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Show At the Fourth Street Clinic in Salt Lake City, which specializes in health care to homeless people, only about 10 percent of the 5,500 different homeless people seen each year (for a total of almost 15,000 office encounters) currently have any kind of third party health insurance coverage (private, Medicaid, Medicare, Veteran's Administration/CHAMPAS). Homeless children readily qualify for Aid to Families with Dependent Children (AFDC) and Medicaid, but have not completed the paperwork necessary to gain eligibility when needing services. It becomes readily apparent, just on the above information, that there is a great deal of difficulty in assuring insurance coverage for homeless people. The same applies to homeless people who are mentally ill. Such people are more often than not unable to complete the necessary forms and are incapable of following through the bureaucratic complexity to gain admittance to programs for which they otherwise qualify. This includes Social Security and Social Security Disability, Medicaid, Medicare, and the state's indigent program, the Utah Medical Assistance Program (UMAP). The same difficulties have occurred over the last ten years throughout the U.S. in attempting to gain eligibility for and to treat this segment of our national population. Congress was unusually far-sighted when in January of 1988 it created and enacted the Stewart B. McKinney Act's Health Care for the Homeless (HCH) Program (Section 340). Over 120 cities throughout the U.S. eventually received 340 funding to provide primary health care services under this Act, which has fundamentally changed the ability of homeless people to receive a comprehensive range of health-related services. The McKinney Act also provided for other social programs to help alleviate the condition of homelessness throughout the U.S., so that it may justifiably be described as a holistic series of programs including funding for substance abuse treatment, emergency shelters under the Federal Emergency Management Agency (FEMA), transitional and permanent housing under the auspices of the Department of Housing and Urban Development (HUD), employment training, and mental health treatment On the whole, the Act has had positive ramifications, particularly for states like Utah where the percentages of homeless people are small enough to manage. The McKinney Act has made a difference in people's lives, enabling an unknown but significant number of people who are best described as episodically homeless to regain housing and employment, and to stabilize their health care while in the condition of homelessness. This is a different picture from what most people visualize when they think about people who are homeless. From the Health Care for the Homeless Program, we have learned that ease of enrollment, portability of coverage, cultural sensitivity or competency, transportation, and case management are important in any discussion about providing health care services in a future system to Utah's periodically homeless. An essential part of the health care package needed to provide services to this population includes coordination and stabilization of a person's mental, social, and housing needs. These are problems which individual states have already found to be difficult, expensive, and sometimes impossible to provide to its poverty population under state managed care plans. For example, most middle-class systems do not consider how to procure clothing within their health care plan. It is not ironic that at the same time that individual states are beginning to examine the cost and feasibility of how or whether to provide funding for social programs for their most difficult to reach populations, the Stewart B. McKinney Act is in danger of being de-funded as a result of federal budget cuts. The lack of irony lies in the fact that most states are clamoring to have more responsibility in how their allocations of federal monies, including Medicaid funding, are spent. States are asking for much more leeway in the decision-making process, and Utah is in the forefront in making these arguments. The danger of such a national movement is that the fifty individual states could then use state monies in fifty different ways with no national standards or agreement of values. Poor people throughout the U.S. are inevitably the losers when such changes occur. The real costs to states for provision of comprehensive health care services to a high risk and high severity of illness population will be much greater than they were under the status quo programs. To combat these costs, impoverished and homeless people will be faced with less access to health care, and thus greater risk of death or disability than at present. Ultimately, this is a cost society assumes and, under these circumstances, the expense will become much greater. While the condition of homelessness is a direct result of the multiple interlocking social issues around poverty, there are some differences between those who simply do not have enough income at the end of the month to buy amenities such as health care, and those who are literally without stable, safe, and private shelter. Homeless people are at high risk for a broad range of acute and chronic illnesses simply because they do not have the stability or security 18 Do We Continue a Two-Tiered Health Care System for People in Poverty? |
