The National Health Care for the Homeless Council (the National Council) is a membership organization comprised of health care professionals and agencies that serve homeless people in communities across America.  The National Council works to improve the delivery of care to people experiencing homelessness, and to reduce the necessity for dedicated health care for the homeless programs by addressing the root causes of homelessness.  Our organizational members receive funds through the federal Health Care for the Homeless (HCH) Program.  The HCH program is part of the Consolidated Health Centers account of the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services. 

Our statement covers the following points: 

• explanation of the intersection of health and homelessness;

• review of the success of the federal government's primary policy response to the immediate health services needs of people experiencing homelessness-the HCH program;

• discussion of the challenges facing HCH projects, including increasing demand and decreasing services;

• recommendations for reauthorizing and strengthening the HCH program;

• recommendations for reauthorizing and strengthening the Community Health Center (CHC) program;

• recommendations for reauthorizing and strengthening the National Health Service Corps (NHSC) program; and

• comments on the Community Access Program (CAP). 

Before we begin, the National Council expresses its profound regret that there is still a need for discussion in this day and age about health care access barriers facing poor people and people without insurance.  It is tragic that our nation continues to fail to guarantee access to health insurance as a fundamental right for every American.  Ultimately, Americans' health care access challenges, including those facing people without stable housing, must be redressed through a universal health care system.  We favor a single-payer mechanism. 

Yet even universal health insurance would not preclude the need for HCH projects.  The abdication of public responsibility for affordable housing is a two-decade long tragedy that is the fundamental factor perpetuating homelessness.  Until our nation invests in a housing stock sufficient for and affordable to all of our neighbors, the economic, social, and human costs of homelessness will mount.

Health and Homelessness 

Poor health and lack of access to health care are among the causes of homelessness.  For people struggling to pay for housing and other needs of daily living, the onset of a serious illness or disability can easily result in homelessness following the depletion of financial resources. 

Homelessness is a health hazard.  The experience of homelessness causes poor health, exacerbates existing illness, and seriously complicates treatment.  Conditions such as frostbite, leg ulcers, and respiratory infections are a direct result of living on the street.  Homelessness precludes good nutrition, good personal hygiene, and basic first aid.  People without a regular place to stay are also at great risk of emotional trauma due to familial estrangement, multiple losses, and the chaos of an itinerant lifestyle.  Children and youth are particularly affected by the chaos of homelessness with greater risk of childhood depression, malnutrition, immunization delay, repeated infections, developmental delay, and discontinuity of school/learning experiences.  People without a regular place to stay are also at greater risk of physical and emotional trauma resulting from muggings, beatings, and rape.  Conditions that require regular, uninterrupted treatment, such as tuberculosis, HIV, diabetes, hypertension, addiction, mental illness, and pregnancy are extremely difficult to treat or manage in the absence of a stable residence. 

The consequences of restricted access to comprehensive health care are reflected in extremely high rates of both chronic and acute health problems among people experiencing homelessness.  The Institute of Medicine has determined that those without a regular place to stay are far more likely to suffer from most categories of chronic health problems in comparison to the general population.[1]  Research also demonstrates that the cost of acute care for people experiencing homelessness is significantly higher than for the general population.[2] 

Access to appropriate treatment and care is hindered dramatically by a lack of a national health care system.   National data gathered by the HCH program[3] reveals that 73 percent of HCH patients have no source of health insurance.   Inaccessible public transportation, inflexible clinic hours, fees and payments, and residency and documentation requirements may also present barriers to health care.

Health Care for the Homeless Program 

Origins and Current Status 

The first federal response to the crisis of homelessness was the passage of the Stewart B. McKinney Homeless Assistance Act of 1987.  Recognizing that homelessness restricts access to mainstream health care services, Congress established through the McKinney Act a health services program specifically designed to circumvent these barriers-Health Care for the Homeless (HCH).  The federal program extended the success of an earlier Robert Wood Johnson/Pew Charitable Trusts program, which demonstrated that health care services specifically targeted to people experiencing homelessness could dramatically improve access to care for this vulnerable population. 

Congress last reauthorized the HCH program in 1996 via the Health Centers Consolidation Act.  That law consolidated community health centers, migrant health centers, public housing primary care centers, and HCH projects under a single, five-year authorization, but retained each of the four programs as a distinct activity.  Authorization of the consolidated health centers account expires in September 2001. 

Program Summary 

The HCH program (Section 330(h) of the Public Health Service Act [PHSA]) makes grants to community-based organizations (referred to as "projects" or "grantees") in order to assist them in planning and delivering high-quality, accessible health care to people experiencing homelessness.  HCH projects assure access to primary care and related services through integrated systems of care.  Projects provide primary health, mental health, addiction, and social services with intensive outreach and case management to link clients with appropriate services. 

Formal evaluations of the HCH program, including a 1995 evaluation conducted for the Department of Health and Human Services, indicate that the projects are meeting the health care and support service needs of people experiencing homelessness-at levels that are unprecedented in the mainstream indigent health care and public health insurance systems. 

Eligible Population 

Projects are required to use their HCH funds to serve people experiencing homelessness, who are defined in the PHSA as "an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and an individual who is a resident in transitional housing." 

In 1999, HCH projects served nearly 500,000 patients.  59 percent of patients were male; 41 percent female.  60 percent were people of color.  15 percent were children and youth under age 19. 

Eligible Projects 

HCH projects are initiated, designed, and managed at the community level.  Any local public or private, nonprofit entity is eligible to apply for HCH funds, including freestanding nonprofit community-based and faith-based organizations, community health centers, hospitals, local health departments, shelters, and homeless coalitions. 

The HCH program currently funds 137 grantees in all states, the District of Columbia, and Puerto Rico.  50 percent of projects are sponsored by community health centers.  Public health departments sponsor 19 percent.  25 percent are sponsored by private, nonprofit organizations, and the remaining six percent are sponsored by hospitals. 

Required Services 

HCH projects, like other health centers, are required to provide the following health and enabling services:

• basic health services related to family medicine, internal medicine, pediatrics, obstetrics, and gynecology;

• diagnostic laboratory and radiologic services;

• preventive health services, including prenatal and perinatal screening; screening for breast and cervical cancer; well child services; immunizations against vaccine-preventable diseases; screenings for elevated blood lead levels, communicable diseases, and cholesterol; pediatric eye, ear, and dental screenings to determine the need for vision and hearing correction and dental care; voluntary family planning services; and preventive dental services;

• emergency medical services;

• pharmaceutical services;

• referrals to providers of medical services and other health-related services;

• patient case management services (including counseling, referral and follow-up) and other services designed to assist health center patients in establishing eligibility for and gaining access to Federal, State, and local programs that provide or financially support the provision of medical, social, educational, or other related services;

• services that enable individuals to use the services of the health center (including outreach, transportation, and translation);

• education of patients and the general population served by the health center regarding the availability and proper use of health services; and,

• addiction services.[4] 

In addition, most HCH projects surpass this scope of services.  For example, many HCH projects offer mental health services to their patients.  Others have secured resources from other federal programs, state and local government, and the nonprofit and private sectors to develop housing for their patients. 

Service Delivery Locations 

HCH service delivery sites vary by project, but include fixed-site health clinics, services provided at homeless shelters and soup kitchens, mobile medical units, and street outreach teams.  Services are provided either directly, by contract with other organizations, or by referral to another organization. 

Award Process 

HCH funds, like funds for other health center programs, are distributed via a competitive award process.  Applications for HCH funds are reviewed by an independent expert panel consisting of HRSA staff and outside experts.  The applicant must:

• describe the target population;

• demonstrate the target population's health services need;

• outline a plan to provide the health services required by the Consolidated Health Centers law; and,

• agree to a number of requirements that are a condition for receiving funds. 

Those conditions include:

• establishing a governance body that includes significant participation from consumers of the health services offered by the project, including people who are experiencing or who have experienced homelessness;

• making the statutorily-required primary health services available and accessible promptly, as appropriate, and in a manner which assures continuity;

• establishing and maintaining relationships with other health care providers;

• developing an ongoing relationship with at least one hospital;

• having an arrangement with the State Medicaid agency to be reimbursed for health services provided to Medicaid beneficiaries;

• making every reasonable effort to collect appropriate reimbursement for health services provided to people entitled to public or private health insurance;

• establishing a schedule of fees or payments for the provision of services and a schedule of discounts based on a participant's ability to pay;

• having an ongoing quality improvement system; and

• developing a plan, budget, and data collection system. 

Appropriations 

In FY 2001, Congress appropriated $1.169 billion for the consolidated health center account, which amounted to $100 million for the HCH program.[5] 

Challenges Facing HCH Projects 

The fundamental challenge facing HCH projects-as well as all health centers and other health care safety net providers-is one of insufficient resources to sustain and expand services to people with limited or no means to pay for health care. 

The failure to appropriately invest in the nation's health care safety net prevents HCH projects from fully responding to the following dynamics among and needs of people without stable housing. 

Increasing Homelessness-As an increasing number of people have incomes that fall below federal poverty guidelines and find themselves living with friends, relatives, in shelters and the streets, more people are seeking services from HCH projects.  Among the new patients of HCH services are families with children exiting the welfare system, people with disabling addictions who have been denied access to Medicaid and Supplemental Security Income, "working poor" individuals whose earnings are insufficient to afford housing or health insurance, emancipated and unaccompanied youth, and veterans unable to obtain Department of Veterans Affairs health services.  HCH projects do not receive sufficient funds to adequately serve their current caseloads, much less address the increased demand for services from these emerging homeless subpopulations. 

Financial Distress of HCH Projects-Many HCH projects report decreasing revenues, especially from Medicaid.  The enrollment of Medicaid beneficiaries in managed care organizations has resulted in a dramatic decrease not in the number of Medicaid beneficiaries served by HCH providers, but in the reimbursements received from Medicaid.  Consequently, HCH projects have been forced to use federal grant and other funds now designated for services to uninsured patients to balance the cost of care for Medicaid patients, thereby reducing or eliminating services for patients who lack health insurance.  HCH projects do not receive sufficient funds to adequately serve both their Medicaid and uninsured patients. 

Untreated Addiction and Mental Illness-HCH projects are required by statute to provide access to addiction services.  Many also provide mental health services.  Regrettably, inadequate funding levels have prevented many projects from providing such services at more than an elemental level, even though projects report that that addictions and mental illnesses are among the most prevalent diagnoses of their patients.  Mainstream addiction and mental health services programs are also underfunded and oversubscribed, and are also not designed appropriately for people in homeless situations, further restraining willing homeless patients from accessing treatment for these chronic conditions.  HCH projects do not receive sufficient funds to adequately meet their patients' comprehensive health services needs. 

Lack of Supervised Medical Care for People in Recuperation-In the absence of a safe place in which to recuperate from illness, medical interventions often prove ineffective for people experiencing homelessness.  The unavailability of appropriate accommodations for those requiring supervised medical care, but not ill enough to remain hospitalized, makes it difficult for individuals to recover from illness and resolve their homelessness.  Several HCH projects have pioneered responses to this service gap in the form of medically-supervised "recuperative care."  HCH projects do not receive sufficient funds to develop or expand recuperative care arrangements for patients in desperate need of such services.  In most communities, there is no other source of funding to pay for recuperative care services to people experiencing homelessness.

Reauthorize and Strengthen Health Care for the Homeless Program 

The HCH program, the statutory authority of which expires September 30, 2001, is still needed to ensure access to health services for people experiencing homelessness.  We urge Congress and the Administration to reauthorize HCH for a five-year period as a distinct program within the Consolidated Health Centers account. 

In addition, we urge Congress and the Administration to amend the HCH statute as follows: 

• Establish an authorization level of at least $172 million in FY 2002 as part of a $2 billion FY 2002 authorization level for the Consolidated Health Centers account.

• Maintain current distribution of Consolidated Health Centers appropriations among component programs within the account.

• Restore ability of HCH grantees to temporarily continue to provide services to their formerly homeless patients.

• Expand range of addiction services that HCH grantees may provide to include harm reduction, outpatient treatment, complementary modalities, and rehabilitation, in addition to detoxification and residential treatment.

• Explicitly identify homeless youth as an eligible target subpopulation for innovative homeless children outreach and comprehensive primary health services grants.

Reauthorize and Strengthen Community Health Center Program 

Mainstream indigent health care programs have historically underserved the homeless population.  Congress recognized this reality and established the HCH program.  Due to funding limitations, however, the HCH program is able to serve only about 1/7 of the population estimated to experience homelessness each year.  Consequently, a majority of people experiencing homelessness relies on mainstream indigent health care providers, including community health centers, for their health care. 

Just as they do in other mainstream indigent health care systems, people experiencing homelessness face multiple challenges in accessing and utilizing community health centers.  For example, the General Accounting Office, in a 2000 report (Homelessness:  Barriers to Using Mainstream Programs, GAO/RCED-00-184), found that community health centers:  1) may not be organized to make some of the special accommodations homeless people may require, such as walk-in appointments; 2) may not thoroughly address other needs that are inextricably linked to a patient's health care needs, such as housing, food, clothing, and other services; 3) do not tend to outstation health services at locations and settings where homeless people congregate.  Denials of or delays in service based on inability to pay have also been reported. 

To redress the barriers that people experiencing homelessness are facing in accessing and using community health center services, we urge Congress and the Administration to amend the health centers statute as follows: 

• Require community health centers to develop outreach and services plans for the homeless population to ensure that community health centers factor the complex medical and social needs of people experiencing homelessness into their service system design and implementation in anticipation of the inevitability that people without housing will be seeking care from them.

• Ensure access to health center services regardless of ability to pay by codifying in statute the long-standing principle that health center services are to be available to patients regardless of their ability to pay and by restoring provisions of prior law that assured that extremely poor people would not have fees or payments imposed on them.

• Ensure that health centers provide assistance in obtaining housing in parity with current law requirements that they assist their patients in obtaining other public benefits (e.g., Medicaid, Food Stamps).

• Add addiction and mental health services as optional additional services to encourage all health centers to expand their scope of services to include treatment for these chronic conditions to the extent practicable.

• Add recuperative care as an optional additional service to encourage all health centers to expand their scope of services to include this service to the extent practicable. 

Reauthorize and Strengthen National Health Service Corps Program 

The National Health Service Corps (NHSC) program, the statutory authority of which has expired, is still needed to ensure that Health Care for the Homeless projects and other safety net providers are able to recruit and retain the health services professionals necessary to operate their programs.  We urge Congress and the Administration to reauthorize the NHSC for a five-year period. 

In addition, we urge Congress and the Administration to amend the NHSC statute as follows: 

• Establish an authorization level of at least $232 million in FY 2002 for NHSC.

• Automatically designate all federally-qualified health centers, including Health Care for the Homeless projects, as Health Professional Shortage Area facilities for placement of Corps personnel.

• Ensure access to health services provided by NHSC professionals regardless of the patient's ability to pay by codifying in statute that services provided by entities with NHSC placements and NHSC private practice option placements are to be available to patients regardless of their ability to pay and by waiving or reducing charges for people who are unable to pay.

Recommendations on Community Access Program 

Health Care for the Homeless projects share the common belief among health care safety net providers and public officials that patients derive improved health and other benefits and that the health care safety net system operates more efficiently when collaboration occurs among disparate providers serving the same people.  As the principal health care safety net providers to people with the most complex and interrelated medical and social conditions possible, HCH projects have had to foster collaboration among health, housing, and support service providers in their communities.  For HCH projects, collaboration and linkages are intuitive processes. 

The National Council has neither supports nor opposes authorization of the Community Access Program or equivalent initiatives.  Our members' views on this topic differ.  Some HCH projects believe that new federal safety net health care resources should be directed to the support of services rather than to interactive functions.  Other HCH projects have reported positive collaborative experiences that are occurring in their communities as a result of CAP projects.  

Should Congress choose to authorize CAP or an equivalent health care safety net collaboration program, we recommend that the following principles guide the program's development.

 

• The program should facilitate improved and expanded access to a full range of health and support services for all people without health insurance, with a focus on those hardest to ensure or hardest to serve.

• Funds should be directed to health and support service access improvement and expansion rather than to the establishment of planning and collaboration infrastructure.

• Applicants should be permitted to propose population-focused projects (e.g., improving access to targeted, disproportionately affected and historically underserved groups, such as homeless, migrant, or youth) as well as geography-based projects (e.g., improving access to all people in a given service area).

• Funds should be permitted for both individual level and system level service interventions.  Examples of individual level interventions include outreach and engagement, public health insurance assistance and advocacy, patient case management, and direct payment for services.  Examples of system level interventions include system integration, care coordination, and patient record exchange.

• Grantees should be the community-based primary health provider or network of providers that is most closely connected to the intended beneficiaries.  Primary health providers are the most appropriate, and most common, gateways to other health and support services.  They are also key players in treating patients and addressing their basic health needs before they present at emergency and specialty care providers.

• As a condition for receiving funds, grantees should be expected to demonstrate collaboration with other health care safety net providers in the community, such as community, migrant, homeless, and public housing health centers, public and charitable hospitals, local public health departments with service delivery components, free clinics, academic health centers providing uncompensated care, addiction service providers, mental health service providers, HIV/AIDS service providers, and family planning clinics.

• The scope of health systems, programs, and providers that should be involved in community collaboration include primary, addiction, mental, HIV/AIDS, maternal and child, oral, vision, emergency, and other secondary and tertiary health services.

• Community collaborations resulting from the initiative should include support systems, programs, and providers (such as housing providers) that are essential to the effective delivery of health services to intended beneficiaries.

• Representatives of intended beneficiaries should be involved at the community level in need identification, project design, and implementation monitoring.