California’s Medicaid experiment spends money to save money — and help the homeless

Sporting a brilliant smile and the polished Tremendous Bowl ring he gained as a star NFL participant within the late Eighties, Craig McEwen would not match the archetype of somebody teetering getting ready to homelessness.

Evicted from his San Diego County house final July, McEwen — who endured repeated concussions throughout his six seasons within the NFL — scoured housing listings for something he may afford.

Working as a part-time groundskeeper at a golf course for $15 an hour, his frantic search turned up nothing. So, feeling overwhelmed by rents pushing $3,000 a month for a one-bedroom house, he made a plan: transfer into his truck or lease a storage container to dwell in — an alternate he turned to when he was beforehand homeless in 2004.

McEwen is hopeful {that a} huge well being care initiative in California providing new, specialised social companies will assist him get again on his toes. He’s considered one of almost 145,000 low-income Californians enrolled in CalAIM, an endeavor Gavin Newsom, the state’s Democratic governor, is spearheading to remodel its Medicaid program, referred to as Medi-Cal, into a brand new form of security web that gives housing and different companies for people who find themselves homeless or prone to changing into homeless and have complicating circumstances like psychological sickness or persistent illness that may make it troublesome to handle life.

California launched the initiative in early 2022, rolling it out quietly, with well being insurers and group teams scrambling to supply social companies and advantages that fall outdoors conventional well being care. It is a five-year, $12 billion social experiment that Newsom is betting will ultimately reduce hovering well being care spending in Medi-Cal, the biggest Medicaid program within the nation with 15.5 million enrollees.

The state is contracting the work to its 23 Medi-Cal managed-care medical health insurance corporations. They’re answerable for delivering a slew of latest advantages to probably the most weak enrollees: not solely these with housing insecurity, but additionally folks with psychological well being or addictive issues; previously incarcerated folks transitioning again to society; seniors and folks with disabilities; kids in foster care; and Californians who frequent hospital emergency rooms or are admitted usually to short-term expert nursing services.

Whereas solely a sliver of the state’s Medi-Cal sufferers are enrolled in CalAIM, tens of 1000’s of low-income Californians may qualify for the brand new advantages. They’re eligible for assist in discovering housing and for paying rental move-in prices like safety deposits.

However the assist goes past housing. The state can also be offering probably the most at-risk sufferers with intensive case administration, alongside pioneering social companies — comparable to wholesome home-delivered meals for diabetes sufferers and mildew removing in houses of sufferers with extreme bronchial asthma.

Prime state well being officers say that with such an formidable program — utilizing Medicaid to assist clear up homelessness and fight persistent illness — they anticipated the rollout to be bumpy. After 2026, when the initiative’s funding ends, the state plans to show the experiment works and completely undertake the advantages. In the meantime, different states are intently watching California, hoping to study from its successes and failures.

“California is a pacesetter, and it is all the time experimenting in new and fascinating methods,” mentioned Dr. Georges Benjamin, government director of the American Public Health Affiliation. “What it may well do is present proof of idea, after which this may develop to different states.”

Insurers, in essence, are constructing a brand new well being care workforce, contracting with nonprofit and for-profit organizations to enroll probably the most weak — and costly — Medi-Cal sufferers. They’re hiring social staff and case managers to seek out those that rack up excessive well being care prices in hospital emergency rooms, nursing houses, prisons, jails, and psychological well being disaster facilities.

As Newsom sees it, the immense funding will repay for taxpayers. Focusing on folks biking out and in of expensive establishments will cut back well being care spending, he argues, whereas additionally serving to folks get wholesome. State well being officers say 5% of high-need Medi-Cal sufferers account for roughly half of all well being care spending within the low-income well being care program.

An important forex in pulling off this huge well being care experiment is belief. And that’s being constructed on the bottom, with group outreach staff scouring hospitals and homeless encampments, for instance, to seek out these eligible for CalAIM.

Essentially the most at-risk Medi-Cal sufferers are being linked to specialised groups deployed below a brand new entitlement profit on the coronary heart of the initiative referred to as “enhanced care administration.” Whereas different companies like protecting safety deposits are optionally available, this isn’t. Health insurers are required to simply accept people who find themselves most in want and supply a variety of well being and social companies.

It may be easy issues like arranging an Uber to get to a medical appointment or shopping for a pc for an enrollee searching for a job. Or buying a motorcycle for a low-income child. However it additionally entails intensive, one-on-one work that may require case managers to take sufferers to get an identification card, make nighttime cellphone calls to make sure sufferers are taking medicines, and search out accessible flats.

“That is the lacking piece, and it is the toughest work — the most expensive work,” Newsom mentioned in an interview with KFF Health Information. “Individuals on the streets and sidewalks, they’ve misplaced belief. They’ve develop into socially remoted. They’ve misplaced connection, and so creating that’s so foundational.”

‘My very own jail’

McEwen, who was a good finish for the NFL workforce now referred to as the Washington Commanders and later for the San Diego Chargers, was hailed as a “legacy.” However taking part in skilled soccer took an excessive toll.

“My place was to dam for the quarterback, and again within the day, you have been allowed to hit folks within the head,” McEwen mentioned, recalling common concussions on the sector that he’d snap himself out of by sniffing ammonia packets. He helped lead the Washington workforce to a Tremendous Bowl victory in 1987, however within the a long time since, his well being has deteriorated.

McEwen has struggled for years to seek out common work whereas coping with ideas of suicide, anger, forgetfulness, and despair that he says stem from traumatic mind accidents sustained throughout his soccer profession. At 57, he endures continuous ache from ruptured disks in his neck and spine, together with shortness of breath from extreme coronary heart illness.

He’d holed up in his house for years, with curtains nailed to his home windows, drowning his ache with alcohol. “I mainly created my very own jail,” he mentioned.

After he was evicted final July, a longtime buddy swooped in to let him keep briefly in a spare bed room at his household’s home simply outdoors San Diego. However McEwen’s monetary and emotional battle to seek out steady housing hasn’t ended.

“We do not name it concern. Us ballplayers, we name it pleasure,” McEwen mentioned on a wet morning in early March, his eyes swelling with tears. “I am excited. I do know what’s at stake. My life is at stake.”

Housing instability is only one a part of it. He’d usually overlook to take his medicines for prime ldl cholesterol and clogged arteries. He felt paralyzing anxiousness and his mind was so scrambled he’d miss essential physician appointments — a facet impact, he mentioned, of the concussions.

McEwen knew he wanted assist.

He’d realized from a buddy that California was serving to Medi-Cal sufferers with not simply medical wants but additionally social companies, and he began making calls, insisting on getting in. “I mentioned wait, you are giving folks a coach? Somebody who could make appointments for me and go to my physician visits with me?”

Weeks after receiving his eviction discover, his Medi-Cal insurer, Molina Healthcare, linked him with a private care supervisor, whom McEwen calls “my advocate, somebody who can train me the best way to do for myself and provides myself a life price residing.”

However who will get in this system is commonly a roll of the cube, relying largely on which Medi-Cal insurance coverage firm an individual is enrolled in. Persistence performs a giant function.

Regardless of early glimmers of hope, the rollout has been chaotic. Suppliers on the bottom scramble to seek out any accessible housing for enrollees. Teams implementing the initiative say insufficient funding and dire well being workforce shortages have severely constrained their potential to serve all these in want. And enrollment by well being insurers is uneven, with some shortly approving new advantages for his or her members whereas others are denied. Some insurers present on-the-spot Uber rides for physician appointments whereas others provide solely a bus move.

“What’s being supplied is inadequate, and this program just isn’t set as much as help those that are literally probably the most weak and want probably the most intensive help,” mentioned Nancy Behm, affiliate director of CalAIM for a San Diego nonprofit referred to as Individuals Helping the Homeless, or PATH.

Working below contracts with Blue Protect of California, Molina Healthcare, and Health Web, PATH launched intensive case administration and housing companies in January 2022. However it has since stopped offering intensive case administration advantages largely because of a scarcity of ample funding to do the grueling work of connecting with homeless folks residing in encampments. “We’re hitting obstacles on each entrance,” Behm mentioned.

Newsom, together with his hovering political ambitions, is promising to assist probably the most weak Californians. Termed out in 2026, hypothesis is mounting that the two-term governor is eyeing a presidential run, and he is utilizing well being care as a core challenge to raise his nationwide profile. In actuality, his Medi-Cal initiative is falling far brief.

“That is a particularly formidable program, however it would not come near serving to the whole thing of the inhabitants it is concentrating on,” mentioned Doug Herman, who labored for former President Barack Obama and former Los Angeles Mayor Eric Garcetti. “This is not a coverage answer large enough to essentially make a dent in homelessness.”

No stroll within the park

On a brisk morning in late February, Jeannine Nash pulled into the drive-thru of a Jack within the Field in Chula Vista, simply south of San Diego. She dug in her pockets to seek out $8.17 for 10 breakfast sandwiches handy out to homeless folks on her common rounds visiting encampments.

“It helps me to return out right here earlier than work, to get an concept of what the wants are,” Nash mentioned as she approached a close-by homeless lady slumped over on a sidewalk who had nothing along with her however a brand-new walker and hospital discharge paperwork tucked in a plastic bag.

Nash is director of referrals for Serene Health, a for-profit well being care firm that’s considered one of almost 500 supplier organizations being paid to hyperlink homeless folks or these in danger with intensive case administration, housing, and different companies.

A recovering addict herself, Nash mentioned her life expertise has helped her join with folks residing outdoors and combating substance use issues. She figures out the best way to get those that seem resistant to simply accept companies. “So many individuals are distrustful of authority,” mentioned Nash, who has a son who’s homeless.

“That is very, very expensive to my coronary heart,” Nash mentioned. In her a long time since changing into sober, she has gained deep expertise getting the folks most prone to spiraling deeper into disaster into therapy beds and even flats. She’s cultivated relationships with housing and nursing dwelling companies so she will be able to shortly determine openings.

However her job comes with extraordinary challenges. She usually has to degree with folks residing outdoors, telling them there may be merely nowhere for them to go. “There’s simply not sufficient beds or housing on the market,” she mentioned. “And if you do not have an revenue, it is not going to occur.”

Nash handed the homeless lady within the doorway two sandwiches, coaxing her to eat. The girl, Christina Gallegos, 38, was affected by excessive liver injury because of persistent consuming and had crawled the few blocks from Scripps Mercy Hospital in Chula Vista, the place she was discharged the night time earlier than.

She had been within the emergency room, her hospital discharge paperwork confirmed — considered one of a number of ER journeys she’d made up to now month. She was given the walker however could not stroll and dragged it right into a doorway for shelter.

“We see this on a regular basis. It is getting actually unhealthy,” Nash mentioned, texting her contacts to discover a mattress for Gallegos. “She’s undoubtedly eligible. It is simply discovering someplace for her to go that’s going to be onerous.”

Gallegos has Medi-Cal however hasn’t been enrolled within the new advantages California is providing. She was amongst an estimated 8,500 homeless folks recognized in San Diego County in 2022, a ten% enhance since 2020.

San Diego County is huge and populous, and whereas homeless encampments permeate suburban enclaves like Chula Vista, homeless persons are largely clustered in San Diego’s downtown neighborhood and its parks.

One standard place to pitch a tent is Balboa Park close to the San Diego Zoo. Its canyons and sprawling inexperienced lawns are peppered with tent communities, whose inhabitants plead for assist from group teams. Many hold on to enterprise playing cards from homeless outreach staff in hopes of scoring a shelter mattress or everlasting housing. Whereas some folks do get housing, many really feel as if outreach efforts quantity to damaged guarantees.

One man, David Lloyd, pulled from his pocket a cellphone quantity for an outreach employee from the homeless companies supplier PATH, who advised him that he was on a ready checklist for housing however that he could possibly be ready within the queue for years.

“It is a large checklist,” mentioned Lloyd, 66. “I simply need to get off the streets. I am uninterested in the cops harassing me on a regular basis.”

Cally Wooden, 35, mentioned she is hooked on fentanyl and has been on the ready checklist for housing for greater than a yr. “It simply feels actually not possible,” she mentioned. “There’s nothing reasonably priced.”

Health insurance coverage executives, together with Martha Santana-Chin, Medi-Cal president for Health Web in California, mentioned Medi-Cal managed-care plans are making progress in serving to get folks off the streets and into companies. But she acknowledged the preliminary rollout falls brief.

“We simply do not have the housing provide that we want,” Santana-Chin mentioned, “to be assured that each one of those people who want help and companies are going to get completely positioned.”

Hampered by sweeps

Throughout the area, sweeps of homeless encampments are frequent and changing into a part of on a regular basis life for folks residing outdoors. Deteriorating and unsanitary circumstances on the streets gas public frustration.

Newsom has ratcheted up the follow of clearing encampments, arguing that individuals coping with homelessness shouldn’t be allowed to dwell open air, regardless of a dearth of options. He is allocating state funding to cities and counties to take away tents from streets and sidewalks and transfer folks into any shelter or housing accessible. San Diego Mayor Todd Gloria, additionally a Democrat, is unapologetic about adopting the strategy.

“We’re doing the cleanups which can be mandatory for public security,” Gloria advised KFF Health Information. “These circumstances are unsanitary, and it places folks’s well being and security in danger, and it results in folks dying. Some folks disagree with me below the guise of caring for these people, however the sidewalk just isn’t a house.”

Outreach staff on the bottom, nonetheless, say the enforcement crackdown solely makes their jobs tougher. One of the crucial targets of the brand new Medi-Cal initiative is to recurrently go to folks on the streets, construct relationships with them, and assist them with well being care wants, all whereas making ready them for housing — if it turns into accessible.

“This actually takes a variety of time. Typically you begin with simply bringing somebody socks or a bottle of water. It may well take 70 encounters for somebody to simply accept our assist,” mentioned Andrea Karrer, an outreach employee with PATH. “However that point is what permits you to construct belief with somebody, and after they should always transfer, you must discover that individual, and generally begin throughout.”

And the disruptions finally trigger folks with out housing to get sicker and go to the ER extra usually, she and different outreach staff mentioned.

“When you must transfer each two or three days, attending to the physician or staying on remedy just isn’t the most important precedence. You are in survival mode,” Karrer mentioned.

A labor-intensive effort

Serene Health is considered one of lots of of suppliers enrolling Medi-Cal sufferers into intensive case administration. Collectively, they’ve signed up 108,000 sufferers statewide thus far, in accordance with California’s Division of Health Care Providers, which administers Medi-Cal. An extra 28,000 are receiving the brand new housing companies comparable to safety deposit funds and assist figuring out reasonably priced housing.

“Numerous the stuff we’re doing is simply actually new to well being care,” mentioned Jacey Cooper, the state’s Medicaid director. She mentioned that well being insurers are providing housing companies in all 58 counties, but she acknowledged that the necessity exceeds capability.

“It takes time for that infrastructure to return to fruition,” Cooper mentioned of the problem of figuring out housing for Medi-Cal sufferers who frequent hospital ERs. “We’re in an enormous training second of even ensuring folks perceive who’s eligible and the best way to refer, and educating the whole supply system, from hospitals to suppliers.”

In the meantime, Newsom is asking the Biden administration for permission so as to add one other housing profit that will cowl as much as six months of direct lease funds.

Veronica Ortiz, a lead care supervisor for Serene Health, has Craig McEwen on her roster of about 60 sufferers — a big caseload that’s troublesome to handle.

However Ortiz bubbles with compassion and power and mentioned working with sufferers like McEwen has given her much more drive to make a distinction. The work is arduous, however McEwen is shortly changing into extra impartial, she mentioned.

“Once we come into their lives, we’re strangers, so now we have to spend so much of time assembly face-to-face with folks and serving to with something they want, in any other case they are not going to belief us.”

However assist did not come quick sufficient for Donna Fontenot, a San Diego County resident who’s being evicted from her house this month. Her landlord advised her she needed to depart following repeated ER journeys, hospitalizations, and expert nursing dwelling stays stemming from an preliminary fall in 2022 that left her in a wheelchair.

“I am petrified and completely panicking, I’ve nowhere to go,” Fontenot mentioned. With one hospitalization alone costing a mean of $18,000 in California, Fontenot, who’s on Medi-Cal, has racked up excessive well being care prices.

She has been hospitalized eight occasions since March 2022, she mentioned. And on 5 events, her accidents to her toes and legs have been so excessive that she wanted placement in a nursing dwelling.

But her Medi-Cal insurer, the San Diego-based Group Health Group, instituted a rule that to qualify for some housing companies, she will need to have a toddler below 18. So she is not receiving housing help that might assist her. She is, nonetheless, enrolled in intensive case administration. However she was not conscious of that till KFF Health Information knowledgeable her.

“I really feel like I gained the lottery,” she mentioned. “Is it going to assist me?”

Her care supervisor hasn’t been as concerned in her life as Ortiz has been with McEwen. Fontenot continues to go looking on her personal for housing, and just lately requested to be switched into Serene Health to get extra hands-on help. “I’ve by no means wanted assist like this earlier than. I really feel so damaged,” she mentioned in tears. “The place am I going to go?”

At present, Ortiz helps McEwen seek for housing. She additionally has centered on serving to him get his coronary heart situation below management and discover extra steady work.

In March, he landed a job as a safety guard patrolling sporting occasions, together with at soccer stadiums. And he scored a hard-to-get surgical procedure appointment for late this month to assist unclog the arteries in his coronary heart.

“Earlier than Veronica, I used to be ready to die. I used to be consuming and consuming to die. However she confirmed up for me. Someone cared about me. And that gave me the braveness to share along with her what my dream could be,” McEwen mentioned. “I believed I wanted soccer to be cherished — then I would be price it.

“However I do know now that my true function is to be of service and to be there for my daughter. I made a decision to get again on the sector, as a substitute of sitting on the sidelines.”

This text was produced by KFF Health Information, which publishes California Healthline, an editorially impartial service of the California Health Care Basis.