For the homeless, federal changes promise better access to health care

By Mary Agnes Carey and Andrew Villegas
Kaiser Health News
Friday, August 20, 2010

BALTIMORE -- Homeless and unemployed, Tianne Hill said she dreads getting mail at the city shelter on Guilford Avenue where she lives because it often includes medical bills she can't pay.

The 40-year-old former waitress and short-order cook owes about $6,000 for abdominal surgery. She's expecting another bill soon for emergency treatment of a seizure. And she has other conditions that require expensive care: asthma, arthritis, anxiety and depression.

Like many other homeless people, Hill is uninsured and ineligible for Medicaid, the state-federal program that covers millions of other poor Americans. But beginning in 2014, Medicaid greatly expands under the new health-care law to include adults without children, who generally have been excluded.

The Medicaid expansion also will enable agencies that serve the homeless to divert resources now spent on medical care to other services such as finding housing and jobs. The new law provides another boost through a five-year, $11 billion expansion of the community health center system that treats many in this population.

These benefits and President Obama's recently announced plan to prevent and end homelessness mark a watershed moment in federal efforts on this issue, advocates say. Among its goals, the plan calls for greater coordination among housing, medical care and behavioral health programs to help end chronic homelessness in five years and homelessness for families and children over the next decade.

In a June report to Congress, the U.S. Department of Housing and Urban Development found that 643,000 people were homeless on a given night in 2009 and that roughly 1.56 million people -- or one in every 200 Americans -- spent at least one night in a shelter last year.

But the new health law won't eliminate some daunting obstacles to improving health care. Locating and enrolling homeless people in Medicaid will be a challenge. Many also suffer from chronic, complex medical conditions, including mental illness and addiction. Low reimbursement rates for some services may lead to access problems. "Caring for this population is not so simple," said John Lozier, executive director of the National Health Care for the Homeless Council.

Hill had a job but no health insurance when she had emergency surgery for a hernia five years ago. After the operation, she had to leave her restaurant job because she could not stand on her feet for long periods.

The lack of income and foreclosure on a relative's house where she was staying helped cause Hill and her husband to become homeless. When they couldn't stay with friends or family members, they slept in abandoned houses. Both now live at the shelter, Hill on the fourth floor and her husband, Linia Jennings, 50, on the fifth.

A Maryland law that provides some preventive-care services to adults covers Hill's medications for depression and helped her get a pair of eyeglasses. But not having comprehensive health insurance means that Hill does not get all the medical care she needs.

"It is a worry when you see a bump or you have an ache or a pain or something just doesn't feel right," Hill said. "And you don't want to keep running to the emergency room because you're going to keep getting these bills."

Just a quarter of the 6,000 clients treated annually at Baltimore's Health Care for the Homeless are covered by Medicare, the federal program for seniors, or Medicaid. Sixty percent of the center's $12.5 million budget is from federal, state and local funds, and the rest is from corporations, foundations and individuals. The Baltimore program also gives grants to facilities in Frederick, Harford, Baltimore and Montgomery counties that provide medical care to the homeless.

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