03/19/2014 - Changing the Terms: How Innovative Communities are Using the ACA to Improve Homeless Services

By Lisa Stand, Senior Policy Analyst for the National Alliance to End Homelessness

Homeless advocates are viewing the implementation of the Affordable Care Act (ACA) with great optimism. As Medicaid enrollment grows and coverage takes effect, more adults experiencing chronic homelessness have better access to comprehensive health care, including mental health services, substance use treatment, and recovery supports.

In states that are expanding Medicaid, the influx of new funding to communities is an opportunity to take a fresh look at how funds from all sources are spent to serve vulnerable populations. Communities activated to end chronic homelessness are showing the way. The National Alliance to End Homelessness recently looked at strategies in five communities to leverage health care for supportive housing capacity.  These communities – Chicago, Cleveland, Minneapolis, Philadelphia, and Portland, OR – tell us what integrating the ACA into homelessness assistance can look like.

The common theme is partnerships – not surprisingly, given all the silos in homeless services at the local level. The good news is that every place can proceed from its own starting point.

In Chicago, Together4Health is a provider network dedicated to finding and serving very vulnerable Medicaid enrollees, including people experiencing or at risk of chronic homelessness. In addition to offering primary care and behavioral health, the partnership has built-in supportive housing capacity and expertise. The venture is financed by pooled resources from diverse sources, including Medicaid reimbursements. As a collaborative effort, Together4Health can coordinate and deliver a full complement of services that are proven effective for helping people who experience chronic homelessness to recover and thrive in permanent housing. A comparable strategy is being pursued in Portland with HealthShare of Oregon (HSO). HSO combines a network of safety-net providers that connects directly in partnership to a Medicaid managed care plan. 

In both locales, provider networks have incentives to pursue targeted housing interventions because their funding is capitated (i.e., limited to a set per-person amount). Partners understand that for very vulnerable people facing homelessness, supportive housing is a critical intervention to support cost-effective health care delivery.

The provider networks in Chicago and Portland show how the ACA can support broad-based innovations that have implications for homeless services as well as health care delivery. However, such a high level of system change is not necessary to have an impact on the lives of people who have experienced homelessness. For instance, through the Medicaid Supportive Housing Initiative, 85 vulnerable people in Minneapolis are housed with health care, behavioral health services, and case management. The program is funded, initially as a pilot, through collaboration between a homeless services agency and a Medicaid managed care plan. Something as modest as a Medicaid health home option can give a health care partnership new ways to bolster supportive housing outcomes. Cleveland is a good example. Their community stakeholders took the initiative to improve health outcomes in supportive housing, anticipating Ohio’s eventual adoption of the Medicaid expansion. Early on, community partners saw that the ACA offered an opportunity to increase access and improve coordination of health care services for tenants in supportive housing. One of the first steps was to develop a Medicaid health home designed specifically to serve people living in single-site supportive housing programs across the city.

The results of all of these efforts will begin to unfold now that the ACA is in full effect. There is still much to learn about what works best to make real progress ending homelessness. Having taken innovative steps now, leaders in ending homelessness can also be at the table with a credible voice when new health care policies are proposed, including ACA improvements. 

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