Changing the Terms: How Communities are Leveraging Health Care for PSH Capacity



December 9, 2013
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In 2013 on a given night, 610,000 people were experiencing homelessness in the United States. Around 92,000 are single adults viewed as chronically homeless, meaning they have a disability and history of long or frequent episodes of homelessness. Health care reform can be a significant component of strategies to end chronic homelessness. The Affordable Care Act (ACA) offers needed resources to states and communities struggling to help individuals, solve their homelessness, and strengthen housing stability. As recognized in Opening Doors, the Federal Strategic Plan to Prevent and End Homelessness, delivering on the promises of the ACA calls for partnerships and collaborations at all levels and across the systems that serve people experiencing homelessness. This paper, describing models that have begun to emerge with ACA implementation, is intended to encourage community leaders to consider opportunities and possible next steps to incorporate health care reform in plans to end chronic homelessness.


Chicago – Network of diverse service providers using new health care resources to reorganize safety net for vulnerable populations, including people who need supportive housing. Together4Health, Appendix, Page 10.
Cleveland – New and renewed partnerships focus on bringing primary care to supportive housing, strengthening recovery of people who have experienced chronic homelessness. Housing First, Appendix, Page 11.
Minneapolis – Homeless services agency teams up with Medicaid managed care organization to integrate housing, primary care and behavioral health for Medicaid enrollees experiencing chronic homelessness. Medica Supportive Housing Initiative, Appendix, Page 12.
Philadelphia – City agency leverages Medicaid funding in strategy to house and support people with behavioral health conditions who need housing to recover. Department of Behavioral Health and Intellectual disAbility, Appendix, Page 13.
Portland, OR – Housing and service providers partner with Medicaid managed care plan to coordinate primary care and long-term supports to end chronic homelessness. HSO, Appendix, Page 14.
Addressing the Needs of People Who Are Chronically Homeless Research shows that people experiencing chronic homelessness are extremely poor and vulnerable, with complex medical, mental health and substance use conditions. These conditions are often co-occurring and may be exacerbated by trauma, injury and physical ailments acquired as a result of homelessness. Despite their severe situations, many chronically homeless people are unable for various reasons to access disability programs such as Supplemental Security Income and Medicaid long-term services and supports. Without any resources, especially health care coverage, they frequently delay seeking care until they are very ill. As a result, people experiencing chronic homeless are heavy users of costly emergency services and hospital care.
There is widespread agreement among policy experts that permanent supportive housing (PSH) is the answer for people who are chronically homeless, and for the safety net systems that serve them. Permanent housing provides a safe setting for recovery and achieving the highest levels of independence in the community. However, housing alone is not sufficient; it must be accompanied by appropriate, voluntary supports – including access to adequate primary and behavioral health care and intensive community-based supports. Research has also shown that PSH is a sound investment for communities, leading to public savings and efficiencies for those with permanent disabling conditions.
Federal policy recognizes the value of PSH for the most vulnerable people experiencing homelessness. However, targeted federal housing resources remain scarce, and communities face significant challenges to develop and sustain the most effective models of PSH to end chronic homelessness.
Opportunities Under Health Care Reform
Certain aspects of health care reform present real opportunities to augment PSH resources and accelerate solutions to chronic homelessness. Taking advantage of these opportunities requires communities to incorporate health care reform into their plans to end homelessness and to act accordingly. Relevant health policy changes for homeless assistance are summarized below.
Medicaid Expansion. The Affordable Care Act of 2010 (ACA) prompts changes in the way communities serve vulnerable people experiencing homelessness. The most important is states’ option to expand Medicaid with generous federal subsidies to cover poor adults – in effect reaching all chronically homeless individuals not already eligible by reason of disability. As a result of a Supreme Court decision in 2011, states can choose to take on this new Medicaid population, but may not be required to do so. When this key provision takes effect in early 2014, around half the states will have opted to expand.
Medicaid expansion under the ACA has implications for ending chronic homelessness on two levels. First, it provides a core set of benefits – including behavioral health coverage – to individuals who have long been excluded from health care insurance. With full state participation, Medicaid would cover up to 16 million more people who are now uninsured. Actual benefits will vary from state to state, within a broad federal framework. In some states, basic Medicaid benefits will be more generous and comprehensive than in other states, as is true of Medicaid generally. Therefore many experts predict that very vulnerable people will continue to face barriers to appropriate health care. Nonetheless, in states that do expand Medicaid, chronically homeless people will have more access to medical services, preventive care, and behavioral health to address mental health and substance use disorders.
Second, coverage for the expanding eligibility group means an influx of Medicaid dollars to local service systems, creating strategic opportunities to reset state and local safety-net funding priorities. For example, as more clinical services are reimbursed by Medicaid instead of local general funds, a county mental health department could use those local funds to offer more rental subsidies, or increase case management in supportive housing. Other federal funding, such as substance abuse and mental health block grants, could also be repurposed in targeted ways.
Community-Based Services and Supports. Apart from expanding the number of people in Medicaid, the ACA expands capacity for communities to serve and support people with disabilities and other vulnerabilities. Very generally, these include a menu of state options and incentives for Medicaid home and community-based services (HCBS), and more funding for community-health centers, among other provisions. With appropriate federal and state approvals, Medicaid HCBS can fund a number of long-term services and supports that have not traditionally been considered “medical” for the purposes of Medicaid coverage. Community health centers, with long experience and competence meeting the needs of underserved populations, will be critical points of access for new Medicaid enrollees with high health risks, as well as those who continue to be uninsured.
Health Homes. To address chronic homelessness and enhance supportive housing, one promising new state option is a voluntary care coordination program for Medicaid enrollees with severe mental illness or other chronic disabling conditions. Known as a health home, this benefit reimburses qualified providers for some of the tasks of organizing the diverse services needed to stabilize people with complicated health care needs. States have flexibility in how they design health homes. In some states, Medicaid health homes are a function of mental health departments. In others, community health providers – including those that offer supportive housing – can be eligible for the program.
Mental Health Parity. Another important federal health policy that will be implemented along with the ACA is behavioral health parity under the Mental Health Parity and Addiction Equity Act of 2008. This law is expected to elevate and standardize coverage of mental health and addiction treatment, relative to other health benefits. New Medicaid benefits for the expanded population group are required to meet parity standards.
Overall Policy Directions. Health policy analysts refer to the “triple aim” of the ACA, in that the goals of the legislation as a whole are to increase access, improve quality, and lower total health care costs over time. The triple aim will guide ACA implementation in how delivery systems will be given new resources and how their outcomes will be evaluated.

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