Yves here. It is sad but telling that the editors of this KFF Health News story find the need to justify health care for the homeless by touting that it is financially self-supporting, as opposed to, say, saving overall medical cost by reducing costly (and designed to be scarce) ER use by the homeless, or improving public health, say by reducing disease outbreaks (tuberculosis, anyone?) or just being the right thing to do. But in our neoliberal system, mercenary considerations dominate all others.<\/p>\n
This example is dated, but consider Malcolm Gladwell\u2019s Million Dollar Murray:<\/p>\n
Murray Barr was a bear of a man, an ex-marine, six feet tall and heavyset, and when he fell down\u2014 which he did nearly every day\u2014it could take two or three grown men to pick him up. He had straight black hair and olive skin. On the street, they called him Smokey. He was missing most of his teeth. He had a wonderful smile. People loved Murray\u2026.<\/p>\n
His chosen drink was vodka\u2026.if he was broke he could always do what many of the other homeless people of Reno did, which is to walk through the casinos and finish off the half-empty glasses of liquor left at the gaming tables\u2026.<\/p>\n
A few years ago, he was assigned to a treatment program in which he was under the equivalent of house arrest, and he thrived. He got a job and worked hard. But then the program ended. \u201cOnce he graduated out, he had no one to report to, and he needed that,\u201d [bicycle cop Patrick] O\u2019Bryan said. \u201cI don\u2019t know whether it was his military background. I suspect that it was. He was a good cook. One time, he accumulated savings of over six thousand dollars. Showed up for work religiously. Did everything he was supposed to do. They said, \u2018Congratulations,\u2019 and put him back on the street. He spent that six thousand in a week or so.\u201d<\/p>\n
Often, he was too intoxicated for the drunk tank at the jail, and he\u2019d get sent to the emergency room\u2026<\/p>\n
O\u2019Bryan and Johns called someone they knew at an ambulance service and then contacted the local hospitals. \u201cWe came up with three names that were some of our chronic inebriates in the downtown area, that got arrested the most often,\u201d O\u2019Bryan said. \u2026<\/p>\n
The first of those people was Murray Barr, and Johns and O\u2019Bryan realized that if you totted up all his hospital bills for the ten years that he had been on the streets\u2014as well as substance- abuse-treatment costs, doctors\u2019 fees, and other expenses\u2014Murray Barr probably ran up a medical bill as large as anyone in the state of Nevada.<\/p>\n
\u201cIt cost us one million dollars not to do something about Murray,\u201d O\u2019Bryan said.<\/p>\n
That was from 2006, in comparatively low-cost Nevada. Since then, substance abuse has exploded, first prescription opioids and now fentanyl. Think this cost dynamic of homelessness has gotten any better? And recall, as our former prosecutor, David in Friday Harbor points out, many of the homeless become abusers as a result of living on the street, as opposed to vice versa.<\/p>\n
That is before getting to the horrible difficulty that even the more functional homeless (remember, a stunning 40% of the unsheltered homeless are employed) have in getting medical care.<\/p>\n
By Angela Hart, KFF Health News senior correspondent, who previously worked for Politico and The Sacramento Bee. Produced by KFF Health News<\/p>\n
They distribute GPS devices so they can track their homeless patients. They stock their street kits with glass pipes used to smoke meth, crack, or fentanyl. They keep company credit cards on hand in case a patient needs emergency food or water, or an Uber ride to the doctor.<\/p>\n
These doctors, nurses, and social workers are fanning out on the streets of Los Angeles to provide health care and social services to homeless people \u2014 foot soldiers of a new business model taking root in communities around California.<\/p>\n
Their strategy: Build trust with homeless people to deliver medicine wherever they are \u2014 and make money doing it.<\/p>\n
\u201cThe biggest population of homeless people in this country is here in Southern California,\u201d said Sachin Jain, a former Obama administration health official who is CEO of SCAN Group, which runs a Medicare Advantage insurance plan covering about 300,000 people in California, Arizona, Nevada, Texas, and New Mexico.<\/p>\n
\u201cThe fastest-growing segment of people experiencing homelessness is actually older adults,\u201d he said. \u201cI said, \u2018We\u2019ve got to do something about this.\u2019\u201d<\/p>\n
Jain\u2019s organization three years ago created Healthcare in Action, a medical group that sends practitioners onto California\u2019s streets solely to care for homeless people. It has grown rapidly, building operations in 17 communities, including Long Beach, West Hollywood, and San Bernardino County.<\/p>\n
Since its launch, Healthcare in Action has cared for about 6,700 homeless patients and managed roughly 77,000 diagnoses, from schizophrenia to diabetes. It has placed about 300 people into permanent or temporary housing.<\/p>\n
Street medicine in most of the country is practiced as a charitable endeavor, aimed at serving a challenging patient population failed by traditional medicine, its proponents say. Living transient, chaotic lives, homeless people suffer disproportionately from mental illness, addiction, and chronic disease and often don\u2019t have health insurance \u2014 or don\u2019t use it if they do.<\/p>\n
That makes designing a business around caring for them a risk, insurance executives and health economists say.<\/p>\n
\u201cIt\u2019s really innovative and entrepreneurial to take all this energy and grit to try and improve things for a population that is too often ignored,\u201d said Mark Duggan, a professor of economics at Stanford University who specializes in homelessness and Medicaid policy. \u201cFinancial incentives matter massively in health care. It\u2019s everything.\u201d<\/p>\n
An estimated 181,000 people were homeless in California in 2023 \u2014 about 30% of the nation\u2019s total. The number living outside, more than two-thirds of California\u2019s total, increased 6.9% over the previous year.<\/p>\n
The state\u2019s leaders, including Democratic Gov. Gavin Newsom, have struggled to make inroads against the mounting public health and political crisis \u2014 despite marshaling unprecedented taxpayer resources.<\/p>\n
\u201cWe have a huge problem on our hands, and we have a lot of health plans and municipalities saying, \u2018We need you,\u2019\u201d Jain said.<\/p>\n
On the Streets<\/p>\n
On a cloudy April morning in Long Beach, Daniel Speller navigated his mobile medical van among the tents and tarps that crowded residential streets, searching for a couple of homeless patients. A physician assistant for Healthcare in Action, Speller said he was particularly worried about the badly infected wounds they developed on their limbs after they used the street drug xylazine, an animal tranquilizer often mixed with fentanyl.<\/p>\n
\u201cThese wounds are everywhere. It\u2019s really bad,\u201d Speller said. If infections progress, they can require toe, foot, or arm amputations.<\/p>\n
\u201cMan, this one is still so deep,\u201d Speller said as he peeled denim pants from the swollen leg of Robert Smith, 66.<\/p>\n
After cleaning and wrapping Smith\u2019s leg, Speller asked him if he needed anything else. \u201cI lost my food stamps,\u201d Smith replied.<\/p>\n
Within the hour, Speller\u2019s team of social workers and nurses had summoned an Uber to take Smith to a state office, where he received a new CalFresh card.<\/p>\n
![\"\"](\"https:\/\/www.nakedcapitalism.com\/wp-content\/uploads\/2024\/07\/00-homeless-.webp\")
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Speller, a street medicine provider for Healthcare in Action, welcomes patients in his mobile medical van in Long Beach, California, on a cloudy April morning. (Angela Hart\/KFF Health News)![\"\"](\"https:\/\/www.nakedcapitalism.com\/wp-content\/uploads\/2024\/07\/00-homeless-2.webp\")
<\/p>\n
Nick Destry Anderson, who is homeless in Long Beach, California, developed a wound from using the horse tranquilizer drug xylazine. \u201cI was so scared. I thought I was going to lose my leg,\u201d he says. (Angela Hart\/KFF Health News)<\/p>\n
Speller then turned his medical van onto a side street lined with more tents and cars-turned-shelters. Nick Destry Anderson, 46, was sleeping on the sidewalk and badly in need of wound care.<\/p>\n
\u201cI was so scared. I thought I was going to lose my leg before I met them,\u201d Anderson said, grimacing as Speller sprayed his leg with antibiotic mist. \u201cThese people saved my life.\u201d<\/p>\n
Anderson reported feeling lightheaded, so Speller asked another team member to use the company credit card to get him a cheeseburger and a Sprite.<\/p>\n
Many homeless people languish on the streets, so entrenched in mental health crises or addiction that they don\u2019t much care about seeing a doctor or taking their medication. Chronic diseases worsen. Wounds grow infected. People overdose or die from treatable conditions.<\/p>\n
Part of street medicine is bandaging infected sores, administering antipsychotic injections, and treating chronic diseases. Street providers often hand out drug paraphernalia such as clean needles and glass pipes to reduce sharing and prevent infections. Perhaps more importantly, these workers build trust.<\/p>\n
Getting homeless patients established with primary care doctors and nurses \u2014 who visit them on the streets, in parks, or wherever they happen to be \u2014 can prevent frequent and expensive emergency room trips and hospitalizations, potentially saving money for insurers and taxpayers, Jain argues. Even though shelter and housing are scarce, Healthcare in Action\u2019s goal is to get patients healthy enough to live stable, independent lives, he said.<\/p>\n
But that\u2019s easier said than done. In West Hollywood that week in April, Healthcare in Action clinical coordinator Isabelle Peng found Lisa Vernon, a homeless woman, slumped over in her wheelchair at a busy bus stop. Vernon is a regular at nearby Cedars-Sinai Medical Center, Peng and her colleague David Wong said.<\/p>\n
When Peng and Wong attempted to examine her swollen leg, Vernon shouted at them and declined aid. \u201cAntibiotics aren\u2019t going to save my life!\u201d Vernon yelled as a mouse scurried for the potato chip shrapnel at her feet.<\/p>\n
They moved on to their next patient, a man they were tracking with a GPS device they sometimes affix to homeless people\u2019s belongings. Use of the devices is voluntary. They work better than cellphones because they less often get taken by law enforcement during encampment sweeps or stolen by thieves.<\/p>\n
\u201cOur patients really move around a lot, so this helps us go find them when we have to get them medication or do follow-up care,\u201d Wong said. \u201cWe have already developed rapport with these patients, and they want us to see them.\u201d<\/p>\n
![\"\"](\"https:\/\/www.nakedcapitalism.com\/wp-content\/uploads\/2024\/07\/00-homeless-3-scaled.webp\")
<\/p>\n
Peng searches for her homeless patients in West Hollywood.(Angela Hart\/KFF Health News)<\/p>\n
Growing Revenue<\/p>\n
Street medicine teams are in demand, largely because of growing public frustration with homelessness. The city of West Hollywood, for instance, awarded Healthcare in Action a three-year contract that pays $47,000 a month. The nonprofit can also bill Medi-Cal, California\u2019s Medicaid program, which covers low-income people, for its services.<\/p>\n
Mari Cantwell, a health care consultant who served as California\u2019s Medicaid director from 2015 until early 2020, said Medicaid reimbursements alone aren\u2019t enough to fund street medicine providers. To remain viable, she said, they need to take creative financial steps, like Healthcare in Action has.<\/p>\n
\u201cMedicaid is never going to pay high margins, so you have to think about how to sustain things,\u201d she said.<\/p>\n
Healthcare in Action brought in about $2 million in revenue in its first year, $6 million in 2022, and $15.4 million in 2023, according to Michael Plumb, SCAN Group\u2019s chief financial officer.<\/p>\n
Healthcare in Action and SCAN\u2019s Medicare Advantage insurance plan generate revenue by serving homeless patients in multiple ways:<\/p>\n
Both are tapping into billions of dollars in Medicaid money that states and the federal government are spending to treat homeless people in the field and to provide new social services like housing and food assistance.For instance, Healthcare in Action has received $3.8 million from Newsom\u2019s $12 billion Medicaid initiative called CalAIM, which allows it to hire social workers, doctors, and providers for street medicine teams, according to the state.It also contracts with health insurers, including L.A. Care and Molina Healthcare in Southern California, to identify housing for homeless patients, negotiate with landlords, and provide financial help such as covering security deposits.
\nHealthcare in Action collects charitable donations from some hospitals and insurers, including CalOptima in Orange County and its own Medicare Advantage plan, SCAN Health Plan.
\nHealthcare in Action partners with cities and hospitals to provide treatment and services. In 2022, it kicked off a contract with Cedars-Sinai to care for patients milling outside the hospital.
\nIt also enrolls eligible homeless patients into SCAN Health Plan because many low-income, older people qualify for both Medicaid and Medicare coverage. The plan had revenue of $4.9 billion in 2023, up from $3.5 billion in 2021.<\/p>\n
\u201cThere\u2019s been an incredible market fit, unfortunately,\u201d Jain said. \u201cYou can\u2019t walk or drive down a street in Los Angeles, rich or poor, and not run into this problem.\u201d<\/p>\n
Jim Withers, who coined the term \u201cstreet medicine\u201d decades ago and cares for homeless people in Pittsburgh, welcomed the entry of more providers given the enormous need. But he cautioned against a model with financial motives.<\/p>\n
\u201cI do worry about the corporatization of street medicine and capitalism invading what we\u2019ve been building, largely as a social justice mission outside of the traditional health care system,\u201d he said. \u201cBut nobody owns the streets, and we have to figure out how to play nice together.\u201d<\/p>\n
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