Medicaid Waiver Good News for L.A.'s Homeless

by Stephanie Stephens, California Healthline Regional Correspondent

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The Los Angeles Homeless Services Authority's biennial Homeless Count Report released last month contained both good and bad news. Los Angeles is "home" to approximately 51,340 homeless people -- a 3% decrease from 2009.

While the overall number dipped a little, the number of homeless seniors and the number of homeless veterans, including younger men and women, grew, according to the survey. Nearly 34% of the region's chronic homeless persons are ages 55 or older, an increase of almost 14% from two years ago, according to the survey.

Because elders in any demographic group -- including the homeless -- generally require more health care, the rise in the number of homeless seniors in Southern California is significant for the area's health care system. The aging homeless population will increase the public cost of homelessness, according to the biennial report.

Poor health is both a cause and result of homelessness, according to the National Coalition for the Homeless. How the two intertwine and how the various support groups offering health care and housing interact is a complex equation in California.

There is some hope that national health care reform and California's Medicaid waiver -- known as the Bridge to Reform -- may help make it easier for government agents and agencies to provide health care and housing for the homeless.

"Health care reform can help break the vicious cycle of homelessness in the United States and aid in state and local efforts to prevent homelessness," Michael Cousineau, a health care policy expert at the University of Southern California's Keck School of Medicine, said.

The California Legislature's Select Committee on Homelessness meets next week in Los Angeles. The July 27 session is devoted to issues concerning youth, women, and family homelessness. 

Strategies May Shift as Changes Come Into Play

Strategies for providing health care to the homeless may shift as California becomes the first state to prepare its Medicaid program and safety-net providers for the eligibility expansion called for by the federal health reform law. With the federal government's approval last winter of the five-year Bridge to Reform Section 1115 demonstration project, California will receive approximately $10 billion in federal funds to expand and improve Medi-Cal, California's Medicaid program.

"Medicaid coverage expansion offers Los Angeles County the opportunity to secure federal investment in strategies that reduce the county's general relief caseload, while decreasing chronic homelessness," according to an analysis by LA Health Action, a not-for-profit advocacy group.

The waiver allows the state to expand Medicaid income eligibility up to 133% of the federal poverty level for uninsured county residents ages 19 to 64. The waiver also will help increase provider payments for uncompensated care, which could have a significant impact on care for the homeless.

The waiver also authorized mandatory, phased-in enrollment over 12 months of vulnerable populations, seniors and persons with disabilities into managed care plans. That process began July 1. Community clinics will play an important role in disseminating information about enrollment and completing the process.

"It was a big day, for there's a lot of opportunity with the waiver," Kathy Proctor -- clinic administrator for the homeless division of not-for-profit Northeast Valley Health Corporation, one of the nation's largest community health centers -- said. "We want to get folks signed up. Some homeless really struggle with pain management, specialty care and mental health access. Until today, a person had to be severely mentally ill -- not just stressed, for example -- to access care through the L.A. County Department of Mental Health. We hope this means improved access."

Waiver's Benefits for the Homeless

The state's Medicaid demonstration waiver won't provide housing per se, but the waiver's funding for health care outreach will connect homeless people to organizations that can provide permanent shelter, which, in turn can improve health and access to health care. Once a connection is made, government agencies can provide "a rich array of services," according to Sharon Rapport, associate director of the California Policy Corporation for Supportive Housing.

Counties have discretion on how to use funds under the waiver's Low Income Health Program, according to Rapport. People eligible for Medicaid expansion in 2014 are able to enroll now in county-administered Low Income Health Programs using federal money through the waiver. Care coordination is a program requirement, and in addition to coordinating medical, mental health and substance use services, a care coordinator could work with housing providers to locate and place the most vulnerable of the homeless.

"They really need someone to hold their hand to help them find assistance," Rapport said.

Rapport hopes the county will join forces with the state to take advantage of several options under the Affordable Care Act, such as Health Homes for Enrollees with Chronic Conditions, to fund "health home" services, including intensive case management in supportive housing.

"Considering these difficult budgetary times, these opportunities are critical to end the cycle of crisis care for homeless people, while improving health outcomes and decreasing county costs of this population," Rapport said.

The waiver also creates opportunities to move homeless people into housing that is linked to an integrated, patient-centered health care delivery system, the medical home -- a concept with far-reaching implications beyond the homeless. It combines continuous, coordinated multidisciplinary services, and also is a key component of California's proposed delivery system reform efforts under the 1115 waiver. Eligible, enrolled adults would receive a core set of services, including inpatient and outpatient services, prescription drugs, mental health and other medically necessary services.

Approximately two million Medicaid beneficiaries will be enrolled in a medical home over the course of the waiver, according to the California Primary Care Association.

Homeless Health Glass Half Full

"Our awareness has profoundly increased, and people are making very valiant efforts, but stigma really prevents and complicates our ability to serve this population, for which we need to develop and tailor appropriate interventions," psychologist Suzanne Wenzel, a professor at USC's School of Social Work, said. "Homeless continue to be at risk of very poor health due to the very fragile infrastructure for health care."

"Bouncing from provider to provider makes continuum of care very difficult," Wenzel said. "Conversely, having support services close to where you typically reside prevents the homeless from dropping through the cracks -- not picking up a prescription or making repeat visits to a regular doctor."

Family physician Susan Partovi of both Homeless Health Care Los Angeles and The Saban Free Clinic said, "We're lucky we have a public health system -- even if it's only a safety net system."

"People can go to our nonprofit clinics -- if they know about them," she said, adding that she worries about lack of timely access to specialty care. She recently saw a patient with a torn bicep who has been waiting 18 months for a specialist appointment.

In a Los Angeles Times opinion piece, Partovi cited studies that show housing the homeless cuts death rates by up to 500% and that assertive community treatment for people with mental illness, which includes housing, results in people being 62% less symptomatic.

"The only thing that will really improve health care is getting the homeless housed," Partovi said.

Housing also gives a shot in the arm to budgets. Data from Neighborhood Legal Services of Los Angeles County and the Corporation for Supportive Housing reveal that formerly homeless people receiving services provided in permanent supportive housing consume 85% fewer county health care costs than homeless general relief recipients, reducing costs by almost $20,000 per person annually.

L.A. 'Doing Positive Things'

About one-third of California's seven million uninsured residents -- or 2.2 million people -- live in Los Angeles County, according to the UCLA Health Center for Policy Research.

"Clinics bear a much larger burden of uninsured than other parts of the state, as well as other parts of the country," Louise McCarthy -- president and CEO of the Community Clinic Association of Los Angeles County -- said.

"For clinics to remain solvent in the current state of affairs, we must get everyone who is eligible enrolled and covered for county, state or federal programs," she said. "It's a challenge for the homeless -- whether it's because they don't have documentation or the resources to document eligibility for these programs and stay on them."

McCarthy said Los Angeles County has "made pretty major strides we can't ignore for homeless health care."

Peggy Edwards, executive director of United Homeless Healthcare Partners, a network of homeless health care advocates and providers in Los Angeles County, agreed.

"Los Angeles is doing positive things for homeless residents, politically and socially," Edwards said. "And it's not just because of our reputation of not dealing with the homeless crisis until a few years ago.

"Instead of saying, 'We can't afford to do that,' we learn from 'black bag' initiatives that reach out to the community, identify those who need help and get them into care," Edwards said. "For years, funding was concentrated in skid row, but we have homeless people all over the county."


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