Friday, November 21, 2014

Medicaid improving access for the homeless, but…

Kaiser Family Foundation
November 13, 2014
Early Impacts of the Medicaid Expansion for the Homeless Population
By Barbara DiPietro, Samantha Artiga and Alexandra Gates

The Affordable Care Act (ACA) Medicaid expansion offers a significant
opportunity to increase coverage and improve access to care for
individuals experiencing homelessness, who historically have had high
uninsured rates and often have multiple, complex physical and mental
health needs.

* The Medicaid expansion has led to significant increases in coverage
that are contributing to improved access to care and broader benefits
for homeless individuals. Providers reported that these coverage gains
have enabled patients to access many services that they could not obtain
while uninsured, including some life-saving or life-changing surgeries
or treatments. Participants also identified other broader benefits for
homeless individuals stemming from Medicaid coverage gains. For example,
providers noted improvements in individuals' ability to work and
maintain stable housing due to better management of health conditions.
In addition, participants said individuals have reduced financial stress
and improved access to other services and programs, including disability

* Providers reported having access to a broader array of treatment
options as a result of Medicaid coverage gains among their patients.
With these increased options, providers said they are better able to
provide care based on the best courses of treatment rather than based on
the availability of charity or discounted resources.

* Gains in Medicaid revenue are facilitating strategic and operational
improvements focused on quality, care coordination, and information
technology. In addition, administrators indicated that Medicaid revenue
gains supported staff increases and led to changing staff roles to meet
increased administrative and billing needs. However, participants
emphasized that, even with Medicaid revenue gains, other funding sources
remain vital for supporting the full range of services needed by the
homeless population.

* Participants from the non-expansion site (Florida - did not expand
Medicaid) indicated that their patients remain uninsured and are
continuing to face significant gaps in care that contribute to poor
health outcomes. Participants also said they are facing an increasingly
challenging financial situation because they are missing out on Medicaid
expansion revenue gains and other funding sources are declining.

* As homeless patients gain Medicaid coverage and are enrolled in
managed care, some challenges are emerging. Participants commented that
some patients are being auto-assigned to providers with whom they do not
have an existing relationship and/or they may have difficulty accessing
due to lack of transportation. Additionally, working within provider
networks can be difficult given the complex needs of individuals, lack
of transportation, and the limited experience among other providers in
serving this population. Lastly, participants emphasized that prior
authorization requirements and limited and/or changing drug formularies
are leading to delays in care for individuals and creating substantial
administrative burdens for providers.


Comment by Don McCanne

The experience of the homeless population under the Affordable Care Act
(ACA) demonstrates both the benefits of reform under ACA and the flaws
of ACA that call for replacement with a single payer system. ACA was
better than nothing, but we can have so much more through enactment of a
single payer system.

The primary ACA benefit for the homeless is that most of them in
expansion states qualify for Medicaid and thus have improved access to
health care without financial barriers. Some of the homeless who access
health care have been noted to have an increased ability to work and to
maintain stable housing. Financial stress is reduced and some have
gained access to appropriate disability benefits. These benefits to the
homeless are more reasons why calls for simple repeal of ACA are bad
policy, devoid of compassion.

Yet the last paragraph from the excerpts above explains why Medicaid
managed care is often a poor choice for the homeless (and many other
lower-income individuals as well). Homeless patients often are unable to
see the health care professionals who would be most accessible and
appropriate for them. Transportation concerns are more likely. Essential
specialized services may not be available. Managed care intrusions such
as prior authorization requirements, limitations and changes in
formularies, or other perverse managed care innovations may impair
access to important health care services or products. Further, those
states that refuse to expand Medicaid are leaving most of the homeless
without any coverage and therefore reliant on often inadequately funded
safety-net institutions.

There are those who believe that we should merely proceed with
implementation of ACA and try to obtain legislative and administrative
patches along the way. Compared to the deficiencies in our dysfunctional
system, patches have only minimal beneficial impact while increasing the
administrative complexity that already overburdens our system. Patches
fall way too short of what we need.

We should not repeal ACA since it does provide some temporary benefit
until we can implement a single payer system. But we should not let ACA
implementation divert us from instituting what we really need - a single
payer national health program. Not only would that benefit the homeless,
it would benefit all of the rest of us as well.

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