About 3.6 percent of the Medicaid population in Hawaii uses 61 percent of the Medicaid budget annually. That’s right, 14,000 people — including those covered under Quest and AlohaCare — utilize $1.2 billion of Hawaii’s Medicaid.
The population comprises the aged, blind and disabled, plus others who meet criteria based on limited income. Because so many of the major drivers of health-related costs are beyond the scope of health care alone, individualized, multifaceted solutions are both essential and justified.
Many of the 7,620 homeless people in the islands are among the high-utilizing Medicaid group. Compared with the general population, the homeless require more emergency room visits and hospital readmissions, which are paid for by the Department of Human Services.
In addition to physical problems, their health care needs often include the dual diagnoses of mental illness and drug addiction.
They also require substantial resources from the Department of Public Safety, particularly the law enforcement and corrections divisions, as well as the state Judiciary.
“We need to synergize our efforts to solve the homeless crisis, care for those with chronic disease and develop a statewide plan to address untreated mental illness and drug addiction. Taking on these challenges in isolation will result in failure,” state Sen. Josh Green (D, Naalehu-Kailua-Kona) said.
The magnitude of human suffering among this fragile population comes with tremendously high, cumulative costs to society. Their problems cannot be solved by temporary, emergency measures or by moving them from one encampment across the street to another. The best strategy is to invest in an effort that addresses all of the problems of each individual, beginning with food and shelter, followed by longitudinal health care that includes management of mental illness and addiction, then initiatives for education and employment. Concurrent efforts must be made to work upstream to identify the at-risk population and, through prevention, avert the need for more costly rescue and remediation.
Health-related social needs are frequently left undetected.
“Needs, such as food insecurity and inadequate or unstable housing, may increase the risk of chronic conditions, reduce an individuals’ ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization,” according to the Centers for Medicare and Medicaid Services.
It has been shown that for food-insecure households, health care costs were 49 percent higher than those of secure households. These findings are not unique to Hawaii or the mainland. High-cost user status was most strongly associated with food insecurity, personal income, and non-homeownership according to another study done in Canada.
With this in mind, U.S. Rep. Tulsi Gabbard has supported two state bills and has provided testimony about nutrition as a social determinant of health, and about available federal dollars that have been left on the table.
Under the CMS Accountable Health Communities Model, $157 million was earmarked to test whether screening beneficiaries for health-related social needs, then making referrals to appropriate community-based services and helping them navigate those services would improve quality and affordability in Medicare and Medicaid.
Multiple factors arise with the medically fragile and homeless population, including wealth disparities, broken homes, alcohol and substance abuse, sexual and physical abuse, obesity, poor nutrition, trauma, mental illness (including post-traumatic stress disorder), and, ultimately, social isolation. The human suffering and cumulative costs demand solutions that address the unique and complex needs of each individual. Such investment is worthwhile.
Ira “Kawika” Zunin, MD, MPH, MBA, is a practicing physician. He is medical director of Manakai O Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
