Medicaid for lease? California desires Med-Cal to cowl 6 months of lease

SACRAMENTO, Calif. — Gov. Gavin Newsom, whose administration is struggling to include a worsening homelessness disaster regardless of report spending, is attempting one thing daring: tapping federal healthcare funding to cowl lease for homeless folks and people susceptible to dropping their housing.

States are barred from utilizing federal Medicaid {dollars} to pay straight for lease, however California’s governor is asking the administration of President Joe Biden, a fellow Democrat, to authorize a brand new program known as “transitional lease,” which would supply as much as six months of lease or non permanent housing for low-income enrollees who depend on the state’s well being care security web — a brand new initiative in his arsenal of packages to battle and stop homelessness.

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“I’ve been speaking to the president. We can not do that alone,” Newsom instructed KHN.

The governor is pushing California’s model of Medicaid, known as Medi-Cal, to fund experimental housing subsidies for homeless folks, betting that it’s cheaper for taxpayers to cowl lease than to permit folks to fall into disaster or pricey institutional care in hospitals, nursing properties and jails. Early in his tenure, Newsom proclaimed that “docs ought to have the ability to write prescriptions for housing the identical method they do for insulin or antibiotics.”

However it’s a dangerous endeavor in a high-cost state the place median lease is almost $3,000 a month, and even larger in coastal areas, the place most of California’s homeless folks reside. Consultants count on the Biden administration to scrutinize the plan to make use of healthcare cash to pay lease and likewise query its potential effectiveness in mild of the state’s housing disaster.

“A part of the query is whether or not that is actually Medicaid’s job,” mentioned Vikki Wachino, who served as nationwide Medicaid director within the Obama administration. “However there’s a recognition that social elements like insufficient housing are driving well being outcomes, and I feel the federal authorities is open to creating approaches to attempt to handle that.”

Bruce Alexander, a spokesperson for the Facilities for Medicare & Medicaid Companies, declined to say whether or not the federal authorities would approve California’s request. But, Biden’s Medicaid officers have accredited comparable experimental packages in Oregon and Arizona, and California is modeling its program after them.

California is house to an estimated 30% of the homeless folks within the U.S., regardless of representing simply 12% of the nation’s general inhabitants. And Newsom has acknowledged that the numbers are probably far larger than official homeless tallies present. Prime well being officers say that, to include hovering safety-net spending and assist homeless folks get wholesome, Medi-Cal has no alternative however to mix social providers with housing.

Statewide, 5% of Medi-Cal sufferers account for a staggering 44% of this system’s spending, based on state knowledge. And most of the costliest sufferers lack steady housing: Practically half of sufferers experiencing homelessness visited the emergency room 4 instances or extra in 2019 and have been extra probably than different low-income adults to be admitted to the hospital, and a big majority of visits have been coated by Medi-Cal, based on the Public Coverage Institute of California.

“What we now have at present doesn’t work,” mentioned Dr. Mark Ghaly, secretary of the California Well being and Human Companies Company, explaining his argument that housing is a crucial element of well being care. “Why do we now have to attend so lengthy for folks to be so sick?”

The federal authorities has already accredited a large social experiment in California, often called CalAIM, which is remodeling Medi-Cal. Over 5 years, the initiative is anticipated to pour $12 billion into new Medi-Cal providers delivered exterior of conventional well being care. In communities throughout the state, it’s already funding providers for some low-income sufferers, together with paying rental safety deposits for homeless folks and people dealing with eviction; delivering ready wholesome meals for folks with diabetes; and serving to previously incarcerated folks discover jobs.

The transitional lease program would add one other service to these already out there, although solely a sliver of the 15.4 million Medi-Cal enrollees really obtain these new and costly social providers.

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Lease funds may start as quickly as 2025 and value roughly $117 million per yr as soon as absolutely carried out. And whereas state officers say anybody who’s homeless or susceptible to turning into homeless can be eligible, not everybody who qualifies will obtain new providers because of capability limits. Amongst those that stand to profit are practically 11,000 folks already enrolled in Medi-Cal housing providers.

“The continued dialog is how will we persuade the federal authorities that housing is a well being care challenge,” mentioned Mari Cantwell, who served as Medi-Cal director from 2015 to 2020. “You need to persuade them that you simply’re going to economize since you’re not going to have as many individuals exhibiting up on the emergency room and in long-term hospitalizations.”

Healthcare experiments in California and across the nation that funded housing helps have demonstrated early success in lowering prices and making folks more healthy. However whereas some packages paid for housing safety deposits or contributors’ first month of lease, none straight coated lease for an prolonged interval.

“With out that foundational assist, we’re taking part in within the margins,” Newsom mentioned.

State well being officers argue that paying for six months of lease will likely be much more profitable at lowering well being care prices and bettering enrollees’ well being, however specialists say that, to work, the initiative will need to have strict accountability and be bundled with an array of social providers.

In a precursor to the state’s present initiative, California experimented with a mixture of housing help packages and social providers by means of its “Complete Particular person Care” pilot program. Nadereh Pourat, of the UCLA Heart for Well being Coverage Analysis, evaluated this system for the state concluding that native trials diminished emergency visits and hospitalizations, saving a median of $383 per Medi-Cal beneficiary per yr — a meager quantity in contrast with this system’s value.

Over 5 years, the state spent $3.6 billion serving about 250,000 sufferers enrolled in native experiments, Pourat mentioned.

And a randomized management trial in Santa Clara County that supplied supportive housing for homeless folks confirmed reductions in psychiatric emergency room visits and enhancements in care. “Lives stabilized and we noticed an enormous uptick in substance use care and psychological well being care, the issues that everyone desires folks to make use of to get more healthy,” mentioned Dr. Margot Kushel, director of the College of California-San Francisco’s Heart for Weak Populations at Zuckerberg San Francisco Normal Hospital and Trauma Heart, who labored on the research.

However insurers implementing the broader Medi-Cal initiative say they’re skeptical that spending well being care cash on housing will save the system cash. And well being care specialists say that, whereas six months of lease could be a bridge whereas folks await everlasting housing, there’s a much bigger impediment: California’s reasonably priced housing scarcity.

“We are able to design unimaginable Medicaid insurance policies to alleviate homelessness and pay for all the mandatory supportive providers, however with out the sufficient housing, frankly, it’s not going to work,” Kushel mentioned.

Newsom acknowledges that criticism. “The disaster of homelessness won’t ever be solved with out first fixing the disaster of housing,” he mentioned final week, arguing California ought to plow more cash into housing for homeless folks with extreme psychological well being situations or dependancy issues.

He’ll ask the legislature to place earlier than voters a 2024 poll initiative that will infuse California’s psychological well being system with a minimum of 6,000 new therapy beds and supportive housing items for folks combating psychological well being and dependancy issues, a lot of whom are homeless. The proposed bond measure would generate from $3 billion to $5 billion for psychiatric housing and therapy villages aimed toward serving greater than 10,000 extra folks a yr. The initiative additionally would ask voters to put aside a minimum of $1 billion a yr for supportive housing from an current tax on California millionaires that funds native psychological well being packages. 

“People who find themselves combating these points, particularly those that are on the streets or in different weak situations, can have extra assets to get the assistance they want,” Newsom mentioned.

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For transitional lease, six months of funds can be out there for choose high-need residents enrolled in Medi-Cal, notably those that are homeless or susceptible to turning into homeless — and people transitioning from extra pricey establishments corresponding to psychological well being disaster facilities, jails and prisons, and foster care. Medi-Cal sufferers susceptible to inpatient hospitalization or who frequent the emergency room would even be eligible.

“It’s a reasonably large problem; I’m not going to lie,” mentioned Jacey Cooper, the Medi-Cal director. “However we all know that folks experiencing homelessness cycle out and in of emergency rooms, so we now have an actual function to play in each stopping and ending homelessness.”

Public well being specialists say the issue will proceed to blow up with out artistic excited about tips on how to fund housing in well being care, however they warn the state should be cautious of potential abuses of this system.

“It needs to be designed fastidiously as a result of, sadly, there are at all times folks seeking to sport the system,” mentioned Dr. Tony Iton, a public well being knowledgeable who’s now a senior vp on the California Endowment. “Choices should be made by clinicians — not housing organizations simply in search of one other income.”

For Stephen Morton, who lives within the Orange County group of Laguna Woods, the journey from homelessness into everlasting housing illustrates the quantity of public spending it will possibly take for the trouble to repay.

Morton, 60, bounced between shelters and his automobile for practically two years and racked up extraordinary Medi-Cal prices because of extended hospitalizations and repeated emergency room journeys to deal with power coronary heart illness, bronchial asthma, and diabetes.

Medi-Cal coated Morton’s open-heart surgical procedure and hospital stays, which lasted weeks. He landed non permanent housing by means of a state-sponsored program known as Venture Roomkey earlier than getting everlasting housing by means of a federal low-income housing voucher — an ongoing profit that covers all however $50 of his lease.

Since getting his condo, Morton mentioned, he’s been capable of cease taking one diabetes medicine and drop some weight. He attributes enhancements in his blood sugar ranges to his housing and the wholesome, home-delivered meals he receives through Medi-Cal.

“It’s normally scrambled eggs for breakfast and the fish menu for dinner. I’m shocked it’s so good,” Morton mentioned. “Now I’ve a microwave and I’m indoors. I’m so grateful and a lot more healthy.”

This story was produced by KHN, which publishes California Healthline, an editorially impartial service of the California Well being Care Basis.

Kaiser Well being Information is a nationwide well being coverage information service. It’s an editorially impartial program of the Henry J. Kaiser Household Basis which isn’t affiliated with Kaiser Permanente.