Intern Paper: How Medicaid Coverage Leaves the Unsheltered Uncovered & Unhealthy
Student Intern Allie Rutland (Furman University, ’22) spent this past summer researching the impact of the lack of Medicaid expansion on the lives of people experiencing homelessness concurrently diagnosed with Diabetes Mellitus Type II. Read her White Paper here!
How Medicaid Coverage Leaves the Unsheltered Uncovered & Unhealthy
Executive Summary
Throughout the United States, twelve states have not expanded their Medicaid healthcare coverage leaving medically vulnerable populations without access to healthcare. This research specifically analyzes the gap in the continuum of care for the medically vulnerable homeless populations in non-Medicaid expansion states. Utilizing a case study of Type II Diabetes Mellitus as it intersects with people living on the streets, this research comes to the conclusion that medical respites an advantageous fiscal and medical response to filling in the “coverage gap” for the post-hospitalized homeless population.
Introduction
As of July 2021, twelve states have “neither expanded nor passed ballot initiatives” to expand Medicaid as recommended by the ACA and the American Rescue Plan.[1] According to researchers at the Commonwealth Fund, this means that approximately 14.6 million Americans, of whom 5.8 million are below 100 percent of the Federal Poverty Line, are projected to be uninsured by 2022[2]. Without Medicaid Expansion, low-income, single, and middle-aged adults are excluded from health insurance coverage[3]. One of the nation’s most medically vulnerable populations fits squarely within this coverage gap: the homeless population. In 2019, there were reportedly 567,715 people in total experiencing homelessness in the United States[4]. Of those experiencing homelessness, seventy percent were individuals living on their own and sixty percent were male.[5]
The demographic trends in homelessness in the United States mirror the nation’s disparity in health insurance rates. In a study conducted by the Journal of Prevention and Intervention in the Community in 2009 in Boston, Massachusetts specifically researching homelessness and healthcare, the researchers found that of 743 homeless individuals, the mean age of homeless individuals who came in contact with the Boston Medical Center was 46.9 years of age. This finding is consistent with data conducted by the Kaiser Family Foundation and the National Health Care for the Homeless Council in 2016 which found that homeless patients who attend Health Care for the Homeless projects (HCH) are more likely to be non-elderly adult males, to have income below the Federal Poverty Line, and are more likely to be uninsured.[6] Health insurance is vital for homeless populations as living on the streets has been statistically proven to exacerbate pre-existing health conditions and create conditions for new health conditions to flourish.
According to the National Health Care for the Homeless Council, experiencing homelessness has deathly consequences as people experiencing homelessness have an average life expectancy as low as 42 years.[7] Of those who die on the streets, approximately thirty three percent die from treatable conditions.[8] Those in need of medical treatment while unhoused are at elevated risk of exacerbation of pre-existing chronic health conditions such as high blood pressure, diabetes, and asthma due to a lack of safe, secure, and temperature-controlled spaces needed to properly store medications.[9] As the majority of those living on the streets in states that have not expanded Medicaid are not covered by health insurance, “evidence indicates homeless individuals visit the emergency department and are hospitalized up to 10 times more often than low-income people with permanent housing.”[10] When homeless people visit the hospital, their stays are significantly longer than their housed counterparts as those experiencing homelessness are discharged directly to the streets. The average hospital stay for most patients is 4.6 days, but those facing homelessness average a stay nearly twice as long.[11] These stays cost on average $2,500 more than hospital stays by patients with permanent housing.[12] Another study found that patients who are living on the streets cost approximately $4,094 more per hospital stay than other low-income patients.[13] Given the multitude of data corroborating the medical vulnerability of homeless populations, this study aims to research the quality of healthcare and treatment of medically vulnerable unhoused population specifically living in non-Medicaid Expansion states through a case study of diabetes mellitus as it intersects with the homeless population.
Research Overview: Case Study
Nationally, the estimated prevalence of diabetes mellitus among US adults is 13.0%.[14] In practical terms this means that approximately 34.2 million Americans suffer from diabetes each year.[15] Among those suffering from diabetes, in 2016 alone 7.8 million hospital discharges were attributed to diabetes as a chief cause of hospitalization.[16] According to a study conducted American Journal of Public Health that studied a sample of people experiencing homelessness in the United States from 1980 to 2014, “rates of diabetes… in the homeless population range from 2% to 18%.”[17] It is worth noting that the American Journal of Public Health’s sample included an overrepresentation of men and African Americans; however, this ratio accurately mirrors the United States’ general homeless population as homelessness disproportionately affects males and Black Americans.[18] Due to the high-cholesterol, high-fat, and high-carbohydrate diet perpetuated by food deserts and chronic poverty, people living on the streets report proportionately higher rates of diabetes. According to the American Journal of Public Health, “evidence exists that foods recommended as part of a healthy diabetic diet are in short supply in low-income, non-White neighborhoods.”[19] Therefore, the living conditions on the streets are uniquely suited to inflame pre-existing conditions for those already experiencing diabetes and trigger the development of new diagnoses for those who previously were not experiencing diabetes.
Homeless people with access to shelters are less likely than their permanently housed counterparts to adhere to structured meal times or have access to healthy foods needed to regulate glucose levels.[20] Dependency on soup kitchens or shelters for nourishment also makes it difficult for diabetics to coincide meal times with insulin administration.”[21]Additionally, studies report that those experiencing homelessness are less likely to monitor their blood glucose levels or have access to healthcare necessary for diabetic treatment.[22] However, the most common challenge for a diabetic person living on the streets to overcome is that of access to treatment- primarily that of insulin. Researchers for the International Journal of Public Health concur claiming, “The most common challenges that are experienced by the homeless population includes the lack of access they have to medication such as insulin due to not having health insurance and the lack of support in gaining prescriptions.”[23] Once unhoused, diabetic patients have access to appropriate storage for insulin. Insulin requires refrigeration which is often impossible to achieve while unhoused.[24] Insulin must be stored in a refrigerator at all times with a maintained internal temperature of approximately 36 degrees Fahrenheit to 46 degrees Fahrenheit.[25] The medication must never freeze, making a more easily accessible cooler an inadequate form of refrigeration. As patients who are living on the streets have little to no access to a refrigerator, people living on the streets are dependent on a shelter or clinic to store and dispense their insulin medications.[26]
Not only do unhoused diabetics struggle with access to insulin and insulin storage, patients must obtain insulin needles and syringes which must be kept clean, never reused, and never shared.[27] Researchers Hwang and Bugeja, “found that one of the major difficulties reported by homeless people were difficulties in prioritizing their diabetes conditions over other problems they may be experiencing, accessing and securing insulin needles and syringes, obtaining medications and exercising.”[28] Another factor to consider in a comprehensive review of the health of people experiencing homelessness is the fact that many are experiencing comorbidities that require medications which may have a negative effect on an individual’s metabolism.[29] The improper treatment of diabetes puts patients at higher risk for more serious, life-threatening infections and diseases.
Skin and soft tissue infections, specifically those involving the feet,are common within a general diabetic population. These infections are more frequent and more severe among those without housing.[30] Homeless populations live transient lifestyles that involve walking as their primary form of transportation. “Foot problems often result from prolonged standing and walking. When combined with diabetes, the patient is at high-risk for foot ulcers” that lead to the development of diabetic foot infections.[31] Additionally, poor oral hygiene is also prevalent among those without permanent housing. Similar to the development of foot ulcers, lack of dental hygiene increases the likelihood of dental abscesses and periodontal diseases that together weaken the body’s glycemic control.[32] Alongside infections, lack of proper treatment, including lack of access to insulin, places homeless patients at high risk for hyperglycemic crisis.[33] 8.6% of annual hospital admissions per 1,000 people are attributed to Diabetes Mellitus.[34] Of those hospitalized at large, 21.1% of patients suffer from Type I or Type II Diabetes Mellitus.[35] Therefore, statistically, 21.1% of patients discharged from the hospital system nation-wide, including those experiencing homelessness, suffer from a form of diabetes. Bearing these data in mind, a specialized healthcare model specifically tailored to provide comprehensive and individualized medical attention to those experiencing homelessness post-hospitalization would provide healthcare for a significant intersection of the homeless and diabetic populations. This specialized healthcare model is known as a medical respite or recuperative care model.
Recommendation: Medical respite
A medical respite refers to a short-term care facility that provides medical care, safe housing, and supportive services for those who live on the streets and have been discharged from the hospital system and are too ill to safely recuperate on the streets. The term “medical respite” is synonymous with “recuperative care,” a term defined by the Health Resources and Services Administration (HRSA) as “short-term care and case management provided to individuals recovering from an acute illness or injury that generally does not necessitate hospitalization, but would be exacerbated by their living conditions (e.g., street, shelter, or other unsuitable places).”[36] Nationally, respite services vary from number of total beds to length of stay, but all respites include a bed, meals, and transportation to medical appointments. Many programs include access to multiple organizations within their local Continuum of Care. Throughout the United States, there are a total of 120 medical respites with a median number of 17 beds and a median length of stay as 28 days.[37] According to the National Coalition for Health Care for the Homeless Council, “medical respite programs fill a gap in the continuum of care for people who are experiencing homelessness.”[38] The Journal of Prevention and Intervention in the Community concurs claiming, “neither shelters, which often require vacating the premises during daylight hours, nor the streets support adherence to post-hospital medical recommendations.”[39] Medical respites are uniquely positioned to provide for the needs of people experiencing homelessness that have previously been neglected. Such needs include those presented by Type II Diabetes as it pertains to those who have been hospitalized.
A medical respite provides clinical support, safety, and medical access that currently is not funded in non-expansion states’ health care systems. For those experiencing diabetes, medical respites are especially vital as a resource in the continuum of care. Medical respites include staff and medical personnel who ensure transportation for all residents to doctor’s appointments. Through consistent medical attention, patients are provided access to medication, opportunities for diabetic diagnoses, education, and prolonged care that is not accessible when living on the streets. Moreover, residents in medical respites, unlike those in shelters, are provided 24-hour access to their residence.[40] This provides patients with 24-hour access to refrigeration which is crucial for insulin’s survival. With a full staff of partners, insulin needles and syringes are kept sanitary, bandages kept clean, pre-existing infections are treated, and high-quality hygiene discourages future infections from developing. As all medical respites offer meals, diabetic patients can be provided healthy meals that intentionally regulate glucose levels. Additionally, consistent meal schedules ensure routine insulin consumption. Outside of physical treatment, the opportunity for physical and psychological safety provides opportunities for rehabilitation and healing that is not possible while experiencing the psychological trauma of living on the streets. According to The Open Health Services and Policy Journal, “research has shown that individuals who are homeless are likely to have experienced some form of previous trauma; homelessness itself can be viewed as a traumatic experience; and being homeless increases the risk of further victimization and retraumatization.”[41] Therefore, medical respites that practice trauma-informed care provide not only medical care to patients but also psychological respite to create a space for multifaceted healing.
Not only are medical respites medically advantageous, but medical respites also provide economic incentives to participating hospitals. A study conducted in Boston between 1998 and 2001 found that “discharge to a medical respite program was associated with a 50% reduction in the odds of readmission at ninety days post-discharge compared to discharge to the streets and shelters.”[42] This generated hospital readmission savings of approximately $1,935 per case.[43] In said case study, the mean charges for a respite stay were $7,929 with a mean length of stay 31.3 days.[44] While $7,929 is not a small amount of money, medical respites qualify for federal funding-- even for states that have not expanded Medicaid. In 2003, recuperative care was added to the Health Center statute as an additional service that Federally Qualified Health Centers could include within their scope of project, enabling them to use their federal funding to provide their medical respite service.[45] Additionally, medical respite programs also qualify for support from the U.S. Department of Housing and Urban Development (HUD) and Health Resources and Services Administration in order to cover the cost of both the beds and provision of care.[46]
Therefore, the twelve states that currently lack comprehensive healthcare for their medically vulnerable homeless populations may fill their medical coverage gap for post-hospital care through medical respite programs. Some states have already pursued this option as outlined in Figure 1. Twenty-four medical respites throughout the nation are currently operating in non-Medicaid expansion states. In summary, 21% of medical respites throughout the country provide healthcare to homeless populations that are neglected by their states’ healthcare systems. Therefore, medical respites not only fill gaps in the continuum of care but also fill gaps in their state’s healthcare coverage by caring for the specific needs of homeless individuals who are discharged from their states’ hospital systems.
Works Cited
Adapting Your Practice: Treatment and Recommendations for Patients Who Are Homeless With Diabetes Mellitus. (2013, June). Retrieved July 26, 2021, from https://nhchc.org/wp-content/uploads/2019/08/2013DiabetesGuidelines_FINAL_20130612.pdf
Benavent, E., Murillo, O., Grau, I., Laporte-Amargos, J., Gomez-Junyent, J., Soldevila, L., . . . Pallares, R. (2019, July 01). The Impact of Gram-Negative Bacilli in Bacteremic Skin and Soft Tissue Infections Among Patients With Diabetes. Retrieved July 26, 2021, from https://care.diabetesjournals.org/content/42/7/e110
Bernstein, R. S., Meurer, L. N., Plumb, E. J., & Jackson, J. L. (2015). Diabetes and Hypertension Prevalence In Homeless Adults In the United States: A Systematic Review and Meta-Analysis. American Journal of Public Health, 105(2), e46–e60. https://doi.org/10.2105/AJPH.2014.302330
Constance, J., & Lusher, J. M. (2020). Diabetes Management Interventions for Homeless Adults: A Systematic Review. International Journal of Public Health, 65(9), 1773–1783. https://doi.org/10.1007/s00038-020-01513-0
Graber, A. L., Davidson, F. A., Brown, M. S., Gaume, J. A., McRae, M. D., & Wolff, K. (1995). Hospitalization of Patients with Diabetes. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 1(6), 399–403. https://doi.org/10.4158/EP.1.6.399
Health Care and Homelessness. (2009, July). Retrieved July 29, 2021, from https://www.nationalhomeless.org/factsheets/health.html
Holahan, J., Buettgens, M., Banthin, J. S., & Simpson, M. (2021). Filling the Gap in States That Have Not Expanded Medicaid Eligibility. Commonwealth Fund. Retrieved July 22, 2021, from https://www.commonwealthfund.org/publications/issue-briefs/2021/jun/filling-gap-states-not-expanded-medicaid
Homelessness & Health: What's the Connection? (2019, February). Retrieved July 26, 2021, from https://nhchc.org/wp-content/uploads/2019/08/homelessness-and-health.pdf
Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings [Abstract]. The Open Health Services and Policy Journal, 3(2), 80-100. doi:10.2174/1874924001003020080
Horowitz, C. R., Colson, K. A., Hebert, P. L., & Lancaster, K. (2004). Barriers to Buying Healthy Foods for People with Diabetes: Evidence of Environmental Disparities. American Journal of Public Health, 94(9), 1549–1554. https://doi.org/10.2105/ajph.94.9.1549
Kertesz, S. G., Posner, M. A., O'Connell, J. J., Swain, S., Mullins, A. N., Shwartz, M., & Ash, A. S. (2009). Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons. Journal of Prevention & Intervention In The Community, 37(2), 129–142. https://doi.org/10.1080/10852350902735734
Krug, M. (2015). The Nightingale Medical Respite Program. Policy & Practice, 73(4), 30-31. Retrieved from https://www-proquest-com.libproxy.furman.edu/trade-journals/nightingale-medical-respite-program/docview/1746606931/se-2?accountid=11012
Matt Warfield, B. (2016, March 29). How Has the ACA Medicaid Expansion Affected Providers Serving the Homeless Population: Analysis of Coverage, Revenues, and Costs – Issue Brief. Retrieved July 21, 2021, from https://www.kff.org/report-section/how-has-the-aca-medicaid-expansion-affected-providers-serving-the-homeless-population-issue-brief/
McClenaghan, M. (2019, March 11). Homelessness Kills: Study Finds Third of Homeless People Die From Treatable Conditions. Retrieved July 29, 2021, from https://www.thebureauinvestigates.com/stories/2019-03-11/homelessness-kills
McMahon, A., & Cha, S. (2021, January 24). Improving Health Outcomes Through Medical Respite Programs. Retrieved July 23, 2021, from https://www.uhccommunityandstate.com/blog-post/dual-author/improving-health-outcomes-through-medical-respite-programs.html
Medicaid and Medicaid Managed Care: Financing Approaches for Medical Respite Care. (2020, April 08). Retrieved July 21, 2021, from https://www.uhccommunityandstate.com/articles/financing-approaches-for-medical-respite-care.html
Medicaid Reimbursement for Medical Respite Services Policy Analysis. (2011, September). Retrieved July 21, 2021, from https://nhchc.org/wp-content/uploads/2019/08/Sept2011.pdf
Medical Respite Care: Financing Approaches. (2017, June). Retrieved July 21, 2021, from https://nhchc.org/wp-content/uploads/2019/08/policy-brief-respite-financing.pdf
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Post, P. A. (2001). Casualties of Complexity: Why Eligible Homeless People Are Not Enrolled in Medicaid (pp. 1-Xxviii, Publication). Nashville, TN: National Health Care for the Homeless Council.
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[1] Filling the Gap in States That Have Not Expanded Medicaid Eligibility, 1
[2] Filling the Gap in States That Have Not Expanded Medicaid Eligibility, 1
[3] How Has the ACA Medicaid Expansion Affected Providers Serving the Homeless Population: Analysis of Coverage, Revenues, and Costs, 1
[4] State of Homelessness: 2020 Edition, 2
[5] State of Homelessness: 2020 Edition, 3
[6] How Has the ACA Medicaid Expansion Affected Providers Serving the Homeless Population, 4
[7] Health Care and Homelessness, 1
[8] Homelessness Kills: Study Finds Third of Homeless People Die from Treatable Conditions, 1
[9]Homelessness & Health: What’s the Connection? 1
[10] The Nightingale Medical Respite Program, 1
[11] Medicaid Reimbursement for Medical Respite Services Policy Analysis, 1
[12] The Nightingale Medical Respite Program, 1
[13] Medical Respite Care: Financing Approaches June 2017, 2
[14] National Diabetes Statistics Report, 2020, 2
[15] National Diabetes Statistics Report, 2020, 3
[16] National Diabetes Statistics Report, 2020, 1
[17] Diabetes and Hypertension, 1
[18] Diabetes and Hypertension, 10
[19] Barriers to Buying Healthy Foods, 1
[20] Diabetes Management Interventions for Homeless Adults, 9
[21] Adapting Your Practice, 10
[22] Diabetes Management Interventions for Homeless Adults, 9
[23] Diabetes Management Interventions for Homeless Adults, 7
[24] Adapting Your Practice, 5
[25] Safe Storage of Insulin, 1
[26] Adapting Your Practice, 13
[27] Diabetes Management Interventions for Homeless Adults, 2
[28] Diabetes Management Interventions for Homeless Adults, 2
[29] Adapting Your Practice, 5
[30] The Impact of Gram-Negative Bacilli, 1
[31] Adapting Your Practice, 11
[32] Adapting Your Practice, 16
[33] Adapting Your Practice, 16
[34] Hospitalizations, Nursing Home Admissions, and Deaths Attributable to Diabetes, 1
[35] Hospitalization of Patients with Diabetes, 1
[36] Medical Respite Care: Financing Approaches June 2017, 1
[37] State of Medical Respite/Recuperative Care Programs, 2
[38] Medicaid Reimbursement for Medical Respite Services Policy Analysis, 2
[39] Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons, 1
[40] Post-Hospital Medical Respite Care and Hospital Readmission of Homeless Persons, 1
[41] Shelter from the Storm, 1
[42] Medicaid Reimbursement for Medical Respite Services Policy Analysis, 4
[43] Post-Hospital Medical Respite, 7
[44] Post-Hospital Medical Respite 6
[45] Medicaid Reimbursement for Medical Respite Services Policy Analysis, 6
[46] Medicaid Reimbursement for Medical Respite Services Policy Analysis, 5
[47] Status of State Medicaid Expansion Decisions: Interactive Map
[48] Status of State Medicaid Expansion Decisions: Interactive Map
[49] Medical Respite/Recuperative Care Directory