Standing outside her sixth-floor apartment in the Bronx, Lissette Encarnacion says she sometimes forgets the place belongs to her.
"I'm thinking I'm at somebody else's [house]," she says. "I'm ringing my own doorbell."
Encarnacion used to have a career in banking, and lived in a real home with her son and husband. Then one night everything changed, she says, when her husband came home drunk and angry, and threw her off a balcony.
"He came home, pulled me from the hair, and just started beating the hell out of me," she says. She was seven months pregnant with her second child, a boy.
Encarnacion suffered traumatic brain injury and was never the same. She and her sons moved in with her sister, but Encarnacion often wandered off.
Eventually she became homeless, she tells NPR affiliate WNYC, and remained that way for a decade. She suffered from epileptic seizures, and was frequently picked up by paramedics and taken to emergency rooms.
Then two years ago, she moved into The Brook, an apartment complex that provides supportive housing to its residents — more than half of whom are formerly homeless.
Now Encarnacion lives in a studio apartment, which she has decorated with stuffed animals and Christmas lights. And though the place is small, she likes to think of it as her "penthouse" apartment.
Brenda Rosen, the director of Common Ground, the organization that manages the building, says The Brook offers a full range of services to keep its residents healthy: social workers, security, a doctor and even an event planner.
And while these services don't come without a cost — an apartment at The Brook runs at about $24,000 a year — Rosen says they are cheaper than the estimated $56,000 per year that the city spends on the emergency room visits and stays at shelters and jails, where many people with severe mental illness end up.
"You know, we as a society are paying for somebody to be on the streets," says Rosen.
Few people would dispute that Lissette Encarnacion is better off in her studio apartment than she was when she was living under the bridge. And it's far cheaper if she has a doctor downstairs than if she has to show up regularly in the ER.
The question is, who pays for this kind of housing?
New York now has about 47,000 supportive housing units, and the state intends to invest $260 million Medicaid dollars over the next two years. But the federal government won't match it.
At the crux of this debate is the question of whether housing qualifies as health care.
This past December, the outgoing New York State commissioner of health argued in an article in The New England Journal of Medicine that housing is health care. Providing housing to the chronically homeless saves health care money, he argues, so Medicaid should help pay capital costs.
New York State Medicaid Director Jason Helgerson went further, arguing that federal Medicaid money already pays for housing, through long stays in nursing homes and hospitals.
But Bruce Vladeck, who formerly administered Medicaid and Medicare in the Clinton administration, says federal Medicaid dollars can't and shouldn't be used to pay for housing — it's not cost-effective.
"Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem," says Vladeck.
Instead, Vladeck argues that housing programs should be paid by housing agencies.
"As a society, both in the private sector and the public sector, we are really cheap and niggling and resentful about paying for social services, and we are much more generous when it comes to paying for health services," he says.
At the moment there is not enough housing money to go around for all the people who need it — people like Encarnacion, who are done living on the streets but still need support. For her, The Brook offers a place in between.
"I stuck it out, and it's good," she says. "And God's been real good to me. And the people that work here have been very good to me — and patient, because I am not easy. I am not easy."
To hear and read more about The Brook and other innovative initiatives in health care reform in New York, check out WNYC's series Prescription for the Bronx.
LINDA WERTHEIMER, HOST:
Being homeless is often associated with chronic health problems and frequent trips to the emergency room. In an attempt to reduce health costs New York is using state Medicaid dollars to build housing for the homeless. It's one of the first states to do this but it's caused a debate over whether housing is a form of healthcare and whether it should be paid for by insurance. Amanda Aronczyk of member station WNYC reports.
AMANDA ARONCYZK, BYLINE: Lissette Encarnacion lives on the sixth floor of The Brook, an apartment building in the Bronx. It's a penthouse apartment according to her even if it's just a studio. She's lived here for two years now, but still sometimes forgets that this is her place. In every way this tidy apartment at The Brook decorated with stuffed animals and Christmas lights is far from where Lissette used to live back when she was homeless.
LISSETTE ENCARNACION: Under the bridge. I had a house under there.
ARONCYZK: Sometimes she slept in Prospect Park in Brooklyn, but mostly she lived beside an industrial canal.
ENCARNACION: I was smelly. I didn't think I smelled. I made it like a home, but it wasn't kosher.
ARONCYZK: Lissette used to have a career in banking and was a homeowner of a real home where she lived with her husband and son. Then everything changed one night. Lissette's husband was an alcoholic; he came home drunk and angry.
ENCARNACION: And he came home, pulled me from my hair and started just beating the hell out of me.
ARONCYZK: She says her husband threw her off the balcony while her son watched from the bed.
ENCARNACION: What saved me, why I'm alive, the snow - yes it was a real bad storm and there was really a lot of snow out. I can never forget that. If it wasn't for the snow, me and my baby would've been dead because I was seven months pregnant.
ARONCYZK: You were pregnant with your second son?
ARONCYZK: She had a traumatic brain injury, injuries to her face and arms. And for a while there, they weren't sure that she would make it. Lissette's baby had to be delivered by emergency C-section. She was in the hospital for months. But both she and her new son survived.
Were you able to look after your sons after you came out of the hospital?
ENCARNACION: My sister helped me raise my kids and then I had times where I wander and I leave.
ARONCYZK: After years of coming and going, she eventually left her kids with her sister and didn't return. All told, Lissette was homeless for a decade before she got her apartment at The Brook. And aside from the emotional costs and the physical wear of being on the streets for years there are also the financial cost for homeless people like Lissette.
Were you going to the hospital while you were living on the streets?
ENCARNACION: A lot, a lot yeah because of my seizures. They were coming back to back, back to back. I used to get multiple seizures. I wasn't properly taking my medications.
ARONCYZK: And now it's under control?
ENCARNACION: Oh, yes, yes. Well, a lot of things changed. I'm no longer using. That's why I'm as big as a house. I live in a clean environment. I'm part of society just a little bit.
ARONCYZK: More than half of the residents who live at The Brook were once homeless. It's called permanent supportive housing. It's an apartment complex with perks - social workers, security, an event planner.
ENCARNACION: And a doctor. We have a doctor on site, too.
ARONCYZK: A full range of services that help keep people healthy. The building is managed by Common Ground and the group's director, Brenda Rosen, says that Lissette's frequent seizures would have likely led to emergency intervention when she was living on the streets.
BRENDA ROSEN: EMS is going to come out and they're going to triage her and take her to the emergency room. So all of those costs from the time they come out to the time you get in the ambulance to the time you go, I mean, that's all expensive costs.
ARONCYZK: Being homeless in the city doesn't mean living off the grid. Services like police and shelters are needed as are jails, where many people with severe mental illness end up. Rosen says, the total figure per person is an estimated $56,000 a year.
ROSEN: That, you know, we as a society are paying for somebody to be on the streets versus coming into apartment-supportive housing building like The Brook which costs roughly $24,000 a year.
ARONCYZK: Few people will dispute that Lissette is better off at her studio apartment than she was when she was living under a bridge. And it's far cheaper if she has doctor downstairs than if she has to show up regularly in the ER. The question is, how do you pay to build this kind of housing?
ROSEN: So we'll start our public comment and question process now.
ARONCYZK: At a public meeting earlier this year, New York State Medicaid director, Jason Helgerson, argued that federal Medicaid money already pays for housing through nursing homes and long hospital stays.
JASON HELGERSON: We pay for nursing homes. We pay to house people in hospitals for lengthy stays. In fact, we have people in hospitals today in this city who shouldn't be hospitals if they had some place to go and can be safely discharged.
ARONCYZK: New York state is investing $260 million in supportive housing over the next two years. But they haven't been able to convince the federal government to match that yet.
HELGERSON: And I think that continues to be our fight and I think we're beginning to get some traction on it. We still got some convincing to do.
ARONCYZK: But New York has the most expensive Medicaid program in the country. Doctor Bruce Vladeck who ran Medicaid in the 1990s says, the federal health insurance program is not permitted to pay for capital costs by law and, he says, it's a bad idea.
BRUCE VLADECK: Medicaid is supposed to be health insurance and not every problem somebody has is a healthcare problem.
ARONCYZK: There are lots of Americans who need better housing, people whose health would certainly improve if they had a better place to live. But once you open that door how do you close it? According to Dr. Vladeck, a housing program should be paid for by a housing agency.
VLADECK: As a society both in the private sector and the public sector we are really cheap and niggling and resentful about paying for social services and we're much more generous when it comes to paying for health services.
ARONCYZK: Which is why people are debating if housing qualifies as healthcare. At the moment, there's not enough housing money to go around for all the people who need it, like Lissette. She's done with living in the streets but she still needs support.
ENCARNACION: Because I'm not ready to be out there.
ARONCYZK: She points towards a large window to the outside.
ENCARNACION: No, not yet.
ARONCYZK: She's not ready for a normal working life yet either. For now, The Brook is a place in between.
ENCARNACION: I stuck it out and it's good and God been real good to me and the people that work here have been very good to me and patient - because I am not easy (laughing). I'm not easy.
ARONCYZK: For NPR News, I'm Amanda Aroncyzk in New York. Transcript provided by NPR, Copyright NPR.