One state plan to push for more affordable health insurance than traditional health care

Jacey Cooper is the director of Medicaid in California, and she is not afraid of big problems.

She drove two hours from Bakersfield to Los Angeles to finish her senior year at the University of Southern California after giving birth to twins.

A few years later, at the age of 27, he helped a large hospital reduce costs and double the size of its program for uninsured and low-income patients by pairing them with care managers, who help them navigate complex health care pathways and stay. outside. of the hazard department.

Now, the 39-year-old has led a national effort to push Medicaid coverage beyond the four walls of traditional health care.

CalAIM, which started on Jan. 1, will affect approximately 15 million people who are covered by Medi-Cal, California’s Medicaid program. It would add new dental benefits, change how Medi-Cal addresses addiction and mental illness, and expand the reach of state managed care, among other changes.

But a very small part of CalAIM focuses on a small group: people who don’t have a safe, stable place to live. With CalAIM, Cooper is betting that if Medi-Cal can help people find and stay in housing, they will be healthier and save the government money in the long run.

A homeless encampment called “Heroin Alley” in Modesto, California.

“It’s more than just paying for an emergency room visit or paying for a hospital visit,” Cooper said. “We’re taking care of the most vulnerable, low-income people in this state, and our job is to do more than that.”

Creating the first Medicaid program

CalAIM began in April 2018, when Cooper traveled across California to hear from Medi-Cal providers and insurers about what they thought was and wasn’t working in the program.

Almost everywhere, he saw counties, hospitals and managed care plans working to solve patients’ problems in order to meet their health care needs.

Cooper spent the next 10 months focusing on turning what he learned into CalAIM.

One of the biggest challenges was figuring out how the federal government would provide non-medical resources. Each state operates its own Medicaid program but shares funding with the federal government, which has strict rules on what it will pay. For example, federal Medicaid funds cannot go toward paying someone’s rent.

All of the programs Cooper saw during his listening tour were supported by health plans, counties or hospitals without Medicaid reimbursement, or were part of small projects managed by Medicaid.

Cooper recalls: “There are all these things that are actually working for people that we haven’t been able to answer historically or we haven’t paid for them. How do I find a payment method? Because once you pay for something, you monetize it and the more sustainable it is, the more it grows. “

To find financial stability, Cooper turned to “in lieu of services,” a section of federal Medicaid law that allows managed care plans to pay for — and be reimbursed for — non-traditional health care services, as long as they are linked to a patient’s health and have data to show that They were cheap and well cared for.

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“It’s more than just paying for an emergency room or paying for a hospital visit,” said Jacey Cooper, CalAIM architect. “We’re serving some of the most vulnerable, low-income people in this state, and our job is to do more than that.”

Over the course of two or three months, Cooper and his colleagues refined their list to 14 “Human Resources” which would be the main components of CalAIM. Almost all of them were related to housing, from helping someone find an apartment and paying the first month’s rent to keeping someone in their home by paying to remove mold from the walls or install bathroom sinks.

“By letting a person stay in the house, they can start thinking about how to do other things in their life because they don’t have to worry about where they will sleep or what they will eat. day,” said Cooper, summarizing the concept of the new works.

Cooper joined the community with another new benefit at CalAIM, good maintenance managementwhich can provide patients with a care manager to help them coordinate all of their medical and social needs.

Cooper spent 2020 and 2021 urging federal and state officials to sign on to CalAIM before receiving the thumbs up from the federal Centers for Medicare and Medicaid Services just days after Christmas 2021.

“I came home and my husband opened a bottle of champagne and, of course, I wrote CalAIM on the cork and I will keep it for a long time,” Cooper said.

CalAIM is active

Dale Stout is one of the first Californians to benefit from CalAIM.

Stout suffered a stroke earlier this year, and while he was in the hospital, the bank took him home.

He said: “It came down like a ton of bricks.”

Stout feared she would end up in a shelter or on the streets, but a hospital worker referred her to the Illumination Foundation, a nonprofit that manages housing and health services in Southern California.

Thanks to CalAIM, Stout’s Medi-Cal insurance paid for his stay at Illumination Foundation’s. hospital rest in Riverside, where he was able to continue his recovery. CalAIM also paid a case worker to help Dale look for a new place to live and apply for housing assistance.

“If [Illumination Foundation] “If they hadn’t stepped in and taken me, I would have been on the streets,” Stout said. “I wish I was dead.”

Instead, Stout has relearned how to walk, stay calm, attended all of his medical appointments and is preparing for brain surgery this fall.

A voluntary program with many challenges

Stout’s story is symptomatic of one of the biggest challenges facing CalAIM: housing affordability.

Months after she was healthy enough to move, Stout was still at the Illumination Foundation waiting for a housing voucher to arrive, something CalAIM couldn’t do to change.

“It’s difficult when you have parts of the picture working well, and then you’re finding a margin that you’re not funding,” said Cooper, the CalAIM architect.

Stout is on track to pick up a voucher before leaving the Illumination Foundation in December. But California still faces a homelessness crisis. The recent estimates placing nearly 161,000 homeless people in California, a greater number than the 3,800 people CalAIM has helped find housing, or the 5,900 helped stay in their homes.

Other concerns center around the mechanics of starting a program with such an ambitious goal: Will the program find enough providers to provide this new service? Can providers adapt to the complex, burdensome nature of Medicaid? Will the doctors, nurses and staff know about CalAIM referrals?

A major concern of state consumer advocates is whether managed care plans — which are responsible for providing these new non-traditional services — will be able to deliver.

“Health policies don’t have a good reputation, even when it comes to providing essential health care — childhood immunizations, providing access to the health care and professionals that patients need,” said Anthony Wright, director of Health Access California. .

Managed care plans are not required to offer group benefits, but as of July 1, all 24 plans were offering at least two.

Will CalAIM help patients and save money?

Paula Lantza University of Michigan researcher who has spent years studying Medicaid’s efforts to improve health care by addressing the needs of the sick, is concerned about claims that CalAIM will save the state money.

When others education have shown that getting people housing and providing them with supportive services saves money in the long run, Lantz says 2019 book review He wrote that he found that linking difficult patients to social services was not as effective or cost-effective as compared to the same patients who received medical treatment.

“These types of strategies are often heavily marketed for political and financial gain by saying they are not participatory,” Lantz said. “

Cooper is confident that CalAIM will save money because many of these services have done the same thing as local pilots. His department estimates that if emergency room, hospital and long-term use declines by 3.3 percent by 2026, that would cut costs for the community.

But that is not the most important outcome in his mind.

“We have to be smart with taxpayer money, but if people’s health is improving and they’re getting the right care they need, I think that’s a win. That’s what we’re trying to do,” says Cooper.

Cooper knows that implementing CalAIM will be a long and messy process, but he is committed to the idea that Medicaid can and should do more for the most vulnerable members.

“I think it just adds to what we need to do, what our team needs to do,” he said. “So it’s a great opportunity, and I hope we meet this time.”

This article is from the health policy podcast Exchange, a partner of Side Effects Public Media. Dan Gorenstein is the editor-in-chief of Tradeoffs, and Leslie Walker is the reporter/producer of the show, which ran. This article on September 22. Explaining Tradeoffs for health care financing is supported, among others, by Arnold Ventures and West Health.