Judy Mohr Peterson has sat at the helm of Medicaid programs in two states that had, as she calls it, a “rocky” start of the program expansion when the Affordable Care Act was launched.
Oregon, where she worked just before taking the post with the Hawaii Department of Human Services, had similar problems with Obamacare. And this state remembers vividly the computerized clash between the DHS data system known as KOLEA and the now-defunct online ACA marketplace, the Hawaii Health Connector.
At 56, Mohr Peterson has had years in the Medicaid program, but that’s not where she started. Born in Mount Vernon, Wash., her career started in academics, earning a doctorate in cultural anthropology, focusing on women’s involvement in social movements. She lived for a few years in a low-income settlement in Guadalajara, Mexico, for that work.
Today, Mohr Peterson is delighted with the promise of improved outreach in Medicaid services that is becoming possible. Hawaii has been part of a competitive federal program that has provided technical assistance with a new approach to Medicaid, one that enables better coordination of health services with housing.
Stable housing for the homeless is one piece of the social-service puzzle that includes health, she said.
And she reports that the tide is turning on the information-technology front, too. KOLEA has been upgraded and is part of an increasingly versatile system to handle various social-services tasks, Mohr Peterson said.
“I am hopeful, also, about our ability to bring those systems more up to date to make it a lot better experience for — I was going to say ‘our workers,’ but really it’s also about the people that we serve, a good experience for them,” she said. “Because ultimately, that’s what this is about.”
QUESTION: How is Medicaid changing under the Affordable Care Act?
ANSWER: I wouldn’t necessarily tie this to the ACA; I think it’s just how the Medicaid program is evolving, with the help of the ACA. …
It’s a focus on a couple of different pathways. One is delivery-system reform … paying for services differently.
And I think the other is — and you’re seeing this in a number of different areas — a real recognition that health is a lot more than that doctor’s visit. Really, it’s talking about what we call the social determinants of health: where it is that we work, where we live, where we play, our education levels. …
Q: Are there changes in practice going on?
A: Yes. That’s what I’m really excited about. There are a lot of changes in practice.
Q: For example?
A: What we’re starting to see, even within the health care delivery system, is stopping and asking. …
Let’s consider somebody with diabetes. Within the health care world, a lot of time you’ll hear the word “compliance,” which is a very interesting way to put that, to frame that.
Q: A little harsh?
A: Yeah. (Laughs) … Instead of saying “They’re out of compliance, and I just need to educate them more about why it is important that people eat right,” start to engage differently with the folks. Find out what else is going on in their life. How is it that they …
Q: Are eating junk food all the time?
A: Exactly. And you find out that they live in what we now call a “food desert.” There are no fresh fruits and vegetables.
Or the list of foods, they are completely foreign to this person’s diet because of their cultural heritage, et cetera. They would never dream of eating those kinds of things. So it’s just a matter of meeting people where they are. …
Q: And sometimes poor people might not even have transportation, right?
A: Right. So on the Medicaid side, one of the things we’re really excited about … is taking a look at the larger system that helps people keep healthy, (which) is around housing and housing support.
We are really actively engaged in working with the Department of Health, the Governor’s Office on Homelessness (and) the Hawaii Public Housing Authority (HPHA) on addressing housing as a social determinant of health. We’re partnering together; we have some technical assistance from the federal government.
Q: Is this related to the federal grant you received?
A: Yes. It’s technical assistance. It wasn’t a grant with money, yet … they’re providing the technical assistance, subject-matter expertise. …
Q: Guidance?
A: They put us in contact with consultants and other resources we can use to bring everybody together. Our focus area is on chronic homelessness, and how Medicaid can play a larger rule in that.
That’s recognition that what we might call behavioral health — people with mental illness, behavioral health challenges, substance use, complex health challenges — recognizing that that’s their health side. … But if you don’t address the housing side, then much of the work you’re going to do on the medical side will go away, will be ineffective.
But in order to adjust it, you really have to partner with the people who are in housing.
Q: I understand that concept in theory. But in practice, how exactly does the health care provider work with HPHA, for example?
A: There are going to be different models that are going to work. … Part of it is that during the office visit they may become aware that the person is homeless.
Our ideas are that then let’s make sure that they or their office staff have a set of resources. They know how to refer, or they have a way to find out that this person has a case manager. The idea is that that case manager is also able to hook people up with the resources they need. …
We also have health care providers who go out to the street, meet people where they are, as we are trying to work on getting them housed.
Q: It sounds like everyone becomes a bit of a social worker.
A: Right. What you’re wanting to do is manage it so you’re not duplicating, but you also want to make sure that you do have the sufficient resources.
Q: Does this work better because people do go ultimately to the doctor, so you have them there?
A: Yes, that is the case. You also have, a lot of times, these individuals, especially if they are the chronic homeless, they may have a higher prevalence rate of really complex health needs, including mental health needs and possibly substance-use needs.
That combination makes it really complicated, complex. They’ll use the hospital system. They’ll use the emergency room, be in and out of the hospital frequently. So that’s another entry. …
Q: So you would say that the technical assistance has been worthwhile, even if no money came with it?
A: Well, I think so, for a couple of different reasons. I think it’s been really helpful because they’ve arranged access to people who are experts in this field of what’s called permanent supportive housing, which is exactly what we’re trying to do. …
Q: So what’s the next step?
A: We are going to continue our work in coordination with the other statewide entities working on this. … The action plan we’re putting together will become part of our overall framework on how we as a state will sustain the Housing First initiatives. …
Q: How is all this working? Do you have any metrics on this approach of getting at the health problem differently?
A: We have information nationally, where we’ve seen it work. …
On the health side, how we know it’s working is just within a few short months of working with these folks, their overall emergency room utilization dropped dramatically, by 50-60 percent. So what we know is if we do make these investments, it actually pays off in the long run because you are able to reduce their intensive use of these really expensive services. …
Q: Recent figures have shown that the ACA hasn’t yet redirected new Medicaid users away from emergency services. Why is it that there is a still that tendency for low-income groups to end up in the ER?
A: It’s a combination. … There’s a couple of things that are oftentimes going on, particularly when you are talking about a population that does not have housing.
The one thing about an emergency room is that they can’t turn you away. And so when you’re on the street, you’re not necessarily able to make your way to a doctor or clinic; it becomes challenging. So you do see that somewhat as a pattern. …
The other thing that’s going on here is, it’s a few individuals that are, one, highly visible and are driving those numbers. …
We also know that many of those individuals who are homeless, living on the streets, actually don’t seek care. And that causes health issues. They wait until things become acute, become severe before seeking care.
That’s why getting people housed will help to break that cycle. …
Q: There were problems with the DHS KOLEA data system when the ACA started. How’s it going?
A: I think all the changes in implementation of Medicaid itself, and the Connector, the marketplace, it was a rocky start in many states. The state I came from, it was a rocky start in Oregon.
Here, rocky start. But unlike Oregon, Hawaii had built a strong Medicaid system. It had its challenges to start, but in the intervening years since that point, they’ve made a number of changes and updates. It actually works well to do the Medicaid determinations. You can go online and enroll.
I think what a lot of people don’t recognize with the ACA was, it wasn’t just the Medicaid expansion. It was the biggest change in Medicaid since its inception. It completely changed how Medicaid was determined.
Instead of looking at it from the philosophy of, “You have to meet this long laundry list of eligibility criteria,” the assumption was that if you were below a certain income level, that you would be eligible for some form of health insurance, and we just had to figure out what level. It’s a very different perspective and philosophy.
