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Since the federal health care law expanded Medicaid in some states, about seven million low-income Americans have gained new health insurance.
But, in Los Angeles, health officials say that's not enough. They want to try going further, using Medicaid dollars to pay for housing for the homeless.
Hari Sreenivasan has our report.
I got appendicitis, OK? Cirrhosis of the liver.
Deborah Mullins blames most of her health problems on this block in downtown Los Angeles. She has been living on the sidewalk here for the past 30 years.
Do you know how many times she went to the hospital? At least eight. At least.
Mullins' health has gotten so bad that even the police have started worrying.
As a matter of fact, no. That's been this year, and we're not even done yet.
She's exactly the kind of person Dr. Susan Partovi and her team from L.A.'s Department of Health Services have been trying to find recently. They say they have an obvious cure for much of what ails the city's chronically homeless. Namely: housing.
DR. SUSAN PARTOVI:
We could put you in a temporary housing.
Put me somewhere, because I'm tired of this.
The health care reform law brought insurance to most of L.A.'s homeless population this year, when California expanded the Medicaid program. But so far, it's done little to improve the health of the 3,500 homeless residents in the infamous Skid Row neighborhood. Because even with better access to doctors and prescription drugs, they're still living on the streets — many with severe chronic and mental health conditions.
Marc Trotz directs a new branch of the county's Department of Health Services called Housing for Health.
MARC TROTZ, Housing for Health: It's daunting out on Skid Row. I mean, just in our quick walk out there, it does feel like a — you're quite overpowered by the number of people.
In the next few years, he plans to use county health funds to put 10,000 of L.A.'s sickest homeless people into permanent supportive housing. Because he says it's not free to let them live on the sidewalk.
It's a very high cost for that person and their health and their well-being. But a very high societal cost, as well, in terms of this constant ricocheting through hospitals, correctional facilities, back on the street and shelters.
Often, this is the site of the priciest of those interactions: Public hospitals like Los Angeles County-USC Medical Center. Most nights, several dozen homeless patients make their way to the emergency department here for health crises made worse by living outdoors. Others camp out in the waiting rooms just to get out of the weather.
KATHY GARVIN, LAC+USC Medical Center:
Just trying to find out why people are here…
Care for the most frequent patients can cost upwards of $90,000 to $150,000 per year. And Kathy Garvin, the emergency department's assistant nurse manager, says the results are often depressing.
If we prescribe antibiotics to somebody with pneumonia and they go back and they lay on the grate right out front, they're not taking their antibiotics. They're not getting any better. We might feel like we have done something, but really we haven't. And eventually we are going to bury them.
Tracy Napoli's story almost ended that way. The former construction worker lost his job and then his house after he fell from a ladder and shattered an ankle, making it difficult for him to walk or work.
Any history of alcohol abuse?
For three years, he bounced between the streets, the shelters, and too often, the emergency room.
Usually, the emergency room was a last-ditch effort, because I had let something go for too long or I was really sick and it wasn't getting any better. Twice, I got into an emergency room because of altercations here in downtown.
One of those times, Napoli heard about the Star Apartments. He was among the first to move in to the 100-unit complex when it opened last year, under the Housing for Health division and the nonprofit Skid Row Housing Trust.
And he was also among Dr. Susan Partovi's first patients at the Star clinic on the ground floor.
Now, can you do it if I push it up a little bit?
Yes, but it still hurts.
It was Partovi who noticed a few months ago that the 50-year-old's eyes looked yellowish — one of the signs of alcoholic hepatitis.
She just asked me. She says, 'Are you going to quit drinking? Do you want to quit drinking?' I said, 'Yes.' So, she says, 'Well, we're going to put you in the hospital.' She gave me a ride to the hospital, had me admitted. And I have been sober since.
Not long ago, Napoli's apartment was covered in beer cans. Now he tries to keep it clean. He is hoping to regain strength in his ankle through physical therapy and then start applying for jobs.
DR. MITCHELL KATZ, Director, Los Angeles County Department of Health Services: My interest in housing is: How do you use housing to change the arc of life of somebody who's homeless.
That's Dr. Mitchell Katz, the director of Los Angeles County's Department of Health Services. He and Marc Trotz helped develop the 'Housing First' idea in the '90s, when they both worked for San Francisco's Department of Public Health.
DR. MITCHELL KATZ:
What we discovered is that, often, once you house people, the other problems often diminished right away. They were using less substances because they wanted to keep their housing. They were less mentally ill because they were not so frightened by the conditions in which they were living. They had a sense of security. They had a sense of community.
The concept has spread to many other American cities. But to take it to the next level, Katz is making a controversial move. He's advocating that the federal government allow him to use funds from the health law's Medicaid expansion to directly purchase or build thousands of additional units for the homeless — taking the program to scale with federal funds.
But, at the moment, top government officials say that's not allowed because housing isn't a direct health service.
This doesn't really make any sense. Because, for a homeless person, housing is the relevant health service.
Not everyone buys the argument.
Bruce Vladeck directed Medicaid and Medicare during the Clinton administration. He is still an advocate for both the Medicaid program and government-funded housing, but he says that combining the two could be dangerous.
BRUCE VLADECK, Former Administrator, Health Care Financing Administration:
I think we need to fund housing as housing. I think the problem with funding it or seeking to fund it through Medicaid is that Medicaid is already under all kinds of political pressure because of its expense.
If you start to say that anything that might benefit a Medicaid beneficiary ought to be covered by the Medicaid program, you're really opening up a bottomless pit, and you're making the program even more vulnerable to those who want to cut or eliminate it.
Others say the concept has already grown too much.
At the Los Angeles Mission, one of the oldest shelters in Skid Row, the goals are short-term help and long-term treatment. Herb Smith, the nonprofit's president, says 'Housing First' works for some people, but there are many who need services like a bed for the night or help quitting their addictions before they try to live independently.
Smith says those things have become much harder to provide in recent years, as funders have shifted toward 'Housing First.'
HERB SMITH, Los Angeles Mission:
It affects people differently, the reason people became homeless, and we need to be able to address that in ways that are effective and target those particular populations.
Tracy Napoli used to stay at the L.A. Mission and very much agrees that kind of help is needed as well. But the 'Housing First' approach is what ended his homelessness, he says. And eventually his drinking.
He also knows he's relatively lucky. The program has helped about 700 people so far; 50,000 more remain homeless in L.A. County — a number the Housing for Health team says would fall dramatically with the federal help they're requesting.
For the "PBS NewsHour," I'm Hari Sreenivasan.
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Hari Sreenivasan joined the PBS NewsHour in 2009. He is the Anchor of PBS NewsHour Weekend and a Senior Correspondent for the nightly program.
Jason Kane is a PBS NewsHour producer, focusing on health care and national affairs.
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