Advocates say Medicaid can shelter the homeless in Pennsylvania

Pennsylvania could use Medicaid to address its homelessness problem, according to advocates that believe the state’s Medicaid program should include additional supportive housing services. Those individuals assert that additional supportive housing services can be included in Medicaid as a “wrap-around support service”—a type of service that CMS endorses and described in a Center for Medicare & CHIP Services Informational Bulletin last year.

Housing services

CMS expressly does not provide Federal Financial Participation (FFP) for room and board as part of additional support services. However, states are permitted to assist individuals through coverage of certain housing-related activities and services. Some of the housing-related services and activities that Medicaid can cover include: (1) services designed to support an individual’s ability to prepare for and transition to housing; (2) services aimed at supporting an individual’s ability to sustain tenancy; and (3) services dedicated to assisting a state in identifying and securing housing options for individuals. Specific examples of each of those services are covered in the Informational Bulletin. The Open Door is an example of an organization that provides housing support services.


In Pennsylvania, advocates like The Housing as Health Campaign are asserting that, for many Medicaid enrollees with substance abuse problems, additional support is needed to keep beneficiaries in their homes. Advocates argue that without a consistent funding stream, Medicaid beneficiaries wind up homeless. The Corporation for Supportive Housing (CSH) created a blueprint, or “Crosswalk,” to serve as a map to assist the Pennsylvania Department of Health and Human Services with aligning Medicaid-eligible services with supportive housing services.


The Crosswalk was designed to guide the state of Pennsylvania, managed care entities, and service providers towards resources that can improve access to substance use treatment and mental health recovery, with a focus on housing. According to the report, individuals with unmet housing needs are often particularly vulnerable due to the high occurrence of low incomes, chronic health conditions, and behavioral health challenges among the population. The report proposes several methods to improve housing and care access for at-risk individuals. CSH started its analysis by considering the services that the state already provides through several Medicaid waivers. While Pennsylvania does have mechanisms to provide some housing support services for elderly individuals, beneficiaries with traumatic brain injuries, and individuals with a physical disability, CSH noted that additional individuals could benefit from supportive housing.


The report identified potential opportunities for alignment, where services that are already covered under the state plan could be aligned to better address housing support service needs. For example, the report suggested that, because the Pennsylvania state Medicaid plan covers Individualized Service Plans (ISPs) for the treatment of individuals with severe mental illness, an individual could, possibly, identify housing goals as part of his or her treatment plan, thereby including housing support services through an ISP. The report lists several other types of services with potential for alignment to reduce or eliminate gaps in housing service coverage.

Rethinking Medicaid

Advocates are not directly asking for a change as to the kind of services covered by the Pennsylvania Medicaid program. Instead, the CSH report and other efforts are asserting that housing problems can be best improved through a better application of existing services under the Medicaid state plan. Advocates hope that such a rethinking of Medicaid will improve health by putting a roof over the head of more individuals.

HELP Committee focuses on access to mental health services

On January 20, 2016, the Senate Committee on Health, Education, Labor, and Pensions (HELP) heard testimony from four experts in the field of mental health with very different perspectives. The three who had been directly involved with patients all testified, however, that there is a dearth of resources for treatment and that serious needs go unmet.

Penny Blake, R.N., C.C.R.N., an emergency room nurse and Chair of the Advocacy Advisory council of the Emergency Nurses Association, told the committee that people with mental health or substance use conditions comprise about 10 percent of the patients that present to the emergency department at the West Palm Beach hospital where she works. The loud noises and chaotic atmosphere of a busy emergency department can be harmful to a patient who may be hallucinating. Because the hospital does not have a psychiatric ward, patients who are dangerous to themselves or others must be transferred to other hospitals. There are so few beds available that they must be “boarded” in the emergency department. Usually the wait is 12 to 24 hours, but it is not unusual for a patient to wait for four days to be transferred.

The need to isolate and observe patients who may require involuntary commitment also diverts staff from other patients who need care. The emergency room physicians lack the experience and expertise to begin treatment of the psychiatric emergency with appropriate medication. Blake attributed the difficulties in accessing treatment to the insufficiency of treatment providers available and the lack of insurance coverage for psychiatric care.

Brian Hepburn, MD, Executive Director of the National Association of State Mental Health Directors, expressed gratitude for the mental health block grant programs and funding for demonstration projects. For example, he believes that the First Episode of Psychosis program, which now receives a 10 percent set-aside from mental health block grants, will make a significant difference. He noted that treatment of serious mental illness is much more likely to be successful when begun in the early stages of the illness. He asked that Congress modify the Medicaid exclusion of services of institutions for mental disease (IMD) to allow payment for adult stays in IMDs. Hepburn also recommended increasing support for monitoring and enforcement of the laws requiring mental health and addiction parity.

Both Hepburn and William W. Eaton, PhD, Professor in the Department of Mental Health at Johns Hopkins University Bloomberg School of Public Health, told the committee that patients with mental illness or substance use disorder also are at higher risk for physical illnesses, such as heart attacks, stroke, or diabetes. Eaton also emphasized the lack of research and resources dedicated to mental illness, especially with respect to public health interventions that could prevent or alleviate mental illness.

Pending legislation

Finally, Hakeem Rahim, representing the National Alliance on Mental Illness, put a human face on the problem by describing the experience of living and coping with psychosis. Rahim told the committee that S. 1893, the Mental Health Awareness Act, which was recently passed by the Senate and is now pending in the House, was a good start. However, he urged the committee to support S. 1945, the Mental Health Reform Act, sponsored by committee members Bill Cassidy (R-La) and Christopher Murphy (D-Conn). S. 1945 would create an Assistant Secretary of Mental Health and Substance Use Disorders and expand funding for many training and treatment programs.

Minding the mental health problem from the start

The alarming incidence of mental health and substance abuse problems in the United States can be mitigated with a reliance on prevention and early intervention (PEI), according to a Mental Health America (MHA) report titled “The State of Mental Health in America 2016.” Due to limited funding, the absence of health insurance, and limited access to mental health care, many Americans are not receiving necessary treatment for mental health and substance abuse issues. The report, which drew comparisons between access and treatment across the fifty states, identified dramatic disparities across the country. For example, in the states with the lowest number of mental health providers, there are approximately 1,100 individuals for every one mental health provider. The report suggests that the problems can be corrected through care coordination, community support, and shared saving efforts.


To evaluate the prevalence of mental health and substance abuse problems and compare the incidence and treatment of those things across multiple states, MHA relied on publically available data, for adults and youths, that captured information regardless of whether a patient used private or public health systems. Specifically, MHA used 15 measures for its 2016 analysis, including: Adults with any mental illness (AMI), adults with dependence or abuse of illicit drugs or alcohol, adults with serious thoughts of suicide, youth with at least one past year major depressive episode (MDE), youth with severe MDE, Adults with AMI who did not receive treatment, and Adults with AMI who are uninsured.


MHA identified an increase in the number of youths becoming depressed. Specifically, there was a 1.2 percent increase in the number of youths with depression. Youth depression is also unevenly distrusted across the states. States with the highest rates of youth depression have nearly twice as many depressed youths as the states with the lowest rates.  Treatment disparities exist as well. For example, youth with severe depression in Nevada are four times less likely to get consistent outpatient treatment when compared to the treatment of youth with severe depression in South Dakota.


The report identified, on average, 57 percent of the adults in the U.S. with mental illness receive no treatment. In other states the non-treatment rates are much higher. For example, in Nevada and Hawaii, the rate of adults with mental illness not seeking treatment reaches 70 percent. The report also revealed that in 2012 and 2013, one in five adults with mental illness was uninsured. Additionally, cost remains a barrier to treatment. One in five adults with mental illness reported difficulty obtaining access to mental health care as a result of costs.


For both adults and youth, access remains a crucial component of the mental health and substance abuse crisis. In addition to the cost and insurance factors, a lack of mental health providers plays a key role in reducing patient access to mental health care. In states with relatively good access to mental health care services—Massachusetts, Maine, and Vermont—there are about 250 individuals for every mental health provider. However, in states with relatively poor access to care—West Virginia, Texas, and Alabama—there are approximately 1,100 individuals for every mental health provider.


The report focuses on the impacts of untreated mental illness and substance abuse problems. The report placed specific emphasis on the impacts for young people. For example, MHA noted that suicide is the third leading cause of death among 10 to 24 year olds.  Additionally, of the over 600,000 youth placed in juvenile detention centers, 65 to 70 percent have diagnosable mental health disorders. Additionally, the existence of a disability dramatically increases a student’s likelihood of dropping out of high school.


To correct the problems, the report makes specific recommendations regarding prevention and intervention. The report suggests that PEI is the best strategy because in addition to providing the necessary support and treatment for individuals, there are benefits to the broader community and country. Specifically, by reducing the number of individuals that reach a crisis state, PEI reduces costs by spending less on late stage expenses like hospitals and disability benefits.  To actually achieve the goal of moving towards PEI for mental health care, the report recommended three approaches: (1) increase incentives to pay for prevention and early intervention with organizations like accountable care organizations; (2) expand health insurance coverage for PEI services; and (3) engage communities in PEI with provider, insurer, government, consumer, and business coalitions. According to the report, the problem is plain and prevention is the obvious solution. Now, it’s just a matter of policymakers taking action.