By Michelle Shumate
Most of our work in Systems of Care is centered on supporting people in finding the help they need to address their material hardship. We’ve focused on necessary outreach programs, systems that help identify and connect individuals to services, and innovative solutions to reduce the administrative burden of maintaining and renewing benefits. In the United States, however, there are two issues where better Systems of Care are insufficient. Even if we were to connect people to services effectively, the demand for those services outpaces the supply – Housing and Mental/Behavioral health.
Housing
The largest housing program in the United States is the housing voucher program, colloquially called Section 8. The program only has enough funding to support a small percentage of eligible households. In 2012, More than 2.8 million families were on voucher waiting lists (an additional 1.6 million were on public housing waiting lists). On average, families that receive a voucher spend 2.5 years on waitlists. But these numbers underestimate the need. Many housing authorities close the waitlist to new applicants when it gets too long. Analysts estimate that 9.8 million families would be on the waitlist if it is not capped.
Moreover, an additional burden is placed on individuals who qualify for the housing voucher program. They must find a landlord willing to accept the housing voucher. Researchers call this the double-take-up problem because the landlord and the tenant must agree to participate. Double-take-up creates an additional burden on recipients. Of the families that receive a housing voucher, only 61% of them can use it within the 180 days allotted. The remainder cannot find a suitable rental unit whose landlord would accept the housing voucher. Landlords often reject housing vouchers because they perceive voucher recipients to be “worse tenants” or because they view the required annual housing inspections as too costly.
For housing, more effective identification of needs, accurately referring eligible families to the right housing programs, and reducing administrative barriers to eligibility won’t solve the housing crisis. Instead, a solution to this problem must address two interrelated issues: 1) the amount of funding dedicated to the housing voucher program and 2) incentivizing landlords to take the housing vouchers.
One of the most promising policies to address housing is called Universal Housing. In Universal Housing, everyone below a set income level is eligible for a housing voucher. Households would be responsible for housing costs up to 30% of their income, and the voucher would cover the rest. This policy is modeled on successful universal housing programs in Great Britain and the Netherlands.
The primary barriers to universal housing are costs and concerns about abuse. Current estimates suggest full housing choice voucher program funding would be $168 billion annually. The current program is funded at about $50 billion per year. A second concern is about abuse. When tenants only pay 30% of their income, the concern is that they will seek out extravagant housing. A universal housing program would need to be coupled with better analyses of the fair market value of housing.
In many states, it’s illegal for landlords to reject housing voucher applicants because of their income source. In these states, landlords often use credit and criminal record checks to disqualify these same applicants. However, a successful program in Seattle, Washington, offers some insight. In this program, people worked with a housing navigator to help secure housing once they received their vouchers. Navigators helped them with searching for housing, developing a housing resume, and with the first month’s rent needed to secure housing. But the biggest value of the program may have been working with landlords. When a tenant was denied housing, the navigator contacted the landlord to find out why. They advocated for the tenant and helped the landlord navigate the paperwork and inspection process. This helps landlords show great promise to open more units up.
Mental and Behavioral Health
Much like housing, mental and behavioral healthcare demand outpaces supply. In 2022, 60% of psychologists reported having no openings for new patients. The national average length of time between a client’s first outreach or referral until their first mental health or substance use appointment is 48 days. Rural counties have fewer resources; for instance, 40% of counties lack an outpatient treatment program for substance use disorder.
One of the reasons for this shortage is there are too few workers to meet the needs of people with substance use disorder and mental health issues. According to SAMHSA, the US needs an additional 4.5 million behavioral health practitioners to meet the current mental and behavioral health needs. The numbers are even more stark for rural areas, with only 1.8 licensed behavioral health practitioners per 1000 Medicaid enrollees (compared to 6.4 in urban counties). Many people are dissuaded from mental and behavioral health professions because of the low reimbursement rates in comparison to other healthcare treatments.
One of the additional barriers to care is financial hardship. Although the Affordable Care Act categorized mental health and substance use disorder treatments as essential health benefits, making them part of all insurance plans, the types of services that are covered vary. For instance, wait times for partial hospitalization residential treatments are longer partly because private insurance or Medicaid does not often cover the service.
Ultimately, addressing the lack of behavioral and mental healthcare in the United States is not just about more people asking for help. It’s not about matching them to the right professional or addressing eligibility requirements. Instead, much like housing, the solution requires more funding. Addressing America’s behavioral and mental health crisis requires a three-part solution that includes increasing coverage to those who need it, addressing reimbursement rates, and addressing the workforce shortage.
First, increasing insurance coverage for those who need it is a critical part of the solution. Estimates suggest that if Medicaid funding were extended in all states, 1.5 million additional people who have mental health or substance use disorders would gain access to coverage. In short, the key to accessing care is being able to afford that care.
Second, more must be done to encourage people to enter the mental and behavioral health professions. One example of a program that encourages people to enter these professions is the National Health Service Corps Loan Repayment Program. Individuals are eligible for up to $50,000 in loan forgiveness for a two-year initial term at the NHSC-approved site. If an individual continues for an additional one-year commitment, they may become eligible for an additional repayment of any remaining student loans.
In addition, some states have begun addressing reimbursement rates. For example, as part of Virginia’s 1115 SUD demonstration, they significantly increased (in some cases quadrupled) provider payment rates for some substance use disorder services. As a result, they saw a 173% increase in outpatient providers billing for services and triple the number of providers participating in Medicaid. Fifty-seven percent more Medicaid beneficiaries used substance use disorder services the year after the payment rate increased.
An additional innovation, supported through the SAMHSA expansion grant and Medicaid 1115 demonstrations, shows significant promise. Certified Community Behavioral Health Clinics are designed to increase the number of mental and behavioral health services available. As of 2021, 430 clinics are operated in 42 states, Washington, D.C., and Guam. Results of a survey of these clinics showed that 50% of them provide same-day care, 84% provide care within a week, and 93% within 10 days. This was accomplished by increased hiring, with an average of 41 additional staff added per clinic between program inception in 2017 and 2020.
In short, Systems of Care are essential to help connect people to care. However, housing and mental/behavioral health are insufficient to meet the demand. Instead, solutions must focus on increasing the supply of help.