BILL ANALYSIS Ó
AB 2821
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Date of Hearing: April 19, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 2821
(Chiu) - As Amended March 29, 2016
SUBJECT: Medi-Cal Housing Program.
SUMMARY: Requires the Department of Housing and Community
Development (HCD), in coordination with the Department of Health
Care Services (DHCS) to establish the Medi-Cal Housing Program
(MCHP). Specifically, this bill:
1)Requires HCD, in coordination with DHCS, to do all of the
following:
a) On or before July 1, 2017, design and create the MCHP;
b) On or before July 1, 2017, draft guidelines for
stakeholder comment to fund grants to pay for long-term
housing costs under the MCHP;
c) On or before January 1, 2018, and every year thereafter,
subject to appropriation by the Legislature, award grants
to eligible counties and regions participating in a Whole
Person Care (WPC) pilot program;
d) Collect data midyear and annually from counties and
regions receiving grants awarded pursuant to this bill;
and,
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e) By March 31, 2019, and every year thereafter in which
the MCHP receives funding, report data collected to the
Assembly Committee on Budget, the Senate Committee on
Budget and Fiscal Review, the Assembly Committee on Housing
and Community Development, and the Senate Committee on
Transportation and Housing.
2)Makes a county or a region that includes more than one county
eligible for a MCHP grant if the county or region's lead
entity meets all of the following requirements:
a) One of the following descriptions:
i) Is a lead entity participating in a WPC pilot
program under the Medi-Cal 2020 Waiver (Waiver);
ii) Is a lead entity that had previously participated in
a WPC pilot program that has expired; or,
iii) Is a county with Medi-Cal managed care plans
participating in the Health Home Program and demonstrates
collaboration, as specified.
b) Has formed collaborative relationships with at least one
health plan, county health and behavioral health agencies,
at least one housing authority, and established relevant
continuums of care, as described in the Waiver's Special
Terms and Conditions (STCs), along with nonprofit housing
and homeless service providers, to enable the county or
region to carry out the provisions of this program;
c) For residents participating in the MCHP, has identified
a source of funding for care management and other services
identified in the Centers for Medicare and Medicaid
Services Informational Bulletin regarding Housing-Related
Activities and Services for People with Disabilities,
issued June 2015, and identified in Waive STCs. Requires
funding to include one or more of the following:
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i) County general funds;
ii) WPC pilot housing pool and care management programs;
and/or,
iii) The Health Home Program.
d) Has designated a process for administering grant funds
through agencies administering housing programs; and,
e) Agrees to collect and report data to HCD and DHCS, as
specified.
3)Requires a county or region awarded grant funds under this
bill to form agreements with health plans to collect Medi-Cal
data regarding members' overall health costs.
4)Requires a county or region awarded grant funds to, at annual
and midyear intervals, report all of the following data to HCD
and DHCS:
a) A comparison of health care costs of residents receiving
long-term rental assistance under the MCHP to health care
costs of homeless residents not receiving long-term rental
assistance;
b) The number of participants and the type of interventions
offered through grant funds; and,
c) The number of participants receiving long-term rental
assistance living in supportive housing or other housing
that does not limit length of stay.
5)Requires a county or region to use grants awards for one or
more of the following, which may be administered through a
housing pool, as defined in the Waiver STCs:
a) Long-term rental assistance for periods up to five
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years, as determined by the eligible county;
b) Interim housing; and,
c) A county's administrative costs for up to 5% of the
total grant awarded.
6)Makes a county resident eligible to receive assistance
pursuant to a grant awarded under the MCHP if he or she meets
all of the following requirements:
a) Is homeless upon initial eligibility;
b) Is a Medi-Cal beneficiary; and,
c) Is eligible for the services program identified by
participating counties or regions.
7)Subjects the MCHP to an initial appropriation by the
Legislature. After the initial appropriation, the funding of
grants under the MCHP is subject to annual appropriations by
the Legislature based on decreased costs of care, as reported
by participating counties, of moving eligible participants
into supportive housing.
8)Requires HCD to use no more than 5% of the funds appropriated
for the MCHP for purposes of administering the program.
9)Finds and declares the importance of addressing chronic
homelessness and costs incurred by the Medi-Cal program in
addressing the needs of people who cycle from homelessness,
emergency departments (EDs), inpatient care, and nursing home
stays.
10)Defines various terms including the following:
a) "Interim housing" as a safe place for a participant to
live temporarily while the participant is waiting to move
into an apartment affordable to the participant. Interim
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housing may include recuperative or respite care and shall
not be funded for longer that a period of nine months;
b) "Long-term rental assistance" as a rental subsidy
provided to a housing provider to assist a tenant to pay
the difference between 30% of the tenant's income and the
costs of operating the assisted apartment.
EXISTING LAW:
1)Establishes Medi-Cal, administered by DHCS, to provide
comprehensive health care services and long-term care to
pregnant women, children, and people who are aged, blind, and
disabled.
2)Establishes HCD, to among other functions, implement policies
and programs to preserve and expand affordable housing in
California.
3)Defines "supportive housing" as housing with no limit on
length of stay, that is occupied by a target population, as
defined, and that is linked to onsite or offsite services that
assist the supportive housing resident in retaining the
housing, improving his or her health status, and maximizing
his or her ability to live and, when possible, work in the
community.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, California is
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home to 20% of the country's homeless population.
Homelessness often creates an institutional circuit, where
those experiencing it long enough cycle through living on the
streets, ED visits, inpatient admissions, incarceration, and
often nursing home stays. In addition to the moral cost to
society, this circuit is expensive to our public systems:
homeless individuals cost our public systems an average of
$2,897 per month, two-thirds of that incurred through the
health system. This bill attempts to coordinate delivery of
services between the health and housing systems to further our
goal of eliminating homelessness.
2)BACKGROUND. According to the Substance Abuse and Mental
Health Services Administration, stable housing provides the
foundation upon which people build their lives. Without a
safe, affordable place to live, it is almost impossible to
achieve good health or to achieve one's full potential. But,
according to the Department of Housing and Urban Development
(HUD), on a single night in 2014, more than 578,000 people,
including 136,000 children, experienced homelessness. Of
those people, more than 177,000 were unsheltered. While the
number of people experiencing homelessness has declined since
2007, much work remains to be done to reach the goal of ending
homelessness in the United States. According to HUD's 2013
Annual Homelessness Assessment Report, of those who experience
homelessness, approximately 257,300 people have a severe
mental illness or a chronic substance use disorder.
a) Homelessness and Health Care. According to the National
Coalition for the Homeless (Coalition), homelessness and
health care are intimately interwoven. Inadequate health
insurance is itself a cause for homelessness. Many people
without health insurance have low incomes and do not have
the resources to pay for health services on their own. A
serious injury or illness in the family could result in
insurmountable expenses for hospitalizations, tests, and
treatment. For many, this forces a choice between hospital
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bills or rent. Homeless people are three to six times more
likely to become ill than housed people. Homelessness
precludes good nutrition, good personal hygiene, and basic
first aid, adding to the complex health needs of homeless
people. Additionally, conditions which require regular,
uninterrupted treatment, such as tuberculosis and HIV/AIDS,
are extremely difficult to treat or control among those
without adequate housing. Diseases that are common among
the homeless population include heart disease, cancer,
liver disease, kidney disease, skin infections, HIV/AIDS,
pneumonia, and tuberculosis. People who live on the
streets or spend most of their time outside are at high
risk for frostbite, immersion foot, and hypothermia,
especially during the winter or rainy periods. Although
not many homeless deaths are specifically attributed to
exposure-related causes, the risk of death from other
causes is increased eightfold in people who have
experienced those conditions in the past
The Coalition further notes that many homeless people who are
ill and need treatment do not ever receive medical care.
Barriers to health care include lack of knowledge about
where to get treated, lack of access to transportation, and
lack of identification. Psychological barriers also exist,
such as embarrassment, nervousness about filling out the
forms and answering questions properly, and
self-consciousness about appearance and hygiene when living
on the streets. The most common obstacle to health care is
the cost, without health coverage, many homeless people
simply cannot pay for health care services. As a result,
many homeless people utilize hospital EDs as their primary
source of health care. Not only is this the least
effective form of care for them, since it provides little
continuity, it is also very expensive for hospitals and the
government. As a result of these factors, homeless people
are three to four times more likely to die than the general
population. This increased risk is especially significant
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in people between the ages of 18 and 54. Although women
normally have higher life expectancies than men, even in
impoverished areas, homeless men and women have similar
risks of premature mortality. In fact, young homeless
women are ip to 31 times as likely to die early as housed
young women. The average life expectancy in the homeless
population is estimated between 42 and 52 years, compared
to 78 years in the general population.
b) Waiver. On December 30, 2015, DHCS received federal
approval from the Centers for Medicare and Medicaid
Services (CMS) for a renewal of its Medicaid Section 1115
Waiver. The new waiver "Waiver 2020" builds upon the
Bridge to Reform Waiver (BTR) that was approved in 2010.
In addition to preserving many of the existing elements of
the BTR, the new Waiver includes several new, ambitious
initiatives aimed at continuing the delivery system
improvements that began five years ago. The Waiver
provides opportunities for innovation through WPC pilots,
expanded care opportunities for California's remaining
uninsured and a Dental Transformation Initiative. The new
Waiver will provide California with at least $6.2 billion
in ongoing federal funding over the next five years. The
Waiver represents a shared commitment between California
and CMS to provide 13 million Medi-Cal beneficiaries with
efficient, high quality care that will ultimately improve
health outcomes and reduce costs.
c) WPC Pilot. One of the most innovative aspects of the
Waiver is a new opportunity for counties to leverage
resources more effectively by coordinating physician
health, behavioral health, and social services in a
patient-centered manner with the goal of improving the
health and well-being of beneficiaries. The new WPC pilots
will enable counties and their partners to target these
high users, share data between systems, coordinate care in
real time, and evaluate progress in improving individual
and population health. The WPC pilots provide extensive
local flexibility, enabling a county, city and county, a
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health or hospital authority, or a consortium of entities
to design approaches that address the specific needs of
their most vulnerable Medi-Cal beneficiaries. While there
must be one "Lead Entity," the WPC pilot applications will
identify the comprehensive set of participating entities
that will work together to provide beneficiaries with more
integrated, person-centered care. The WPC pilots also
permit applicants to choose target populations, identify
strategies for meeting the needs of the populations, and
develop payment methodologies.
The formal allocation of WPC funding is under development,
but in order to participate, WPCs will need to meet the
following conditions:
i) The WPC must have an established infrastructure to
integrate services among local entities that serve the
target population;
ii) Services provided must not be otherwise covered or
directly reimbursed by Medi-Cal; and,
iii) The WPC must employ strategies to improve
integration, reduce unnecessary utilization of health
care services, and improve health outcomes.
One of the likely target populations for the WPC pilots is
individuals at risk of or experiencing homelessness who
have a demonstrated medical need for housing or supportive
services. Permissible housing interventions included in the
WPC pilot are:
i) Tenancy-based care management services. Services
such as individual housing transition services,
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individual tenancy sustaining services, and
housing-related collaborative activities designed to
assist the target population in locating and maintaining
medically necessary housing.
ii) County housing pools. These pools, which may
include contributions from county entities, will directly
support medically necessary housing services with the
goal of improving access to housing and reducing churn in
Medi-Cal. Services can include respite care or interim
housing arrangements and services to enable timely
discharge from inpatient stays or nursing facilities
while permanent housing is being arranged. While federal
funds cannot be used to support long-term housing
arrangements, state or local contributions can be used
for rental subsidies.
3)SUPPORT. Western Center on Law and Poverty states that
Californians experiencing homelessness incur disproportionate
costs to local and state programs, many of which are Medi-Cal
costs. Despite these high health costs, people experiencing
homelessness have poor health outcomes, and are at significant
risk for early mortality. This bill is a one-time investment
that would decrease Medi-Cal costs resulting from dramatic
improvements in clinical outcomes.
The League of California Cities states that providing
wrap-around services for homeless men, women, and children has
not only proven to be the most effective way to end chronic
homelessness but is a smart use of tax dollars.
4)RELATED LEGISLATION. AB 1568 (Bonta and Atkins) and SB 815
(Hernandez and De Leon) are identical bills dealing with the
implementation of the Waiver. AB 1568 is pending in Assembly
Health Committee and SB 815 is pending in Senate Health
Committee.
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5)TECHNICAL AMENDMENT. Since the Assembly and Senate Health
Committees have jurisdiction over the Medi-Cal program, the
Committee recommends that the report relating to the MCHP
should also be submitted to these committees.
REGISTERED SUPPORT / OPPOSITION:
Support
Western Center on Law and Poverty
League of California Cities
Opposition
None on file.
Analysis Prepared by:Rosielyn Pulmano / HEALTH / (916) 319-2097
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