Hawaii has asked the CMS to help it care for chronically homeless people more efficiently by addressing a major social determinant of health: housing.
The state's waiver asks for federal reimbursement for Hawaii's efforts to help homeless Medicaid recipients find and maintain housing. Both states and providers are looking for new ways to address social issues that undermine patients' health and care plans.
Hawaii wants to use federal Medicaid funds to appoint state employees to help people find housing and provide moving assistance to those beneficiaries, according to a pending waiver application now under CMS review. The state has one of the highest homeless populations in the country.
Hawaii also wants to be reimbursed for providing tenant support services, such as conflict management training between enrollees and landlords.
"We anticipate that by providing these services, we will not only reduce our health costs, but we will help reduce people suffering from chronic homelessness, which ultimately saves lives," said Judy Mohr Peterson, the state's Medicaid director.
The waiver doesn't ask Medicaid to cover actual housing costs, which is prohibited by federal law.
Hawaii hopes to build off its success with the state-funded Housing First program that started in 2014. The initiative focused on helping homeless people in the Honolulu area, and helped decrease healthcare costs for people in the program from an average of $10,570 per client per month to $5,980 per client per month.
For doctors, stable housing means there is a greater likelihood patients will adhere to their medication regimen and comply with preventive care recommendations.
Many of Hawaii's homeless have very poor health and suffer from issues including diabetes, renal failure and heart disease. These conditions need preventive care and ongoing monitoring to prevent longer-term, more challenging and costly medical care, like dialysis or amputations, according to Dr. Scott Miscovich, a family medicine practitioner in Kaneohe, Hawaii.
"Having a home or reliable location to find a complicated patient with multiple comorbidities allows for outreach including home health services or case management," Miscovich said.
Other states like California, Maryland, New York, Oregon and Washington have convinced the CMS to pay for housing support service initiatives, but Hawaii's waiver is unique. The state's request targets people who are at risk or currently are homeless and also have significant health needs, according to Peggy Bailey, director of the health integration project at the Center on Budget and Policy Priorities.
"Providers often struggle with finding funding sources to pay for the intensive support services that keep people with significant behavioral or physical health needs in housing," Bailey said. "Medicaid financing would make a huge difference in the state's efforts to end homelessness."
It's unclear whether the Trump administration will approve the waiver. Other state waivers that included similar housing provisions were approved by the Obama administration, Bailey said.
HHS Secretary Dr. Tom Price has made clear he is looking to cut Medicaid spending. However, Hawaii officials hope that the long-term healthcare savings will be enough to get the request approved.
"Republicans would agree that if we have a better model that saves money that's good," said state Sen. Josh Green, who is also a practicing emergency room physician. "I hope that the administration will see this as an opportunity."
The CMS will accepts comments on the waiver request through Oct. 17.