If the promise of new and emerging approaches to integrated and cost-effective care for people experiencing chronic homelessness and PSH tenants is to be realized, many aspects of Medicaid state plans will have to be brought into alignment. Service definitions will need to be updated, examining them to assure that they can accommodate the evidence-based practices and emerging, more-integrated models of care that are particularly important for people who have co-occurring behavioral health and chronic health conditions or other medical needs. Administrative silos (involving, for example, physical health care, mental health care, and substance use disorder treatment) will have to be breached so service providers can treat people holistically, sharing medical records, requesting payment, reporting performance, and performing similar tasks through streamlined and coordinated mechanisms.
Gaps in covered services (e.g., outreach and engagement, collateral contacts, and services that explicitly focus on helping people get and keep housing as a social determinant of health and a driver of health care utilization and costs) will have to be closed to the extent possible under Medicaid, and alternative funding mechanisms identified if possible to fill those gaps. Given the enormous pressures currently facing state Medicaid agencies working to implement changes consistent with Affordable Care Act requirements, in the short term it may not be easy for them to find the time to focus on the needs of the relatively small population of PSH tenants and people still experiencing homelessness who could benefit from PSH.
Although our target population is a very small part of all Medicaid-eligible people, the population has some of the most complex needs, and it is no simple matter to design programs within Medicaid that meet those needs. For this reason, it makes sense to work with other constituencies who need home and community-based services to develop care structures that work across a wider range of populations.
Louisiana has taken an approach that seems on the verge of working for the population of interest in this research. It is concentrated in one Medicaid state plan amendment using 1915(i) authority, but it is embedded in a wholesale restructuring of the state's Medicaid system for health and behavioral health. The restructuring involves many waivers and plan amendments, and is likely to have taken at least five years by the time all the pieces are in place. The many state agencies that have participated and are still participating in this overhaul have devoted their attention to both the proverbial forest and the trees, which has provided the opportunity to determine where this target population fits in and what plan amendments are needed to allow the appropriate array of services to the range of people who need them. Minnesota did the same extensive, multifaceted planning in preparation for its Health Care Delivery System Demonstration that began in 2011, and continued those planning activities for its Reform 2020 waiver request.112
The optional health home benefit for people with chronic illnesses, a new opportunity for states under the Affordable Care Act, shows great promise as a vehicle for accommodating the care coordination needs of persons with complex health needs, including people who are or have been homeless. Several of the states included in this study were considering how to design health home services, but at the end of the study period none had completed the planning process or submitted a Medicaid state plan amendment to establish these optional benefits for a target population likely to include people who are chronically homeless and PSH tenants.
During this study, as states and health care delivery systems were preparing to meet important deadlines associated with the implementation of major provisions of the Affordable Care Act, including streamlining and expanding Medicaid eligibility and launching health insurance exchanges, we frequently heard about the "bandwidth" challenges they face. The agency leaders and planners working in state Medicaid programs, as well as other state and local government agencies and health care provider organizations, often described the need to focus their time and attention on the tasks most critical to ensuring that policies and systems would be in place by January 2014 and ready to deliver health coverage and ensure access to care for millions of Americans who will benefit from implementation of the Affordable Care Act. Simultaneously, many of these same individuals, public agencies, and provider organizations were also being challenged to implement other ambitious changes in response to budget reductions, lawsuits, and other pressures. In this context, it is remarkable that so many of them have made it a priority to work on using Medicaid to improve care for people experiencing homelessness, and to find ways to better integrate care and connect housing and services to better serve a small number of the most vulnerable people, including those with the most complex needs.
As attention focused on the activities that were most critical to being ready for 2014, stakeholders involved in Medicaid were often reminded that this has been an important deadline for some major activities, but it is not the finish line. While the enrollment of millions of Americans into Medicaid or subsidized insurance coverage began in October 2013 for coverage starting in 2014, the work of ensuring that coverage and care delivery systems work well for the most vulnerable people, including those experiencing homelessness or living in PSH, will require sustained attention in the coming years. Rather than a finish line, 2014 is a beginning of the next phase of work to achieve the goals of health reform.