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Heath Care Needs
of Homeless
Populations in a
Health Reform
World
January 16, 2013
Kevin Lindamood, MSW Barbara DiPietro, Ph.D.
President and CEO
Health Care for the Homeless
Director of Policy
Health Care for the Homeless
& National HCH Council
+ Overview
 Prevalence
& causes of homelessness
 Connection
 Model
to health & health conditions
of care & current environment
 The Affordable
 Importance
 Who’s
Care Act & changes coming
of Medicaid
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
(National Center on Family Homelessness)
each year
 All
health centers (FQHCs): 1,087,431 patients
noted as homeless (HHS, 2011)
 K-12 Education: 1,065,794
(U.S. Department of Education)
students in SY 2010-11
+ Homelessness in Maryland:
1 Night in January 2012
Maryland
Baltimore City
Total households
6,914
3,204
Total persons
9,454
3,854
3,512 (37%)
3,399 (36%)
2,543 (27%)
1,795 (47%)
867 (22%)
1,192 (31%)
“Chronic”
1,259
308
Severely Mentally Ill
1,353
466
Chronic Substance Use
1,414
650
Veterans
617
274
HIV/AIDS
89
63
Domestic Violence
531
14
Street
Shelter
Transitional
Source: HUD, 2012. http://www.hudhre.info/index.cfm?do=viewHomelessRpts
+ Homelessness in Maryland Shelters:
FY 2009
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 days
N/A
∆ Transitional Housing LOS
127 days  162
days
N/A
(FY 08-09)
Source: DHR, 2011. http://www.dhr.state.md.us/documents/Data%20and%20Reports/Central/AnnualReport-on-Homelessness%20Services-in-Maryland-Fiscal-Year-2009.pdf
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Causes of Homelessness:
Poverty is the Underlying Theme
Individual Factors
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Abuse/family instability
Foreclosure/eviction
Unemployment
Mental illness
Addictions
Illness/disability/poor
health
Incarceration
Fire/disaster
Bankruptcy
Structural Factors
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Lack of affordable
housing
Lack of adequate
health care
Lack of livable
incomes
+ 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

Homelessness
is the equivalent of
another diagnosis
(ICD9=V60.0)
Source: Institute of Medicine (1988). Homelessness, Health and Human Needs. National Academy
Press:Washington, DC.
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Homelessness Limits “Adherence”
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Medications lost or stolen

No watch, calendar, or bus token
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No routine supplies
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Co-pays unavailable
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Meals unavailable (or of poor quality)
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Some treatments risk arrest (e.g., diuretics)
Common Medical Conditions - Adults
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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 Disease
 HIV
 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
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Behavioral Health Conditions

Rates depend on population
being screened

HUD
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Severely mentally ill: 18%
Chronic substance abuse: 21%
Co-occurring: 50% of mentally ill
have a substance abuse disorder
HCH Experience
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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.
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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
 Leads
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on school attendance/performance, nutrition
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
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50% uninsured*
20% Medicaid
5% Medicare
25% Other [e.g., the Primary Adult Care program(PAC)]
 HCH
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Maryland: 9,189 patients
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.
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Homelessness: An Ongoing Problem
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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?
+ HCH Model of Care
 Services
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Outpatient primary care
Mental health
State-certified OP/IOP addictions
Pediatrics
Dental clinic
Outreach and case management
Supported housing and convalescent care
 Approach
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Team-based care
Low barrier access
Use harm reduction &
motivational interviewing (EBPs)
Patient-driven care
Goals:
Increase stability
Improve health
End homelessness
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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 Act

Health insurance “exchanges”(required)
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Medicaid expansion to those ≤138% FPL (optional)
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Marketplaces for individual & small group market
Private insurance plans compete on cost, coverage, quality
Subsidies/credits available for those 100-400% FPL
State-run, federally facilitated, or partnerships
Federal financing: 100%  90% over 6 years
Effective January 1, 2014

Open enrollment: October 1, 2013
Insurance Status: HCH v. All Health
Centers v. U.S.
Health Care for the Homeless
All Health Centers
U.S.
62%
515,000
individuals
54%
42%
36%
30%
16%
17%
5%
None/Uninsured
Sources: 2011 UDS Data, HRSA
2011 Census data
Medicaid/other
public
8%
14%
12%
Medicare
3%
Private Insurance
Nonelderly Health Insurance Coverage by
Family Poverty Level, 2011
Number
400% +
90.5 M
200% - 399%
72.1 M
100% - 199%
47.4 M
Under 100%
56.3 M
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
250%
185%
Minimum Medicaid Eligibility under Health
Reform - 133% FPL
($25,390 for a family of 3 in 2012)
63%
37%
0%
Children
Pregnant
Women
Working Parents Jobless Parents
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.
Childless Adults
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Medicaid Expansion: Filling the Gap

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Currently eligible: children, pregnant women, those
disabled, and some parents of children
Newly eligible: Law expands Medicaid to non-disabled adults
earning at or below 138% FPL.
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About $15,000/year for singles
About $25,500/year for family of 3
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15 million individuals newly eligible
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Must be a U.S. citizen or legal resident here for at least 5 years
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8 states have started expanding Medicaid already (in full or partial)
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CA, CT, CO, DC, MN, MO, NJ, WA
+ ACA Improves Enrollment Process
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Electronic verification of income & identity
Uses gross income information (no asset tests)
Faster approvals
No in-person interviews & automatic 12-month renewal
(unless there’s a change)
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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 state
Alternative points of contact possible
Enrollment assistance available
+ 12 Reasons Why Medicaid Expansion is Critical
1.
Improves access to care
2.
Improves financial stability
3.
Improves health status/reduces mortality
4.
Patient satisfaction is high
5.
Improves local and state economy
6.
Maximizes federal funding
7.
Reduces current state spending
8.
Reduces ER & hospital utilization
9.
Ensures healthier workforce
10.
Helps low-income veterans
11.
Helps children & families
12.
Reduces health disparities
+
CBO Projected Medicaid Enrollment (U.S.)
15 million adults newly eligible
+ Outreach & Enrollment

Law requires states “establish procedures for outreach
and enrollment activities to vulnerable & underserved
populations” (ACA §2201)
Children
Eligibility does
Unaccompanied homeless youth
not
Children and youth with special health care needs
automatically
Pregnant women
equate to
Racial and ethnic minorities
enrollment
Rural populations
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Victims of abuse or trauma
Individuals with mental health or substance-related disorders
Individuals with HIV/AIDS
Currently eligible for Medicaid:
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4.4 million adults
2.9 million children
Trends in Medicaid Enrollment in MD
2014
2016
2018
2020
Newly eligible
(including PAC)
90,639
119,634
133,201
143,207
Currently eligiblenewly enrolled
11,046
32,301
41,793
44,069
986,347
1,004,559
1,032,785
1,056,676
1,088,032
1,156,494
1,207,779
1,243,952
(“woodwork effect”)
Current Medicaid
(excluding PAC)
Total Medicaid
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-enrolled
25%: Undocumented/ineligible
immigrants
Change in Percentage of Uninsured in MD
Remaining
Uninsured
2014
2016
2018
2020
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
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Patient-centered medical homes
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Electronic health records
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Coordinated care across multiple venues
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Health care viewed in a wider perspective
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Renewed attention to social determinants of health
+ Recommendations
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Ensure targeted, in-person outreach
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Track enrollment of those at lowest income levels
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Literally “beating the bushes”
Possible “StateStat” measure?
Grow medical and behavioral health service capacity
Ensure MCOs appreciate breadth of services needed to
achieve cost-savings
Train providers to understand impact of poverty and
homelessness on health
Ensure services for those remaining uninsured (and pursue
additional insurance expansions)

Maximize state options for providing services in supported
housing
+
RISKS
OPPORTUNITIES

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Improved individual & public
health
Reduced personal bankruptcy
& poverty
Increased individual & family
stability

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Continued barriers to
enrollment

Inability to find provider(s)

Difficulty engaging in care
Increased employment &
productivity
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Reduced recidivism to criminal
justice

Preventing & ending
homelessness
Fail to reach newly eligible
(lack of outreach)
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Ongoing housing instability
risks engagement in care
Poor transition to exchange
jeopardizes gains in health,
income
Ongoing homelessness & poor
health
+
More Information


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Health 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/