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 to assure that they can accommodate evidence-based practices and emerging, more integrated models of care, particularly for people who have co-occurring behavioral health and chronic health conditions or other medical needs. The administrative silos in which physical health care, mental health care, and substance use disorder treatment currently reside in many states will have to be breached so service providers can treat people holistically, request payment, and report performance 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 make 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 the population of people experiencing chronic homelessness or living in PSH is a very small part of the total Medicaid-eligible population, it is no simple matter to design programs within Medicaid that meet its needs. For this reason, it makes sense to work with other constituencies who need services delivered in their homes and communities to develop care structures that work across a wider range of populations.
In the context of preparing to meet the 2014 requirements of the Affordable Care Act and other major pressures for change, it is remarkable that so many states and health care providers 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. It is not surprising that in some cases this work has moved more slowly and that progress has been more uneven than some might have hoped.
As attention focused on the activities that were most critical to preparing 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. This reality makes 2014 a beginning for the next phase of work to achieve the goals of health reform.