09/25/2013 - The Day that Really Matters for the Affordable Care Act

By Richard Cho, Policy Director, USICH

There’s been a lot of attention lately on certain dates in the implementation of the Affordable Care Act, not least of which is October 1st, the day when enrollment opens for health insurance and Medicaid through the Affordable Care Act’s new health insurance marketplaces. There’s no doubt that October 1st is an important date. At the same time, I think too much of the wrong kind of attention has been placed on that single day. It’s not as if it’s the only date that matters. It may be tempting for pundits to reduce the biggest improvement to the U.S. safety net in decades down to what will happen on a single day. But we should remember that October 1st is just the first of many more days to come when millions of Americans—including people experiencing homelessness—will have access to health coverage (Medicaid for most and affordable private insurance for others), many for the first time.  

For my part, the date that interests me most is the date in the not-so-distant future when we will have forgotten that there ever was a time when millions of American simply could not get health coverage or access health care. And I know that day will come just as I know there will be a time when we will think how strange it was that there were ever millions of Americans who did not have homes, who lived out on the streets, in their cars, or in huge rooms full of cots.  

All of the noise and clamor in the news about what will happen on October 1st obscure the more interesting stories being told about how the Affordable Care Act is changing the terms in so many ways, not least of which is its role in ending homelessness in America.  If you listen closely enough, you’ll hear those stories.  Stories about how the Affordable Care Act is making it possible for more people experiencing chronic homelessness to benefit from permanent supportive housing and Health Care for the Homeless. Stories about people like Scotty, who went from the emergency room’s revolving door to the front door to his very own apartment—and found unimagined stability on the other end.  And even stories about people like Alicia, whose severity of illness and years of living on the streets led to her death, but where compassionate services and a stable apartment allowed her to die with dignity at home after reuniting with her family.  

It’s stories like these that remind me that the real transformation through the Affordable Care Act is not just about what happens on October 1st, but what’s already been happening since the law was passed to change and expand what health care means in America. And that transformation is quite remarkable.  Here are four emerging and exciting trends in that transformation:

  • Permanent supportive housing is becoming part of new care delivery approaches
    In places like Oregon and Illinois, we are seeing the formation of new, never-before-seen collaborations between hospitals, community health centers, health payers, social services providers, and affordable housing providers. These collaborations create one-stop shopping for people who have complex health conditions and are experiencing chronic homelessness. Models like Accountable Care Organizations and Health Homes were intended to focus health care on outcomes rather than procedures, packaging together services, making people healthier while (wait for it…) actually lowering costs.  And these innovative collaborations have realized that, for beneficiaries experiencing chronic homelessness, affordable housing needs to be a critical part of that package of care. 
  • Managed care benefits covering supportive housing services 
    In places like Massachusetts, Minneapolis, and Pittsburgh, we are seeing managed care organizations (both of the altruistic community-affiliated and allegedly profit-minded varieties) reaching out to permanent supportive housing providers and paying them a flexible fee to provide supportive services linked to housing for their high-need, high-cost enrollees who are experiencing homelessness. It’s not hard for managed care companies to figure out that delivering permanent supportive housing to their complex-need cases is not only good for their health, but also good for business.   
  • States are adopting and covering supportive housing services in their Medicaid plans   
    In states as different in geography and political culture as Louisiana and New York, permanent supportive housing (and a special focus on people experiencing chronic homelessness) has become a central part of their state Medicaid policies and health reform efforts. Health policymakers and Medicaid officials in both states recognize the value of permanent supportive housing in improving health and lowering costs.  
  • Efforts focused on Medicaid “super-utilizers” are seeing the importance of linking care management to housing    
    More and more states and counties are recognizing that to bend the Medicaid cost curve, they need to address the health and social needs of “super-utilizers”—the small subset of Medicaid enrollees whose frequent use of hospitals and emergency rooms drive up overall health care spending. They are also recognizing that housing is key to addressing the needs of super-utilizers. Housing’s role was included in the Center for Medicare and Medicaid Services’ (CMS) recent information bulletin on “super-utilizers” and is being discussed as part of the National Governors Association’s Developing State-Level Capacity to Support Super-Utilizers policy academy

“Housing is health care” has become a mantra—nay, a battle cry—for many of us who have been working for years to end chronic homelessness and who have seen the transformative impact that permanent supportive housing has had on people’s health, recovery, and dignity. It may not be on Oct. 1st, but the day will soon be upon us when that phrase will no longer be just a slogan, but actual policy and practice. And that’s the day that matters most to me for the Affordable Care Act.  

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