Dec. 12, 2024  |  Vol. 28 No. 9  |  Archives

In this issue:

Mark your calendars: The National Health Care for the Homeless Council, National Coalition for the Homeless, and National Consumer Advisory Board (NCAB) - a standing committee of NHCHC - are organizing a virtual Homeless Persons’ Memorial Day event on Friday, Dec. 20, 2024 from 2-3:30 CST. This event brings communities together to recognize those who have lost their lives while living in homelessness.  We asked NCAB and Clinicians Network Steering Committee members for their insight on what this day means to them:

Over the last 20 years, I’ve lost many friends to homelessness. Each time, I’m reminded of the countless others across our country facing the same fate. HPMD is a way to honor those lives and to remind ourselves how much work needs to be done to prevent more loss.

Amy Grassette
NCAB member

On this Homeless Persons Memorial Day, I wish for one more shout at me: "You're late again!" followed by the warm chuckle of a homeless friend who waited for me every Wednesday. My friend is no longer here to shout at me because they died in the bitter cold, without a home. 

Colleen Ryan
Heartland Alliance Health
Chicago, IL

People experiencing homelessness deserve to be remembered and celebrated when they pass away, and care teams deserve to have space to remember clients that they worked closely with and cared for deeply.  

Physician
San Francisco

Despite continued advocacy efforts, experiencing homelessness has enormous health consequences and increases an individual’s risk of death, regardless of whether they are in a congregate shelter or on the streets. A lack of standardized nationwide data collection and reporting mean that the actual number of individuals who die each year while experiencing homelessness is unknown. The Council’s Homeless Mortality Data Workgroup, established in 2019, continues to unite expertise and share best practices on how localities can carry out their own homeless mortality work.

This fact sheet offers current high-level mortality estimates, action steps for using this data, links to local/state mortality reports, and additional resources on homeless mortality.  Use this data in your work to illustrate the dire health consequences of homelessness.

Unhoused people are 3.5-4.2 times more likely to die than housed people.

Unhoused people die 20 years earlier than housed people.

Sheltered and unsheltered people have similar mortality risks.

Unhoused people have 60% greater mortality risk than other poor, but housed, people.

Related Reading on Homeless Mortality

Take Action

On May 1, 2023, Daniel Penny killed Jordan Neely (a man experiencing homelessness) on a New York City subway car in full view of many people—some of whom filmed the murder. This week, a jury found Daniel Penny not guilty of criminally negligent homicide (after second degree manslaughter charge was dismissed). Penny is a White veteran, while Neely was Black and had mental health issues.

Mobilizer readers may recall a Closer Look blog focused on this crime at the time—Three Kinds of Murder—where we talked about the pervasive direct violence that kills people (murder #1), but also about the murders committed indirectly by public policies (murder #2) and the violence that comes from the all-too-common silence when people say or do nothing in the face on injustice (murder #3). The post also mentioned a fourth kind of violence—the trauma to the spirit and the soul of all this violence.

Four types of murder at work here: the prolonged chokehold, the lack of support Neely clearly needed, the people who said and did nothing as they watched this murder unfold…and ultimately, the lack of accountability for the crime. It corrodes the soul to see yet another White man killing a Black man with impunity.

Vocal-NY, a local advocacy group in NYC, released a statement that included this sentiment: “This case will harm and scare people who are seen as invisible or a danger when they walk into a subway station. Are unhoused New Yorkers’ lives not worth the same as other subway riders because they sleep on the train? “

The return of Donald Trump to the White House with a Republican-controlled House and Senate will bring significant policy change. Their policy intentions have been made clear in numerous public statements as well as publications including Trump’s Policy Platform, Project 2025, the FY2025 Republican Study Committee budget plan, and the FY2025 House budget resolution. Outlined throughout these proposals are numerous policies that impact health care and housing and would have enormous impact on the HCH Community.

Our new fact sheet focuses on those policies most impactful to the HCH Community, outlines the implications of these changes, and offers initial action steps to consider in anticipation of an Administration that has promised rapid, substantial policy change. Topics covered include Medicaid, public health, immigration, substance use, housing, and homelessness (among others).  Check out this month’s Closer Look blog to learn more about President-elect Trump’s nominees for leading the Department of Health and Human Services.

Take Action

In preparation for the anticipated changes, we recommend the HCH Community take the following 8 action steps (see more detail about these action steps in the fact sheet!):

By Barbara DiPietro, PhD, Senior Policy Director

President-elect Trump is nominating his next Cabinet as well as other advisors who will carry out the President’s agenda. These folks will make policy and funding decisions that directly impact the HCH Community—and it’s important to know who these folks are and what perspectives they bring to these roles. This month, we’ll focus on three people nominated to lead the U.S. Department of Health and Human Services (and agencies within HHS), which houses programs that administer Medicaid, Medicare, health centers, public health, and much more. 

Health and Human Services (HHS)

Robert F. Kennedy, Jr., is the nephew of President Kennedy and the son of Attorney General Robert F. Kennedy—both assassinated in the 1960s. RFK, Jr has dedicated his life to environmental causes and is the founder of Waterkeeper Alliance (a clean water advocacy group) and the Children’s Health Defense (a group focused on childhood chronic diseases and toxic exposures). He has never run a large organization. 

A vaccine skeptic and conspiracy theorist, Kennedy promotes the widely debunked myth that vaccines cause autism, has been critical of the COVID-19 vaccines, and has significantly contributed to online misinformation about vaccine safety. He will likely move to weaken vaccine mandates (or eliminate them altogether). He does not believe that HIV causes AIDS (it does), opposes adding fluoride to water (a core public health advance), and promotes drinking unpasteurized, “raw” milk (dangerous, don’t do it). 

We don’t yet know much about his positions on Medicaid, health centers, or other program areas that most directly impact the HCH Community. His interests and public comments have focused solely on the public health issues mentioned above—but his views on these issues are highly concerning for an official in charge of the nation’s health. If he changes vaccine policy, it’s possible we’ll see higher rates of measles, meningitis, polio, and other infectious disease. In response, the American Public Health Association has opposed his nomination, and 77 Nobel prize winners have signed a letter urging the Senate not to confirm him. 

Centers for Medicare and Medicaid Services (CMS)

Dr. Mehmet Oz is a physician (a cardiothoracic surgeon) who is best known for his daytime tv show, The Dr. Oz Show, which ran for 12 years and ended in 2022 when Oz ran as a Republican candidate for the Pennsylvania Senate (which he lost to John Fetterman). Like RFK, Jr., he has no experience running a large organization. He promoted (and profited from) dubious claims and debunked recommendations on his tv show (to include “miracle weight loss supplements”) and advocated for ineffective COVID-19 treatments as well as other unscientific endorsements. Oz is a staunch supporter of the private Medicare plans known as Medicare Advantage—and has written articles proposing to do away with traditional Medicare in favor of these (more expensive) private plans. 

Like Kennedy, he holds anti-science public health views and brings an outsider view toward government. His views on privatizing Medicare give some perspective on where he might focus within CMS, however, his positions on Medicaid remain unknown. 

Centers for Disease Control and Prevention (CDC)

Dave Weldon is a physician (internal medicine) and former U.S. Congressman from Florida (1995-2009). During his time in office, he was an outspoken critic of public health systems and vaccines—and introduced a bill to transfer the CDC’s vaccine program to an independent agency to reduce CDC authority.  

Like Kennedy, Weldon has never run a large organization, is not an expert in infectious diseases, and believes vaccines cause autism. Given that he would be overseeing the agency specifically tasked with developing vaccine guidance, responding to infectious disease, and other core public health functions, his leadership could lead to significant policy shifts that undermine both vaccine support and public health broadly. 

These three nominees bring a completely different set of priorities and personal views to core health care functions of our government than the current administration. Most Americans indicate they do not trust Kennedy or Oz (or Trump) on health care issues. We do not yet know what specific changes they will seek, how they plan to roll out new initiatives, or how they will approach larger programs such as Medicaid and HRSA’s health center program (which cover/deliver vaccines).  

Stay tuned in 2025 as we continue to focus on the new Administration and how the HCH Community can remain up to date on developments and advocate for constructive solutions. 

Although Medicaid was only briefly mentioned during the 2024 election cycle, Republicans have made clear their intentions to repeal Medicaid waivers, lower the federal match rate, and add work requirements. The policies are likely to have major impacts on the HCH Community because 55% of HCH patients  rely on Medicaid. States like California, New York, and Hawaii are urgently pushing to get Medicaid requests approved before Trump takes office. The states are hoping to use Medicaid expansion to pay for social services including housing and food assistance, which are unlikely to be a priority under the Trump administration.

Trigger laws: The reduction in federal Medicaid funding is one of the biggest potential changes on the horizon. Nine states (Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia) have “trigger” laws in place that automatically end Medicaid expansion if the federal match rate drops below 90%. These trigger laws could cause millions of individuals to automatically lose Medicaid coverage, with no state action necessary. For states without trigger laws, reducing the match rate would shift more financial burden to the state and force them to decide whether to absorb the increased costs or cut coverage, reimbursement rates, or services.

Work requirements: Numerous Republican proposals have included adding Medicaid work requirements, despite overwhelming evidence that most Medicaid enrollees are already working and that work requirements reduce coverage and do little to increase employment. These policies could come as a national rule or state option and would impose major barriers to access for vulnerable populations, even those who are already working or may be exempt from the requirement.  

Related Reading: 

Congress is back and scrambling to fund the government before the continuing resolution (CR) expires on December 20th. Unable to reach an agreement on fiscal year 2025 spending bills, Congress will need to pass another CR – also known as a stop-gap funding bill – to avert a shutdown. 

Among CR negotiations is a Republican proposed health care package that includes a one-year extension of traditional Medicaid provisions, a one-year physician payment adjustment of 2.5 percent, and flat funding for federally qualified health centers. The package also includes proposals to offset the cost of these extensions through a full repeal of the Biden administration’s nursing home staffing rule and delinking pharmacy benefit manager transparency provisions from Medicare Part D.

A major budget concern for the HCH Community that needs to be addressed before year end is reauthorization of the Community Health Center Fund (CHCF), a line of mandatory funding that provides 70% of health center funding. The CHCF expired in 2023 and was temporarily extended through December 31, 2024. Our partners at the National Association of Community Health Centers are urging Congress to include $5.8 billion for the Community Health Center Fund in any year end package before the fund expires.

Take Action

Contact your legislators today! Illustrate the vital importance of your health center’s services and ask them to increase health center funding!

Related Reading

DEA & HHS: Telehealth Flexibility Extended: The DEA and HHS announced another extension of the COVID-era telehealth prescribing flexibilities through 2025, maintaining the conditions of the original extension which allow Schedule II-V controlled substances to be prescribed via telemedicine (e.g., Suboxone/buprenorphine and methadone). Advocates have been urging the federal government to make the extension permanent. This latest one-year extension punts the permanent extension decision to the Trump administration, who will have to decide by the end of 2025. For HCH providers, this flexibility helped reduce barriers to medications for opioid use disorder and ease some of the financial burden for clinics who can reimburse tele-visits. Permanently extending the telehealth flexibilities is essential to continuing care and preventing disruptions for patients.

Related Reading

HRSA: Funding and Policy Notice for Justice-Involved Populations: The Bureau of Primary Health Care (BPHC) released a final policy information notice (PIN) providing guidance to health centers on services to support justice-involved individuals reentering the community. The PIN includes definitions for the population to be served, allowable new services, criteria for adding new services into scope of project, and how to document the provision of care. To support these service expansions, BPHC released $52 million to 54 health centers to focus on managing chronic conditions, reducing the risk of overdose, addressing behavioral health conditions, and screening/treating infectious disease.

On December 4th the Supreme Court heard oral arguments for a case that will determine whether states can ban gender affirming care for young people. The case, US v. Skrmetti, considers the constitutionality of Tennessee’s law (SB1) which prohibits the use of puberty blockers and hormone therapy for minors and establishes a private right of action against medical providers who violate the law. The question at hand is whether the law violates the Equal Protection Clause of the Fourteenth Amendment since the law explicitly classifies minors based on sex and transgender status.

Although the case is specific to Tennessee, the Court’s ruling has the potential to impact state law across the country. Currently 23 other states ban best practice medication and surgical care for transgender youth, although not all bans are in effect. The families challenging the law argue that this care is lifesaving, and studies have found that youth who receive gender affirming care have lower rates of suicidal ideation and attempts. If the Court upholds Tennessee’s law, transgender youth across the country may lose access to medically necessary care, a decision that could extend to adults – impacting the future of health care for transgender individuals more broadly.

The Court’s ruling is expected by July 2025 and likely have a strong impact on how/whether health centers can provide care to transgender adults and youth.

Related Reading

A recent court decision in British Columbia and Ontario ruled that people experiencing homelessness can lawfully sleep outside if no shelter beds are available. In the decision, the Justice wrote that evicted people from municipally owned property deprives the encampment resident of “life, liberty, and security of the person.”  One city, who had come to a growing recognition that encampment sweeps were not a solution, used the ruling to begin experimenting with regulating, not sweeping encampments. Halifax, Canada temporarily approved nine sites allowing for individuals experiencing homelessness to lawfully camp within the city. Each site has a proposed limit of twelve tents, has portable toilets, and outreach workers come by weekly.  

The rulings by the Canadian courts and the approach by Halifax represent a stark contrast to the approach the U.S. has taken in the wake of the Johnson v. Grants Pass case, which has increased encampment sweeps across the states. San Francisco has continued to ramp up policing of homeless camps and its Mayor, London Breed, implemented a relocation program that requires city workers to offer individuals experiencing homelessness a bus ticket before offering a bed or other services. The approach aims to ship people out of the city rather than providing care. These punitive approaches are harmful, inhumane, and perpetuate cycles of poverty and hardship. ProPublica released a new article, Swept Away, that breaks down the impact of these policies on individuals across 16 cities.

Laura Brennan
Senior Policy Manager
National Health Care for the Homeless Council

lbrennan@nhchc.org

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