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December 20, 2022 | Volume 26, No. 11| Archives
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| All Hands on Deck:
Let's Get the MAT Act Passed!
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| In This Issue:
- MAT Act Update
- Homeless Persons' Memorial Day
- New Resource on Encampment Sweeps
- Upcoming Events: Medicaid Redetermination
- Reckoning with (Proposed) Rules
- Substance Use and Harm Reduction
- Administration
- Congress: On or Off the Omnibus
- News to Know: Medicaid
- Local Spotlight: Colorado Coalition for the Homeless
- A Closer Look: Committed to Each Other
- COVID Corner
- What We're Reading
- Good News Corner!
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Three providers in the HCH community have published op-eds in their local papers—to catch the eye of their respective U.S. Senators—describing the need to pass the MAT Act: Jacob Rickoll, Primary Care Provider from Crescent Care in New Orleans; Christopher Smith, Nurse Practitioner from the Fourth Street Clinic in Salt Lake City; and Courtney Pladsen, Nurse Practitioner at Greater Portland Health in Portland, Maine and Director of Clinical and Quality Improvement at NHCHC.
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Take Action NOW to Get This Measure Added to the End-of-Year Budget Package Being Considered in Congress!
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| Homeless Persons' Memorial Day: Virtual Live Event on Dec. 21
The National Consumer Advisory Board, the National Coalition for the Homeless, the National Alliance to End Homelessness, and the National Health Care for the Homeless Council are promoting Homeless Persons’ Memorial Day events on (or around) Dec, 21, the first day of winter and the longest night of the year.
At these events we remember those who have died and strengthened our resolve to work for a world where no life is lived or lost in homelessness. We state clearly, together with others in scores of communities across our nation, that no person should die for lack of housing. See our HPMD Advocacy Agenda for 2022 for ideas on how to push for needed change.
Wednesday, Dec. 21, 2022
3:30 PM EST / 2:30 PM CST / 1:30 PM MST / 12:30 PM PST
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| New Resource! Impact of Encampment Sweeps on People Experiencing Homelessness
Unsheltered homelessness is difficult enough, but being forcibly displaced through encampment “sweeps” is especially traumatic. Our new issue brief describes the impact of sweeps on encampment residents and local communities, and provides recommendations for more constructively responding to unsheltered homelessness. Specifically, encampment sweeps:
- Damage health, wellbeing, and connections to care
- Compromise personal safety and civic trust
- Undermine paths to housing and financial stability
- Create unnecessary costs for communities
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Jan. 19 Town Hall: Medicaid Redeterminations
National Town Hall: Medicaid and Homelessness
Join us on Jan. 19, 2023, at 3 p.m. ET for a town hall conversation with the National Coalition for the Homeless as we discuss Medicaid coverage for people experiencing homelessness. Topics will include: Medicaid redetermination at the end of the Public Health Emergency (PHE), new guidance from the Centers for Medicare and Medicaid Services (CMS) on how states must complete applications, and Medicaid Expansion. Register Here to join this important conversation as we discuss what these upcoming events and changes mean for your community and how you can help.
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Reckoning with (Proposed) Rules
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- Confidentiality of Substance Use Disorder (SUD) Patient Records: The Substance Abuse and Mental Health Services Administration (SAMHSA) released a proposed rule that would change privacy standards for health records of patients with substance use disorder. This new rule aims to make it easier to provide care coordination while still protecting patient records under HIPAA. Importantly, it prohibits use of patient records from being used in civil or criminal proceedings. Read SAMHSA’s fact sheet for more information. Comments are due Jan. 31, 2023.
- Medications for the Treatment of Opioid Use Disorder: SAMHSA also released a proposed rule designed to expand access to treatment for opioid use disorder. The rule includes many provisions related to methadone and Opioid Treatment Programs (OTPs), however, the key provision impacting the HCH community is a proposal to make permanent the COVID-19 flexibility to allow buprenorphine inductions via telehealth. Read SAMHSA’s press release for more information. Comments are due Feb. 14, 2023.
- Advancing Interoperability and Improving Prior Authorization Processes: The Centers for Medicare and Medicaid Services (CMS) released a proposed rule aimed at streamlining the prior authorization process, reduce provider administrative burdens, and improve patient access to health information. Note that they propose to require impacted payers to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests. Read CMS’s fact sheet for more information. Comments are due March 13, 2023.
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Substance Use and Harm Reduction
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| - States are receiving $26 billion in opioid settlement funds. While each state has their own plan on how to spend the funds, 70% of the money must go into opioid-related expenses like expansion of Medication Assisted Treatment. However, rural areas are getting a small portion of the funds even though they are disproportionately impacted. Rural communities need more resources to address opioid addiction in part because they need to develop greater treatment capacity, and do not have the existing infrastructure found in more urban areas. Unfortunately, this approach may lead to widening health disparities.
- Several cities have opened naloxone vending machines to provide greater accessibility to overdose prevention measures. Traditionally conservative states like Texas, North Carolina, and Kentucky have also implemented this program and found high rates of vending machine use. Similarly, Nevada is pioneering a needle exchange vending machine in Las Vegas.
- San Francisco plans 12 proposed safe consumptions sites, with the first planned to open by June 2023. Conversely, New York Governor Kathy Hochul said none of the state’s opioid settlement money will go to funding for safe consumption sites.
- Texas Governor Greg Abbott changed his mind about fentanyl test strips and says he now supports decriminalization. Meanwhile, the Ohio House passed a bill to decriminalize fentanyl test strips on a bipartisan basis (it now goes to the Ohio Senate for consideration).
- Substances containing fentanyl are appearing with a more concentrated form of the drug that can be up to 100 times stronger making it harder to prevent overdose. Xylazine is also being found in fentanyl and is causing necrosis and amputations.
- Overdose deaths across the United States have increased to 107,735 fatalities in the 12 months prior to July 2022.
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- U.S. Interagency Council on Homelessness: On Monday, the USICH released its newest strategic plan to end homelessness. Save the date for a national webinar to go deeper into the plan: Tuesday, Jan. 10, at 2 p.m. ET. More details will be available in the coming weeks.
- White House: President Biden signed into law the Respect for Marriage Act, which enshrines federal protections for same-sex and interracial marriages. The Medical Marijuana Research Bill also became law, allowing researchers more freedom to study the substance despite its Schedule I status. The White House also unveiled a new website designed to track nonfatal overdose deaths. This data will help first responders be more effective and target areas with a rise in overdoses as well as distribute naloxone in those high-risk communities.
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| | CONGRESS: On or Off the Omnibus
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| - The current continuing resolution is set to expire Dec. 23 but lawmakers may have reached an agreement for an omnibus appropriations bill. The topline budget numbers have yet to be released but lawmakers sent an $858 billion defense package to President Biden, which is a 10% increase over current funding. It also repeals the military’s COVID-19 vaccine mandate.
- The domestic funding levels have been the sticking point with Democrats asking for social services funding to combat inflation and Republicans claiming enough has already been done. Senate Majority Leader Schumer has made few promises about the budget package beyond saying it will include the Electoral Count Act and funding for Ukraine.
- An omnibus would allow extra policy provisions to be attached to the bill—like The MAT Act (see Action Alert above). These provisions, among the most important to our community, have an uncertain fate. The omnibus package hasn’t been passed yet and Congress likes to give us last-minute surprises. With the new CR taking us up to the last minute, we won’t know if we are getting on or off the omnibus until Congress punches our ticket.
- Republican leadership for the House is still undecided. Amid Kevin McCarthy’s struggle to obtain the votes he needs to be Speaker, Arizona Republican Rep. Andy Biggs has announced his candidacy for the top position. Rep. McCarthy’s uncertain path to the Speaker’s role is delaying key committee assignments and magnifying a split within the Republican party.
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| - Several Republican-led states are considering Medicaid expansion. As more and more rural hospitals are at risk of closure, non-expansion states are desperately trying to keep them afloat. North Carolina, Kansas, and Wyoming are all making forward progress toward Medicaid expansion. Forward progress can be loosely defined, and it remains to be seen how much longer it will take non-expansion states to catch up to the evidence-based data.
- Unfortunately, onerous ballot requirements in Florida and Wyoming make expanding Medicaid in many states difficult, if not impossible.
- South Dakota’s Medicaid expansion may hit some administrative and political hurdles as it moves into implementation. Hundreds of new staff and updated technology are needed for a successful expansion to the estimated 52,000 newly eligible South Dakotans. Advocates also fear a Republican legislature will slow or try to prevent the process.
- Georgia now will implement work requirements for Medicaid eligibility after a federal court ruling. This new measure is anticipated to expand access to 50,000 people (a fraction of the 450,000 it would have been able to cover with an unrestricted Medicaid expansion). People experiencing homelessness will most likely be unable to meet the high-barrier work requirements, and it remains uncertain if the 12 other states that wanted to impose work requirements on Medicaid enrollees will take advantage of this ruling.
- Advocates are still pushing to pass the Medicaid Re-Entry Act (S. 285; H.R. 955), which would allow Medicaid to cover health care services in the 30 days preceding release from prison or jail. The bill has passed the House as part of several different legislative packages but has not passed the Senate.
- Advocates are also trying to include 12 months of postpartum coverage for Medicaid recipients into the end-of-year package.
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Local Spotlight: Colorado Coalition for the Homeless
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| The Colorado Coalition for the Homeless in Denver is driven by a philosophy of creating lasting solutions for homelessness through collaboration and community engagement. Serving almost 23,000 clients a year, CCH provides employment, housing, health care, and other social services to the Denver community. CCH just opened a brand new medical respite care facility called Stout Street Recuperative Care Facility which can serve 400 people annually. Congratulations, CCH on such a wonderful achievement!
On the advocacy front, CCH led a successful 2022 ballot initiative to allow the city to keep extra tax funding dedicated to homelessness. Their efforts allowed an additional $1.3 million to go toward shelter services, support services, case management, housing construction and pandemic responses—beyond the $40 million already collected. Cheers to your successful advocacy!
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A Closer Look: Committed to Each Other
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| On Nov. 29, New York City Mayor Eric Adams announced a plan aimed at people with severe mental illness (SMI). Mayor Adams said New Yorkers had a “moral obligation” to act when they saw people with SMI living on the streets in the throes of their illness. This directive allows New York Police Department (NYPD) officers, first responders, and others to pursue involuntary hospitalization for a person “who appears to be mentally ill and displays an inability to meet basic living needs even when no recent dangerous act has been observed.” The previous standard for commitment was “danger to self or others.” Providers like Dr. Katherine Koh, a psychiatrist at Boston Health Care for the Homeless, asserts the focus should be on expanding community-based mental health services and access to permanent supportive housing.
This proposal raises some safety and civil rights concerns. People with untreated mental illness are 16 times more likely to be killed during a police encounter than others, hence the NYPD might not be the best point of contact to engage people in crisis. Nearly two thirds of the NYPD have not undergone crisis intervention training on how to properly handle mental health calls, yet this new policy asks police officers to make decisions about the health and safety of vulnerable individuals.
The Bazelon Law Center, specializing in mental health law, released a statement signed by nearly 300 organizations (to include NHCHC) to press for a broader range of more effective and humane approaches. Many are concerned that this policy leaves out an essential piece of recovery: supportive housing. To learn more about this issue from a provider’s perspective, Mobilizer staff sat down with Van Yu, a psychiatrist in New York City who works with people experiencing homelessness, and is a member of the NHCHC Board of Directors.
NHCHC's Corinne Lovett: What are the outcomes for patients who experience involuntary commitment?
Van Yu: There is a small subset of people who are street homeless in New York City, I would guess maybe 100-200, for whom regular treatment doesn’t work for and who might need involuntary commitment to stay safe. That being said, there are plenty of people with SMI who could benefit from inpatient hospitalization even when they don’t want services. The key to helping these patients in the long run, however, is supportive housing. Around 90% of my patients could get better with access to supportive housing. People with SMI can be successful if they can stay connected to care in the community upon discharge.
Corinne Lovett: Are you able to maintain contact with patients who have been involuntarily committed or maintain trusting relationships?
Van Yu: An effective therapeutic relationship requires trust. We have a saying here that the relationship is the treatment. Patients are the ones doing the hard work of taking their medication and making behavioral changes. I can give recommendations and prescribe medications but it’s the doctor-patient relationship that is the most effective treatment I can provide.
While involuntary commitment can sever these relationships, that is not always true. I had a patient who was having a manic episode in the emergency room. I hadn’t seen him in over a year so when the ER called to consult me, I told them that. The patient got admitted involuntarily and called me from his unit really angry. He blamed me even though I had nothing do to with it. I didn’t see him for another six months after that but then he popped back into the office. We re-established our relationship and we never ended up talking about how he was hospitalized.
Corinne Lovett: Do you think it will be harder to find your patients or keep them connected to care under the mayor’s new policy?
Van Yu: I think it might because it already is. When NYPD officers or other first responders choose to commit someone, they often don’t tell the health care or homeless services providers because they often don’t know who to tell. Then the hospital doesn’t know who to reach out to for discharge and we can lose the connection to that patient.
Corinne Lovett: Do you think the mayor’s new initiative will support people experiencing homelessness with mental health issues? What is your position on this topic?
Van Yu: I think there is more to it than that. I believe the involuntary commitment law as it was originally written was meant to include people who could not care for themselves. I agree with the mayor’s sentiment that we have a moral responsibility to people with SMI but taking people to the hospital is only part of what would help.
Hospitals face monetary and capacity limitations. There may not be enough hospital beds to treat all the patients that might qualify under this directive. Then you need sufficient, effective places to go when they are discharged. It’s our goal to have people living in the community. Permanent supportive housing is a proven solution for many such people. People engage in treatment after they are housed and have a measure of stability.
Corinne Lovett: Do you have any stories about involuntary commitment that speak to this issue?
Van Yu: I had a patient who was very mentally ill. She had breast cancer and would not acknowledge or admit it. She refused all treatment. I was unsure if she lacked capacity to make that decision, so I did not involuntarily commit her and force her to get care. I ended up slowly watching her die from that cancer. She would have had to have chemo or surgery which are impossible to involuntarily provide. I let her make her own decisions. It’s been 20 years and I still think about her and whether I made the right choices.
Corinne Lovett: What do you admire about your patients?
Van Yu: So much! I can empathize with their struggle, but I can’t understand their journey. It is incredibly difficult to live with symptoms of mental illness. I don’t know if I could do it. It is inspiring to watch people carry on and stand up for themselves. They are brave people.
Corinne Lovett: If you could make any change to society, how would you better the lives of people with SMI?
Van Yu: I’ve been thinking about whether instead of coerced treatment the system could design some kind of humane, compassionate coerced housing. If someone is experiencing homelessness, we could show up and offer them three choices of a place to live, let them pick one, and hand them their keys. But they have to pick one. No more living outside. Once someone is housed, then they can fully engage in treatment voluntarily, or not. It would end homelessness by giving people housing.
Van Yu’s perspective is his own. His concern for his patients and their welfare is obvious. Drawing conclusions from this interview, it is clear that for the mayor’s policy to be effective there needs to be a systems-level change that involves supportive housing in the community. People with SMI deserve help, health care, and housing to improve their lives.
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Vaccinations: This fall has brought a barrage of respiratory illnesses. As winter gears up, the Biden Administrations is pushing to get more Americans up-to-date on their COVID-19 vaccinations. As part of this effort, HRSA announced a new $350 million vaccine initiative. These one-time funds can be used to expand outreach and education, community engagement, and coordinated events to increase vaccinations. A recent study found a 10-fold return on COVID vaccine investment, serving as a reminder of the importance of getting people experiencing homelessness vaccinated. Our recent publication on Calculating Vaccination Rates can serve as a guide to tracking your efforts.
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We often share bad policy news, but we’re committed to finding good policy news out there! Here are stories we found this month that lifted our spirits:
- The Food and Drug Administration has fast tracked review of over-the-counter naloxone. This life-saving medication could be available on shelves as early as next March. Advocates say making naloxone more accessible could reduce stigma around the medication. It is unclear how this will impact the HCH community. Requiring payment for Narcan makes the medication out of reach for many PEH. There is also a concern that clinics and local health departments will stop getting free Narcan doses. Officials may argue that expanded over-the-counter access negates the need for public health distribution. However, over-the-counter Narcan could expand access in communities without nearby local health departments or pharmacies
- Sen. Bernie Sanders will be the new chairman of the Health, Education, Labor, and Pensions committee! A long-time supporter of single-payer and Medicare for All, Sen. Sanders will push for our policy priorities!
- Hakeem Jeffries will be the first black lawmaker to lead a party in Congress. House Democrats elected Rep. Jeffries to replace Nany Pelosi as she steps down from her leadership position.
- Raphael Warnock emerged as the winner in the Dec. 6 Georgia Senate runoff, giving greater assurance that legislation adverse to the interests of the HCH community is less likely to pass the Senate.
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Did you receive Mobilizer as a forwarded email or hear about it via social media? Register now to receive our action alerts each month!
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This publication and all HCH advocacy are funded by dues from Organizational Members of the Council and by private donations. Consider joining the Council to support this work.
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