+Heath Care Needs of Homeless Populations in a Health Reform World
January 16, 2013
Kevin Lindamood, MSWPresident and CEO
Health Care for the Homeless
Barbara DiPietro, Ph.D.Director of Policy
Health Care for the Homeless & National HCH Council
+Overview Prevalence & causes of homelessness Connection to health & health conditions Model of care & current environment
The Affordable Care Act & changes coming Importance of Medicaid Who’s left behind Models of care Recommendations Opportunities and Risks
+Prevalence of Homelessness in U.S. Single Night in January 2012: 633,782
people counted on street/shelter/transitional housing (U.S. Department of Housing and Urban Development, 2012)
Annual Prevalence in 2011: 1,502,196 people in emergency shelters/transitional housing programs (HUD, 2012)
Children: 1 in 50 children homeless each year (National Center on Family Homelessness)
All health centers (FQHCs): 1,087,431 patients noted as homeless (HHS, 2011)
K-12 Education: 1,065,794 students in SY 2010-11 (U.S. Department of Education)
+Homelessness in Maryland: 1 Night in January 2012
Source: HUD, 2012. http://www.hudhre.info/index.cfm?do=viewHomelessRpts
Maryland Baltimore CityTotal households 6,914 3,204
Total persons Street Shelter Transitional
9,4543,512 (37%)3,399 (36%)2,543 (27%)
3,8541,795 (47%)867 (22%)1,192 (31%)
“Chronic” 1,259 308Severely Mentally Ill 1,353 466 Chronic Substance Use
1,414 650
Veterans 617 274HIV/AIDS 89 63Domestic Violence 531 14
+Homelessness in Maryland Shelters:
FY 2009
Source: DHR, 2011. http://www.dhr.state.md.us/documents/Data%20and%20Reports/Central/Annual-Report-on-Homelessness%20Services-in-Maryland-Fiscal-Year-2009.pdf
Maryland Baltimore City
Age: 0-17 18-30 31-50 51+
30%19%37%14%
22%15%42%21%
Male 59% 70%% Family members 49% 31%African-American 57% 79%Turnaways 32,740 20,085∆ Shelter LOS (FY 08-09) 28 days 48
daysN/A
∆ Transitional Housing LOS(FY 08-09)
127 days 162 days
N/A
+Causes of Homelessness:Poverty is the Underlying
Theme Abuse/family
instability Foreclosure/eviction Unemployment Mental illness Addictions Illness/disability/poor
health Incarceration Fire/disaster Bankruptcy
Lack of affordable housing
Lack of adequate health care
Lack of livable incomes
Individual Factors
Structural Factors
+Homelessness is Hazardous to Your Health Causes health problems Exacerbates existing illnesses Seriously complicates treatment and
continuity of care Is a risk factor for early death
Source: Institute of Medicine (1988). Homelessness, Health and Human Needs. National Academy Press: Washington, DC.
Homelessnessis the equivalent ofanother diagnosis
(ICD9=V60.0)
+
Medications lost or stolen No watch, calendar, or bus token No routine supplies Co-pays unavailable Meals unavailable (or of poor quality) Some treatments risk arrest (e.g.,
diuretics)
Homelessness Limits “Adherence”
Common Medical Conditions - Adults Infectious disease (Hepatitis,
HIV, TB) Chronic disease (diabetes,
asthma, hyptertension, heart disease)
Parasitic skin infections (scabies, lice)
Dermatolgic conditions (psoriasis, impetigo, seborrhea, nonspecific dermatitis, cellulitis)
Weather-related (Hypo/Hyperthermia, Trench Foot)
Foot problems (callus, bunion, tinea pedis, nails), lower extremity edema
Chronic pain Poor dental health Chronic wounds, injuries Poor nutrition/nutritional
deficiencies
Infectious DiseaseHIV
Prevalence of HIV in homeless population compared to general population in US: 3.4% v. 0.4%
Estimated 50% of people living with HIV/AIDS are at risk of becoming homeless.
Hepatitis C Virus (HCV)One homeless veterans study: prevalence of 44%Baltimore HCH: 26% had HCV in top 3 ICD-9 codes in
2009 Increased serologic testing 2009-2010 show closer to
45% of adults are positive for chronic HCV
+Behavioral Health Conditions Rates depend on
population being screened
HUD Severely mentally ill: 18% Chronic substance abuse:
21% Co-occurring: 50% of
mentally ill have a substance abuse disorder
HCH Experience SMI: 34% Co-occurring: 25%
+Morbidity & Mortality in Homeless Adults Average age of death is
between 42 and 52y…despite an average life expectancy of almost 80y in the U.S. Source: O’Connell, J. (2005.) Premature Mortality in Homeless Populations: A Review of the Literature.
Homeless persons >50 years often have the physical health of 70 year olds (but do not qualify for Medicare)
Average 8-9 concurrent medical illnesses Source: Breakey WR, et al. (1989.) Health and mental problems of homeless people living in Baltimore. JAMA ;262: 1352-1357.
+Health of Homeless Children Growing population (doubled in MD)
Greater than twice as likely as middle class children to have moderate to severe, acute and chronic health problems
Impact on school attendance/performance, nutrition
Leads to increased rates of: anxiety and depression developmental delays asthma anemia elevated lead levels dental problems STIs in adolescents
+Health Insurance Among HCH Patients
HCH Maryland: 9,189 patients 50% uninsured* 20% Medicaid 5% Medicare 25% Other [e.g., the Primary Adult Care program(PAC)]
HCH National: 825,295 patients 62% uninsured 28% Medicaid 5% Medicare 3% private 2% other
Source: HHS, 2012. Available at: http://bphc.hrsa.gov/uds/view.aspx?fd=ho&year=2011.
+
The result of intentional policy decisions, starting in the 1970s and continuing to today
Dis-investment in housing, especially public & rental housing
Cost of living increasing faster than paychecks; evictions and unemployment high among lowest income groups
De-institutionalization created street homelessness among those with serious mental health conditions
Who is able to and inclined to provide health care?
Homelessness: An Ongoing Problem
+HCH Model of Care Services
Outpatient primary care Mental health State-certified OP/IOP addictions Pediatrics Dental clinic Outreach and case management Supported housing and convalescent care
Approach Team-based care Low barrier access Use harm reduction &
motivational interviewing (EBPs) Patient-driven care
Goals: Increase stabilityImprove healthEnd homelessness
+The Current Environment Poverty is the core issue Myriad of federal, state and local “10-Year Plans
to End Homelessness” Changing population Allocating resources differently and
public/political will essential to realize any policy changes
Health Reform: major changes that will improve health for millions, to include those experiencing homelessness
Are we ready for a paradigm shift?
Christopher: Bringing together health,
housing, and support services
+Insurance Expansions in the Affordable Care ActHealth insurance “exchanges”(required)
Marketplaces for individual & small group marketPrivate insurance plans compete on cost, coverage, qualitySubsidies/credits available for those 100-400% FPLState-run, federally facilitated, or partnerships
Medicaid expansion to those ≤138% FPL (optional)
Federal financing: 100% 90% over 6 yearsEffective January 1, 2014
Open enrollment: October 1, 2013
62%
30%
5% 3%
36%42%
8%14%16% 17%
12%
54%
None/Uninsured Medicaid/otherpublic
Medicare Private Insurance
Insurance Status: HCH v. All Health Centers v. U.S.
Health Care for the Homeless All Health Centers U.S.
Sources: 2011 UDS Data, HRSA2011 Census data
515,000 individuals
Nonelderly Health Insurance Coverage by
Family Poverty Level, 2011
56.3 M
47.4 M
72.1 M
90.5 M Number
Under 100%
100% - 199%
200% - 399%
400% +
NOTES: Data may not total 100% due to rounding. The Federal Poverty Level for a family of four in 2011 was $22,350 (according to the HHS poverty guidelines). SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.
Median Medicaid/CHIP Eligibility Thresholds, January 2012: National Averages
SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.
250%
63%37%
0%
185%
Children PregnantWomen
Working Parents Jobless Parents Childless Adults
Minimum Medicaid Eligibility under Health Reform - 133% FPL
($25,390 for a family of 3 in 2012)
+Medicaid Expansion: Filling the GapCurrently eligible: children, pregnant women, those disabled, and some parents of childrenNewly eligible: Law expands Medicaid to non-disabled adults earning at or below 138% FPL.
About $15,000/year for singlesAbout $25,500/year for family of 3
15 million individuals newly eligibleMust be a U.S. citizen or legal resident here for at least 5 years8 states have started expanding Medicaid already (in full or partial)
CA, CT, CO, DC, MN, MO, NJ, WA
+ACA Improves Enrollment ProcessElectronic verification of income & identityUses gross income information (no asset tests)Faster approvalsNo in-person interviews & automatic 12-month renewal (unless there’s a change)Online applications (but can also do by phone and mail)Do not need a permanent address and do not need to prove residency in your stateAlternative points of contact possibleEnrollment assistance available
+12 Reasons Why Medicaid Expansion is Critical
1. Improves access to care2. Improves financial stability3. Improves health status/reduces mortality4. Patient satisfaction is high5. Improves local and state economy6. Maximizes federal funding7. Reduces current state spending8. Reduces ER & hospital utilization9. Ensures healthier workforce10. Helps low-income veterans11. Helps children & families12. Reduces health disparities
+CBO Projected Medicaid Enrollment (U.S.)
15 million adults newly eligible
+Outreach & EnrollmentLaw requires states “establish procedures for outreach and enrollment activities to vulnerable & underserved populations” (ACA §2201)
Children Unaccompanied homeless youthChildren and youth with special health care needsPregnant womenRacial and ethnic minoritiesRural populationsVictims of abuse or traumaIndividuals with mental health or substance-related disordersIndividuals with HIV/AIDS
Currently eligible for Medicaid: 4.4 million adults 2.9 million children
Eligibility does not
automatically equate to
enrollment
Trends in Medicaid Enrollment in MD
2014 2016 2018 2020Newly eligible (including PAC) 90,639 119,634 133,201 143,207
Currently eligible-newly enrolled (“woodwork effect”)
11,046 32,301 41,793 44,069
Current Medicaid (excluding PAC) 986,347 1,004,559 1,032,785 1,056,676
Total Medicaid 1,088,032 1,156,494 1,207,779 1,243,952
REMEMBER:The Affordable Care Act
is a solid step in the right direction but…it does not establish a right to
health care &
does not establish universal coverage
+Those Remaining Uninsured (U.S.)
Remaining Uninsured:37%: Medicaid-eligible but un-enrolled25%: Undocumented/ineligible immigrants
Change in Percentage of Uninsured in MD
2014 2016 2018 2020
Remaining Uninsured 599,003 488,539 439,614 390,352
+Models of Care: Good for All (Especially those with multiple chronic conditions)Integrated care (mental health, addictions, medical)
Focus on quality and outcomes, not quantity of procedures
Patient-centered medical homes
Electronic health records
Coordinated care across multiple venues
Health care viewed in a wider perspectiveRenewed attention to social determinants of health
+RecommendationsEnsure targeted, in-person outreach
Literally “beating the bushes”Track enrollment of those at lowest income levels
Possible “StateStat” measure?Grow medical and behavioral health service capacityEnsure MCOs appreciate breadth of services needed to achieve cost-savingsTrain providers to understand impact of poverty and homelessness on healthEnsure services for those remaining uninsured (and pursue additional insurance expansions)Maximize state options for providing services in supported housing
+
Improved individual & public health
Reduced personal bankruptcy & poverty
Increased individual & family stability
Increased employment & productivity
Reduced recidivism to criminal justice
Preventing & ending homelessness
Fail to reach newly eligible (lack of outreach)
Continued barriers to enrollment
Inability to find provider(s)
Difficulty engaging in care
Ongoing housing instability risks engagement in care
Poor transition to exchange jeopardizes gains in health, income
Ongoing homelessness & poor health
OPPORTUNITIES RISKS
+More InformationHealth Care for the Homeless of Maryland: Prevents and ends homelessness for vulnerable adults & families by providing quality, integrated health care & promoting access to affordable housing and sustainable incomes through direct service, advocacy, and community engagement. www.hchmd.org @hchomeless
Kevin Lindamood, President & CEO: [email protected] @kevinlindamood
Barbara DiPietro, Director of Policy: [email protected] @barbaradipietro
National HCH Council: www.nhchc.org @NatlHCHCouncil
Health Reform page: http://www.nhchc.org/policy-advocacy/reform/
