Medicaid and Health Reform
In the Field: An Interview with John Parvensky of the Colorado Coalition for the Homeless
USICH Tips: Questions to Ask in Using Health Reform to End Homelessness
Deputy Director Jennfer Leimaile Ho: Health Reform Matters
For over a decade, evidence has been mounting from communities across the country about the relationship between chronic homelessness, poor health and high health costs: people experiencing homelessness seek care in the most expensive emergency room and hospital settings. The high cost to society of homelessness, combined with proof that helping someone in supportive housing leads to better health expenditures and better health outcomes, helped to energize efforts and increase funding to reduce chronic homelessness.
Now we’re expanding our application of these lessons. Health reform generally, and Medicaid expansion in particular, is the secret weapon in the fight against homelessness. Many services in supportive housing are paid for out of the $1.68 billion in HUD Homeless Assistance Grants. But comparatively, the 2010 federal Medicaid expenditure is $275 billion, and states contribute their own funding to make that total even higher.
The passage of The Affordable Care Act in March put an incredible wind in our sails driving us towards an end to homelessness. The local cost benefit argument for ending chronic homelessness becomes a compelling federal argument, as people who previously did not have health insurance get federal coverage between now and 2014 under health reform.
With Medicaid expansion, the federal government is investing in coverage for single adults who don’t have a disability according to the requirements of the Social Security Administration. In states where this population is already covered, that offers some financial relief. In states that don’t have a General Assistance program, this is the first time this population will have access to coverage. Families will have increased coverage through Medicaid expansion and health exchanges.
Health reform matters because increased access to affordable health insurance reduces the chances that an unexpected medical event will lead to personal bankruptcy and to foreclosure, thrusting someone into homelessness.
Health reform matters because in pockets around the country, organizations are finding ways to tap into Medicaid to pay for some of the supportive services needed to help people out of homelessness and into homes.
Already, health reform is investing significant dollars into Community Health Centers and Health Care for the Homeless programs. In some communities, Federally Qualified Health Centers and Health Care for the Homeless programs are on the leading edge helping people escape homelessness. And when a community structures its efforts to end homelessness around a community health center, they are not only providing access to culturally competent health care, they are also tying homeless services to a significant source of funding.
John Parvensky, Colorado Coalition for the Homeless
John Parvensky has served as President and CEO of the Colorado Coalition for the Homeless since 1986. In this capacity, he has spearheaded development of over 1,400 affordable housing units throughout the Denver area and has directed the day-to-day activities of an organization providing housing, health care, mental health care, substance abuse treatment, counseling, and other supportive services to more than 16,000 people experiencing homelessness each year. He was instrumental in the creation and passage of the McKinney-Vento Act, and he serves on the board of directors for both the National Coalition for the Homeless and the National Health Care for the Homeless.
USICH: There’s a lot of talk around the country about tapping into Medicaid for supportive housing services. What role does Medicaid play in your programs?
Medicaid is critical to our funding for integrated primary health care, mental health care, and substance abuse treatment services for homeless individuals and families through our Health Care for the Homeless program. The ability to receive cost-based reimbursement through the Federally Qualified Health Center (FQHC) designation is vital.
We have been able to expand services outside of our Stout Street Clinic into supportive housing in a number of ways. First, FQHC Medicaid reimbursement allows us to pay for clinical services (primary health care, mental health counseling, etc.) within supportive housing developments and at scattered site housing. One problem has been paying for case management and non-clinical supportive services (employment services, connection to community resources, etc.) for residents of supportive housing. These services are not reimbursable under Medicaid in most states (unless the state has included it in their state Medicaid plan). Also, many supportive housing service providers do not (and are not able to) bill Medicaid. This requires a partnership with a Medicaid provider and a sharing of the reimbursements with the housing service providers.
In addition, currently, only a fraction of residents of supportive housing qualify for Medicaid. Thus, dedicated staff cannot be funded solely with Medicaid. After 2014, this will hopefully change as the majority of those living below the poverty standard will become eligible.
For more intensive services for chronically homeless individuals, Assertive Community Treatment (ACT) services are the best practice approach, but whether they are viable or not depends on how states pay for ACT services. “Bundled payments” that are based on the average cost of providing a package of services seem to work best.
USICH: What has been your biggest lesson learned in using Medicaid to pay for supportive services?
Our greatest success has been creating teams of clinical case managers (LCSW’s) who are eligible to bill for Medicaid services provided to residents in supportive housing and non-clinical case managers who work together. With FQHC billings for the clinical services, the reimbursement is sufficient to pay the cost of both the clinical staff and the non-clinical staff (assuming a high enough percentage of Medicaid eligible persons).
We have done this for chronically homeless individuals, and are replicating this with teams to serve homeless families through the Section 8 Family Unification Program.
USICH: What next step would you suggest agencies take if they’re looking to broaden their funding sources for supportive housing to include Medicaid?
Agencies need be become FQHC qualified, or team up with FQHC providers to develop a service plan and reimbursement plan to sustain it.
Changes need to be made to state Medicaid plans to allow and encourage home-based services to include case management and on-site clinical services.
Aggressive Medicaid enrollment efforts are required to ensure the highest penetration of Medicaid eligibility for residents of supportive housing.
Richard Frank
Department of Health and Human Services:Office of the Assistant Secretary for Planning an Evaluation
Richard Frank is a Deputy Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services. He directs the Office of Disability, Aging and Long-Term Care Policy, concerned with providing health care, long-term services, and supports and related services to a range of vulnerable populations, including those with severe and persistent mental disorders and those with substance use disorders. Prior to coming to HHS, Frank was the Margaret T. Morris Professor of Health Economics at Harvard Medical School. He is the co-author with Sherry Glied of the book Better But Not Well that reviews U.S. mental health policy since 1950. He is a member of the Institute of Medicine.
USICH: In what ways will the Affordable Care Act’s expansion of Medicaid help end chronic homelessness?
There are a number of provisions in the Affordable Care Act that offer opportunities to provide services and supports for people who are chronically homeless. Central among those are the expansion of the Medicaid program to cover people with incomes under 133% of the poverty standard. This will enable uninsured, single, childless adults who are disproportionately represented in the chronically-homeless population gain access to a range of health and behavioral health services. The ACA also allows states new options for coordinating care for low-income populations with multiple chronic conditions and severe mental disorders, through the health homes options. Coordination of health, behavioral health and human services is critical to evidence-based supportive housing arrangements. Other ACA provisions enable states to organize and pay for evidence-based behavioral health treatments that have been shown to be successful in treating and supporting chronically homeless people in the community through the so-called 1915i waiver provisions (Supported Employment and Assertive Community Treatment). There are also provisions that support great integration of health and behavioral health care through Federally Qualified Health Centers and community behavioral health organizations.
USICH: How will it help address family and youth homelessness?
The financial protections offered to families through coverage expansions and subsidies for insurance will enhance economic security and provide access to health care to adults and children in low-income households. In addition, the ACA contains provisions that aim to provide targeted support to sub-groups that are particularly at risk for homelessness (for example, young adults aging out of foster care).
USICH: There are many new demonstration programs coming under health reform. What should states and homeless advocates & services providers be paying attention to?
One key thrust in the provisions around delivery system reform involves efforts to coordinate care for populations with complex health, human service, and long-term services and support needs. These include the health home initiative mentioned earlier, the patient-centered medical home, the Independence at Home demonstration (a home visitation program for frail elderly people), the behavioral health integration demonstration, and new efforts to coordinate care for people who are dually-eligible for Medicare and Medicaid. Each of these efforts can serve as important elements of modern supportive housing efforts.
USICH Tips: Questions to Ask in Using Health Reform to End Homelessness
- Learn the language of Medicaid in your state. Some states call it Medicaid; some states call it something else. What is Medicaid called in your state?
- Are there other state-operated health insurance plans? What are they called and who are they for?
- Does your state pay for Medicaid through health plans, or does it pay providers directly, fee-for-service?
- Does your state have a Medicaid package of benefits that pays for supportive services in the community for people with mental illness or people who might otherwise be in an institutional setting?
- How much money does your state contribute to Medicaid? How does that compare to state spending on homelessness?
- How much federal money does your state get for homeless programs? How does that compare to how much your state gets from the federal government for its Medicaid program?
- How will health reform and Medicaid expansion change who has health insurance in your state?
- Are there providers helping people experiencing homelessness in your community who are able to use Medicaid to fund all or part of the services they provide?
- Who are they? How do they do it?
- Who is your state's Medicaid Director?
- Who are other Medicaid experts in your community? How can you meet them and talk with them about the benefits of the work you are doing to end homelessness?
