Barbara DiPietro, Ph.D. Director of Policy Health Care for the Homeless & National HCH Council

1. Kevin Lindamood, MSWPresident and CEOHealth Care for the Homeless Barbara DiPietro, Ph.D.Director of PolicyHealth Care for the Homeless & National HCH Council Heath Care Needs of Homeless Populations in a Health Reform World January 16, 2013

3. 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

4. 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)

5. Homelessness in Maryland: 1 Night in January 2012 Source: HUD, 2012. http://www.hudhre.info/index.cfm?do=viewHomelessRpts

6. 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

7. Causes of Homelessness:Poverty is the Underlying Theme Individual Factors Structural Factors • 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

8. 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. Homelessness is the equivalent of another diagnosis (ICD9=V60.0)

9. Homelessness Limits “Adherence” • 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)

10. 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

11. 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

12. 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%

13. 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.

14. 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

15. 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.

16. Homelessness: An Ongoing Problem • 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?

17. 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 stability Improve health End homelessness

18. 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?

19. Christopher: Bringing together health, housing, and support services

21. Insurance Expansions in the Affordable Care Act Health insurance “exchanges”(required) 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 Medicaid expansion to those ≤138% FPL (optional) Federal financing: 100%  90% over 6 years Effective January 1, 2014 Open enrollment: October 1, 2013

22. 515,000 individuals Sources: 2011 UDS Data, HRSA 2011 Census data

23. Nonelderly Health Insurance Coverage by Family Poverty Level, 2011 Number 400% + 90.5 M 72.1 M 200% - 399% 47.4 M 100% - 199% 56.3 M Under 100% 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.

24. 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. Minimum Medicaid Eligibility under Health Reform - 133% FPL ($25,390 for a family of 3 in 2012)

25. Medicaid Expansion: Filling the Gap 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. About $15,000/year for singles About $25,500/year for family of 3 15 million individuals newly eligible Must be a U.S. citizen or legal resident here for at least 5 years 8 states have started expanding Medicaid already (in full or partial) CA, CT, CO, DC, MN, MO, NJ, WA

26. ACA Improves Enrollment Process 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) 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

27. 12 Reasons Why Medicaid Expansion is Critical Improves access to care Improves financial stability Improves health status/reduces mortality Patient satisfaction is high Improves local and state economy Maximizes federal funding Reduces current state spending Reduces ER & hospital utilization Ensures healthier workforce Helps low-income veterans Helps children & families Reduces health disparities

28. CBO Projected Medicaid Enrollment (U.S.) 15 million adults newly eligible

30. Outreach & Enrollment Law requiresstates “establish procedures for outreach and enrollment activities to vulnerable & underserved populations” (ACA §2201) Children Unaccompanied homeless youth Children and youth with special health care needs Pregnant women Racial and ethnic minorities Rural populations Victims of abuse or trauma Individuals with mental health or substance-related disorders Individuals with HIV/AIDS Currently eligible for Medicaid: 4.4 million adults 2.9 million children Eligibility does not automatically equate to enrollment

31. Trends in Medicaid Enrollment in MD

32. 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

33. Those Remaining Uninsured (U.S.) Remaining Uninsured: 37%: Medicaid-eligible but un-enrolled 25%: Undocumented/ineligible immigrants

34. Change in Percentage of Uninsured in MD

35. 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 perspective Renewed attention to social determinants of health

36. Recommendations Ensure 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 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

37. OPPORTUNITIES RISKS • 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

38. More Information 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: klindamood@hchmd.org @kevinlindamood Barbara DiPietro, Director of Policy: bdipietro@hchmd.org @barbaradipietro National HCH Council: www.nhchc.org @NatlHCHCouncil Health Reform page: http://www.nhchc.org/policy-advocacy/reform/