceted and important topic. [applause] you are watching booktv on cspan2 with top nonfiction books and doctors every weekend. Booktv television for serious readers. Here are some programs to watch on booktv. American Enterprise Institute scholar Charles Murray weighs in on how to reduce the power of the federal government through the use of technology. Susan looks at nagasaki japan, from the morning of aug. Ninth 1945 to today