Kaiser Health News: Signing up the homeless, one at a time

By Anna Gorman, KHN Staff Writer

LOS ANGELES – On a recent winter morning, health outreach worker Christopher Mack walked through the streets and alleys of the city’s Skid Row, passing a man pulling a rusty shopping cart and a woman asleep on a crumpled blue tarp. The smell of marijuana wafted through the cold air.

“Do you have health insurance?” Mack, a towering man with long dreadlocks, asked one woman. “Do you go to the doctor?” he asked another.

Homeless men and women who didn’t qualify for insurance in the past now have the chance to sign up, and Mack – who was once homeless himself — is there to help.

The national health law allows states to expand Medicaid to include poor people without children or disabilities who haven’t been able to get free insurance in the past. Experts say determining how many homeless people are eligible for Medicaid is difficult but estimates range from about 500,000 to as many as 1.2 million. About half of the states are not expanding their Medicaid programs, however, leaving many homeless residents uninsured and continuing to depend on emergency rooms and safety net clinics for care.

Health outreach worker Christopher Mack, who once lived on the streets, knows the challenges facing homeless residents of Los Angeles (Photo by Anna Gorman/KHN).

The National Health Care for the Homeless Council, based in Tennessee, has held training sessions and webinars for outreach workers nationwide on how best to reach homeless people, many of whom have complex medical conditions and little knowledge of health insurance. The federal government also has given outreach grants to community health centers, which treat more than one million homeless patients each year.

But advocates said most of the work will occur at a grassroots level. Across the country, advocates and outreach workers are visiting shelters, churches, encampments and soup kitchens to tell homeless residents about their new insurance options and to help them get enrolled.

The Chicago Coalition for the Homeless, for example, has dispatched workers to drop-in centers to specifically target homeless youths. Graham Bowman, who heads the healthcare project, carries a laptop and a scanner so he can sign up people for Medicaid on the spot. “I can’t rely on follow-up meetings,” he said.

In Baltimore, one organization is counting on homeless residents to help educate their peers through conversations, flyers and a street newspaper. In Denver, the Colorado Coalition for the Homeless, which provides housing, health care and other social services, has trained case managers throughout the organization so they don’t miss anyone who may be eligible for the free coverage.

Insuring homeless people and connecting them to doctors could lead to more routine medical care and less reliance on costly emergency rooms, doctors and health care advocates say. The effort also may help them get them off the streets by addressing unmet health needs and connecting them to housing and other necessary services.

“They are very complicated patients,” said Michael Cousineau, a health policy expert at University of Southern California’s Keck School of Medicine. Engaging homeless people and bringing them into medical care, Cousineau said, “is a very important first step to helping stabilize this population.”

Outreach and enrollment among the homeless is challenging, however, in large part because many are addicted to drugs or are mentally ill, and they distrust government and public programs. Homeless people are transient and usually lack permanent mailing addresses. And while many live in plain sight, others are harder to find, hidden beneath bridges or under freeway overpasses.

Mack knows the barriers well. A former addict himself, he spent decades on the streets before getting clean. Now, he is a lead outreach worker for the John Wesley Community Health or JWCH Institute, which has several clinics that provide healthcare and other services to the homeless and underserved.

No I.D. Needed

On this morning, he stepped out of one clinic and soon saw Martha Castro, a 64-year-old woman hunched over, a scarf wrapped around her face to ward off the cold.

Slurring her words, she said that she had been homeless for four years and had been to the doctor just once, to be treated for a lung infection.

“If anything else happens to you, you can come now again,” Mack said, explaining that she may qualify for insurance.

She shook her head emphatically. “No, I don’t want to apply for nothing else right now.”

Castro said she didn’t have any identification or money. “We are here from Skid Row,” she said. “How we gonna have insurance for the clinic?”

Sakeenah Borscha, right, tells Christopher Mack about her medical needs (Photo by Anna Gorman/KHN).

The coverage is free and she only needs a Social Security number to apply, but Mack knows now isn’t the time to explain further. He can’t push anyone to enroll or go to the doctor. He has to gain their trust over time, helping them see the upside to coverage. “You let the person decide for themselves,” Mack said. “You never know when it might be the day.”

The sooner the better, said Dr. Dennis Bleakley of the JWCH Institute. Many homeless people suffer from chronic diseases such as diabetes, high blood pressure and asthma, and they often wait until they are in dire shape to seek medical treatment.

From their perspective, they have much more important and urgent things to worry about, Bleakley said. “They are literally sleeping on a doorstep.”

‘God Bless You’

At the busy JWCH clinic the morning after Mack’s Skid Row visit, enrollment workers were signing up patients for Medi-Cal, California’s Medicaid program, and making sure they knew where to go for care.

George Farag, 56, who sleeps at a local mission each night, said he lost his job as a security guard when he fell asleep on duty. He ended up on the streets and got hit by a car, resulting in a leg injury that causes him to limp.

Farag, an Egyptian immigrant who speaks with a thick accent, also has asthma, diabetes, depression and insomnia.

“This is the final step before your transition into Medi-Cal,” enrollment worker Alberto Moreno told him. “Your doctor will be assigned here.”

“God bless you,” responded Farag, carrying a black plastic bag filled with papers.

Mack tries to put the patients at ease.

On Skid Row, he stopped to talk to Sakeenah Borscha, an overweight woman sitting on a motorized scooter overflowing with bags of belongings.

Recently arrived from Arizona, Borsha said she was diabetic and had an injured knee. She needed medication for both, she told Mack. She’d had coverage in the past but didn’t know if she was still insured.

Mack patted her knee and smiled.

“Come see me in the morning,” he said before heading back through the maze of shopping carts, tarps and tents.