Housing is the best medicine for seniors, but Monterey County is struggling to build enough
This article was produced as a project in partnership with the USC Annenberg Center for Health Journalism’s 2018 California Fellowship.
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Up until just a few months ago, friends Shannon Smith and Doug Sullivan were living out of their car. They are not recent transplants who drifted into Monterey County seeking benefits or handouts – they’re seniors who have lived here for many years and consider this area their home.
The two – who asked to be identified by pseudonyms, given their precarious housing situation – found out-of-the-way places to park their four-door SUV around the Monterey Peninsula, a place which Smith finds beautiful, and says she draws inspiration and peace. It’s also near doctors and other services Smith needs, as well as friends.
Each night, Sullivan would hang fabric over the windows and lay down an inexpensive mattress topper purchased at Kohl’s and some pillows in the back seats for Smith, who suffers from back problems. Sullivan slept in the front, but it was cold, and it was far from comfortable. Just getting enough rest was a challenge.
“It wasn’t easy being older living in a car,” Smith says. With more than one health issue to deal with, she worried that living in a car made it harder to get well.
The good news is that over the summer Smith and Sullivan were able to get a roof over their heads for the first time in more than a year, after Smith – who loves to write – carefully crafted a Craigslist “housing wanted” ad and a local businessman served as a reference.
Smith also received guidance, encouragement and other assistance from Gathering for Women, a nonprofit homeless day center in Monterey, during their housing search.
Last year, Gathering for Women helped more than 680 women. Over half were over the age of 50, and one-third of that group were over the age of 60, according to Executive Director Jennifer Dalton. In July, there were 32 women visiting GFW in their 80s who were considered homeless, either living in vehicles or in temporary shelters.
Dalton and other homeless providers in Monterey County say adult diapers are in high demand – not because the women are incontinent, but because they do not feel safe leaving their cars at night to go to the bathroom. It’s not only a safety issue, it’s also a serious health issue.
“Only until people really realize there are 70 – and 80-year-old women living in their cars will we as a society be forced to change,” Dalton says, hopefully.
However, it’s a situation that has been well known for years among many homeless advocates and policymakers, and yet the situation has not changed, and it’s in danger of becoming a monumental crisis.
THE NUMBER OF CALIFORNIANS OVER THE AGE OF 65 IS GROWING AT A FASTER RATE THAN THE OVERALL POPULATION, according to a November 2017 study by the UC Berkeley Labor Center. Monterey County is no different, according to the 2018-2019 Monterey County Area Agency on Aging Plan Update, which reported the county’s more than 73,000 residents over age 60 – more than 17 percent of all residents – grew in population by 3 percent in 2016. Over 20 percent of county residents are expected to be seniors by 2020.
One recent study of homeless seniors in Oakland by Margot Kushel, a doctor and professor of medicine at UC San Francisco, reported that 44 percent of homeless adults experienced their first bout of homelessness after age 50. In a presentation last November, Kushel reported that California only has 21 units of affordable housing for every 100 extremely low-income households.
Add to that the following factors: Seniors will suffer a greater number of age-related illnesses and conditions; they have less income; and the cost of housing is only going to rise higher without significant additions to the housing stock.
And yet, ensuring that seniors have a roof over their heads – especially with the support of social workers, caregivers and others – is one of the key indicators of stable health and longevity. Housing is what’s known as a social determinant of health, one of many that include things like access to health care, employment, food security and safety.
Housing is, data shows, a far less expensive solution to keeping them – as well as other medically fragile people and the chronically homeless – healthy than repetitive emergency room visits and costly hospital stays. Potential cost savings aside, there is the cost of human suffering that seniors are subjected to when living without a safety net.
A wave of communities nationally have recognized this and are actively using health care dollars – monies that typically would have gone toward treating patients, expanding health care clinics, hospitals and other initiatives – to build supportive housing. Meanwhile, Monterey County continues to struggle with the pressing need. There are some beginning efforts, but it will take an enormous amount of political and moral will for the community to add the amount of housing needed by seniors and medically fragile residents that will keep them healthy.
“We can no longer assume that others are going to take care of the problem and that people in high places are going to do the right thing, or that our leaders can work alone,” Rev. Michael Reid, co-founder of the Fund for Homeless Women, told a group of more than 120 people last September in Salinas at a summit on senior housing and homelessness.
“Only together will we be able to transform the systems in our culture that create barriers for women, seniors and people with disabilities,” he said.
“We can’t wait for others to do it for us. We have the power to do it ourselves.”
IF REID WAS THE SUMMIT’S MORAL COMPASS THAT DAY, Joshua Bamberger – a physician with the San Francisco Department of Public Health for almost 30 years – was the summit’s medical opinion. Backed with lots of data, he drove home the message that housing is the best medicine.
As Bamberger worked with AIDS patients in the 1990s, he noticed his homeless patients were dying at a higher rate than those who were housed. Three-quarters of the more than 600 homeless patients he was treating died during that time period. Of the patients who were housed, only two of 71 died. It convinced him that housing was the key to treating his patients.
“If I could only monetize this, put it into a little capsule, people would pay $100,000 without blinking an eye,” he said. “But because we call it something else, we don’t pay for it. It drives me nuts.”
In a recent interview, Bamberger lays out the problem in physician terms: “I can write a prescription for high blood pressure medication, but I can’t write a prescription for a house, even though that’s what’s needed most.”
That he couldn’t write a prescription didn’t stop him, however. He remembers helping a homeless man move into supportive housing with caseworkers, who then became healthy enough that his emergency room visits and hospital stays plummeted.
“I just saved San Francisco a helluva lot of money,” Bamberger remembered thinking.
Since 1999, the San Francisco Department of Public Health has been able to create 1,800 permanent supportive housing units – advocates say the supportive function that includes help from caseworkers is key – under its Direct Access to Housing program, according to a 2017 report titled “Innovative Models in Health & Housing.” Affordable housing advocates are quick to point out that San Francisco is a unique situation being both a county and a city. It can carry out both public health responsibilities typically done by counties and affordable housing finance functions done by cities.
About half of the 1,800 units are renovated, single-room occupancy residential hotels and half are apartments owned by nonprofits and developed with capital funding from city housing agencies, as well as traditional affordable housing financing options. Approximately one-third are designated for seniors.
One study estimated the city was saving $30,000 in health care costs per tenant, one year after move in, due to reductions in emergency room visits, inpatient care for both psychiatric and medical reasons and skilled nursing stays. In a separate study of one apartment complex, the city’s health care costs dropped from an estimated $3 million a year to $1 million, one year after residents moved in.
Those kinds of results are spurring communities around the country to catch on, including Los Angeles, Portland, Boston and Phoenix, among others. A new requirement for most nonprofit hospitals under the Affordable Care Act to use revenues in what’s called a community benefit, along with an increase in patients newly insured thanks to the ACA, helped push investment in housing.
But it’s not always an easy sell, and even if there’s funding to build affordable units there is the challenge of NIMBYism (Not In My Backyard) that plagues most affordable housing projects, along with challenges like financing and building codes.
But Bamberger believes the data will ultimately win out and more hospitals and government agencies will be persuaded to build supportive housing. Monterey County’s hospitals are so far not considering investing in affordable housing. But one regional health insurer has opened the door.
THERE IS ONLY ONE MEDI-CAL INSURANCE PROVIDER IN MONTEREY COUNTY, the nonprofit Central California Alliance for Health. The Alliance serves three counties, including Santa Cruz and Merced, with a total of 350,000 members, 156,000 of whom live here, representing one-third of Monterey County’s population. And like many insurers, there is a reality to the business that holds constant: A small percentage of the members account for a majority of the costs.
In the Alliance’s case, 8 percent of its members account for 75 percent of the costs due to chronic conditions, substance abuse and other issues, according to Kathleen McCarthy, director of strategic development. Those numbers were a driver behind the Alliance’s board creating a capital grant program in 2016 to invest in building new clinics, behavioral health centers and housing.
The Alliance chose two Monterey County housing developments to invest in: One is Moon Gate Plaza in Salinas’ Chinatown, developed by MidPen Housing, a nonprofit developer and owner of affordable housing projects in the San Francisco and Monterey Bay areas. The other is Junsay Oaks Senior Apartments in Marina, by Salinas-based nonprofit developer CHISPA.
Each nonprofit developer received a $2.5 million grant from the Alliance. Both developments are targeting frequent users of emergency rooms, mental health care centers and nursing homes.
Moon Gate Plaza broke ground on June 29 and could be ready by fall 2019. It is not specifically for seniors, but it’s expected at least some of the units for high medical services users – like the chronically homeless and drug users – will go to older residents.
In Marina, 47-unit Junsay Oaks is under construction next door to the Marina Post Office and an MST transit center, with a completion date of next spring. (It’s named for former Marina City Clerk Joy Junsay.)
In exchange for the $2.5 million grants, both Moon Gate and Junsay Oaks are setting aside 20 units each for CCAH members for at least 10 years. The goal is twofold: Improve the quality of members’ lives, and save the agency money through reduced use of services.
While Moon Gate Plaza is a $40 million project, and Junsay Oaks is $17 million, the $2.5 million from CCAH is only one piece of the puzzle. But both housing agencies say the grant is key.
Affordable housing builders use a complex formula of government and foundation grants, low-income tax credits, Section 8 vouchers and other components to leverage bigger bank loans with low interest, and a grant like the one from CCAH is part of that leverage.
Another key component is a commitment by the Monterey County Health Department to provide health care to the projects’ residents through its Whole Person Care program. That program is currently in a five-year pilot phase, using grant monies from the federal government. It’s designed to identify the high-cost users of the county’s physical and mental health services and, using caseworkers, shepherd them through the health care process. The government grant is set to sunset Dec. 31, 2020, but Monterey County Health Department Director Elsa Jimenez says they are optimistic they will receive state funding to keep the program going into the future.
The Health Department will need those funding sources, since it’s committed to providing Whole Person Care Services for five years to Moon Gate Plaza. (Jimenez says they will utilize unused funds from the first year of the pilot.) The funds will go toward caseworkers provided by MidPen. County health nurses will visit, just as they do at neighboring Dorothy’s Place, a nonprofit homeless services provider.
The Health Department also made a commitment to provide 10 years of services to Junsay Oaks and will work out of an office that was built into the site design. A county health clinic is nearby, as is a grocery store – factors that encouraged CHISPA to purchase the property several years ago.
“We think that will make a big difference,” says Dana Cleary, CHISPA’s director or real estate development. Supportive services like caseworkers make all the difference, linking residents to physical and behavioral health services, as well as helping residents get connected to social activities that make them less isolated.
CHISPA will also provide services to the seniors in partnership with other nonprofits, like classes, social events and healthy meals. Cleary says they are currently in search of funding to provide daily lunches in the community room. They also expect to work with agencies like the Visiting Nurses Association, as they have done at other CHISPA developments. “We hope it will make life better for them, with a stable roof over their heads,” Cleary says.
CHISPA President and CEO Alfred Diaz-Infante sees the trend toward using health care dollars for supportive housing as one that makes sense, and gets to the root cause of poor health.
“Health funding accomplishes two things: It allowed us to be more competitive for tax credits and it provides housing for a population that desperately needs it,” he says.
Health insurance giant Kaiser Permanente, based in Oakland with $73 billion in revenue last year, made a media splash in May with an announcement that it is committing $200 million over the next two to three years to reduce homelessness and increase housing in several states where it operates. Insurance giant UnitedHealthcare recently invested $35 million to build four new affordable developments in Michigan.
It’s not just health insurance companies. Hospitals around the country are also investing in housing. Examples include Boston Medical Center, which is investing $6.5 million in revamping dilapidated apartment buildings, and the Bon Secours Health System in Baltimore, which is developing more than 700 units. In Portland, Oregon, six health care organizations – including five major hospitals – donated a combined $21.5 million to help the city with affordable housing, homelessness and health care services.
In Los Angeles more than $40 million has been invested in what’s called a flexible housing subsidy pool, with monies coming from the Los Angeles County Department of Health Services – which encompasses four hospitals and numerous clinics and other services – the Conrad Hilton Foundation, as well as other sources, to create supportive rental housing targeting the chronically homeless. To date, 2,400 units have been created. Twenty-three percent of the residents are age 60 and above.
“I’m glad the health field is recognizing that, and that we need to be working more closely together,” Diaz-Infante says. “It’s a great strategy.”
And yet, Monterey County’s hospitals don’t appear to be ready or able to jump in.
MONTAGE HEALTH CEO STEVEN PACKER is sitting in a big, bright corner conference room inside Community Hospital of the Monterey Peninsula, the cornerstone of the nonprofit organization that includes a medical group, wellness center, foundation, Aspire Health Plan and Community Health Innovations, an affiliate organization focused on initiatives to improve health and drive down costs. Montage has $993.3 million in net assets, according to the 2017 annual report. Its net operating revenue was $623.4 million, with $559 million in operating expenses.
While Montage has made an investment in workforce housing with 32 units on Lighthouse Avenue in New Monterey for doctors, nurses, visiting medical staff and other employees, it’s not currently considering investing in affordable housing for patients.
“Our approach has always been, that’s not our forte,” Packer says. “We are not fluent in that language (affordable housing funding) because that’s not where we focus all of our energies, nor is it our primary mission. But it’s important for us to say, as part of a larger community solution, we would happily look at anything.”
Packer points out that there is a difference between a health provider like Montage, and health insurers like Kaiser that are investing in housing.
“When you are the payer, you are at risk for the expenses that your beneficiaries are incurring, so it is top of mind and a high priority that if there is a particularly high-spending segment of your population to do anything possible to try to mitigate what is spent,” he says.
“If I’m a health plan I get the whole premium, and if I can keep people out of the hospital that’s good for me,” he says. But Montage – the health provider – only gets paid when people get sick and enter the hospital. The system, Packer says, serves as a disincentive.
Montage recently created the Aspire Medicare Advantage Plan in partnership with Salinas Valley Memorial Healthcare System. It’s an insurance plan that covers approximately 3,500 senior citizens in Monterey County. Members receive annual wellness exams, and those with chronic conditions are assigned care managers to coordinate services. Homelessness, or the risk of it, hasn’t been identified as a significant issue for those members, Packer says.
He points to other initiatives, like the mobile free clinic that visits Seaside once a week, as well as Gathering for Women. Last year Montage, SVMHS and Natividad partnered with nonprofit Community Homeless Solutions to underwrite a six-room respite residence in Seaside where homeless patients can recover after being released from the hospital. The home runs at about 80-percent capacity, with average stays lasting 20 to 30 days. About a third of the patients are over age 65.
The Weekly asked Jimenez whether Natividad, the county’s hospital, would possibly commit monies toward housing, similar to how San Francisco’s medical system did. She deferred to Natividad’s leaders, but a spokesperson referred back to Jimenez.
SVMHS President and CEO Pete Delgado echoes Packer at CHOMP when asked about investing in affordable housing. “It’s not been on our radar, it’s not a part of the scope of our mission,” Delgado says. “Our mission is to create inpatient care and keep the community healthy as well.”
Like Packer, Delgado does not rule it out in the future.
SVMHS has made investments in emergency housing as well as the respite residence, and last year spent $117 million in uncompensated care to the underinsured and uninsured, according to spokesperson Karina Rusk.
Retiring Monterey County Supervisor Simon Salinas, a long-time affordable housing advocate and member of Natividad’s board of trustees, thinks the region’s hospitals can do more, however.
“You can’t just ask government to provide housing, it’s up to all of us,” he says. “We want them to at least engage in that discussion.”
BUILDING AFFORDABLE HOUSING IS NOT FOR THE FAINT OF HEART.
“Developing affordable housing is 50-percent harder than regular housing,” says Starla Warren, president of the Housing Development Consulting Corporation.
Developers face a complicated funding process. Strict building and environmental regulations at the local, state and federal levels can hold affordable housing projects to a higher standard than regular developments, making the construction process lengthy and more costly.
Supervisor Salinas believes the county is on a track to streamline the process. It started with a farmworker housing development in Spreckels, constructed by Tanimura & Antle. Salinas corralled the architects and county employees into a room to hash out building and code details. The whole process, from proposal to board approval, took eight months.
“That was unheard of, to get 100 apartments in eight months,” he says. “We should be able to do that for any other affordable housing developments.”
There are other obstacles. During a housing workshop hosted by Monterey Bay Economic Partnership last November, Gonzales City Manager Rene Mendez spoke to some of those woes, including NIMBYism.
“Are you going to be at city council meetings to stand up for affordable housing?” he urged the audience. It’s hard to approve developments, he said, when there are “a thousand people screaming at you.”
Bamberger suggests communities start with senior housing developments, as opposed to projects for the chronically homeless that often evoke strong objections from neighbors. “Most communities are less likely to NIMBY senior housing,” he writes by email.
It was neighbors who showed up at meetings with complaints about what would become the just-opened 19-unit Van Buren Senior Housing complex in Monterey. It’s a joint project between the city and MidPen Housing. The building was initially conceived of as a three-story building, but after resident complaints at informational meetings held in 2013, the city opted for two stories, says Elizabeth Wilson, MidPen’s director of housing development.
“We almost always get some opposition and Monterey was no different,” Wilson says.
When the application period for the Van Buren complex opened in February, more than 1,000 people responded. Of those, almost 400 people ages 62 or older who met income eligibility requirements filled out applications. Future residents were chosen by the order of applications received. The lucky 19 started moving in in July.
“The bottom line is that people fear change and they think if they stop a project it will stop change,” Wilson says. “Unfortunately, it just means they get other kinds of change, like traffic for example – because by stopping housing there isn’t enough housing near jobs, or homelessness because with more jobs and less housing, prices go up and the most vulnerable people are pushed onto the streets.”
Salinas hopes those who support affordable housing of all types will raise their voices to counter the negative, NIMBY perspective.
“Work with your city council, work with your mayor, your Board of Supervisors,” he says. “Don’t be afraid to come out and support it. Tell them, ‘I support this project, it’s a good addition to our neighborhood.’”
[This story was originally published by Monterey County Weekly.]