When you travel along bustling Seventh Street in Mission Bay, San Francisco’s gleaming center of health science and research, it’s impossible to miss the line of tents clinging to the chain link fence along the Caltrain tracks. The mini-village is one of many makeshift encampments of homeless people across the city — like the one behind the backstop on the city ball field at Potrero and Cesar Chavez, where children play. Or the one along the wall at Wisconsin and Eighth Street. Or the one in front of the murals on Florida near Mariposa. It is estimated that 6,600 of San Francisco’s residents are homeless.
Homelessness has long been a pressing national social problem; the desire to do something about it may now be approaching critical mass in California. In Sacramento, state officials are discussing a $2 billion bond issue to support housing for homeless people with mental illness. Around California, local law enforcement leaders are warning that efforts to reduce prison crowding are increasing the populations of people living on the street.
This week San Francisco media outlets jumped into the discussion in a big way. A collaborative of journalists from many newsrooms in San Francisco set aside their usual fierce competitiveness to coordinate coverage of perhaps the most painful of all social diseases, to be nobody to anybody. It’s an unprecedented media effort to prod each of us to bring our humanity, our ingenuity, and our plentiful resources to bear on a social ill that has plagued government officials, civic leaders, and philanthropy for decades.
Our purpose at the California Health Care Foundation is to foster health care that works for all Californians. As a health philanthropy we understand our responsibility to be a part of the solution to help California design a system of supports that includes long-term affordable housing for the chronically homeless — a system that can be easily navigated and that provides care and treatment of medical and social conditions alike.
The lack of affordable housing, unemployment, poverty, disability, and low wages are powerful determinants of whether people become chronically homeless. We need a care system that sees and takes into account the needs of the whole person — their mental, physical, and social service needs and conditions. Many people who are chronically homeless cope with serious mental illness, substance use disorders, physical and mental disabilities, and multiple chronic medical conditions that overwhelm their capacity to manage their needs. It’s nearly impossible to navigate a fragmented health care and social services safety net when you’re living in a torn tent under a freeway.
Recent changes in the policy environment give me reason to believe that we can, working together, find ways to meet this problem head on. The first is the expansion of Medi-Cal as part of our state’s implementation of the Affordable Care Act (ACA). As a result, many who today find themselves living on the streets are eligible for Medi-Cal. In addition, the ACA both broadened the services covered through Medi-Cal to address behavioral health care conditions and expanded the requirement that plans offering mental health or substance use disorder coverage must do so at the same level of benefits as they provide for general medical treatment.
In this ACA environment we have the policy framework to make meaningful strides in addressing the needs of people who are homeless. Successful approaches to homelessness must include supportive housing — long-term, permanent housing colocated with the services homeless people need to survive: medical and behavioral health providers, social workers, food sources, and counselors to help them manage their general assistance, disability, or other monthly support payments. Stable housing is a safe place to come back to after discharge from institutional settings.
Funding for supportive services has been particularly challenging to arrange, as there are few funding streams that are specifically designed to cover services in supportive housing. The good news here is that opportunities now exist within the Medi-Cal financing framework to sustain the creation of services necessary for the supportive housing model.
Medi-Cal’s Whole Person Care Pilots — authorized by the federal government under the state’s newest waiver, Medi-Cal 2020 — provide one such opportunity. This pilot program will support county and regional efforts to integrate care for vulnerable groups of Medi-Cal beneficiaries — including people experiencing homelessness and those at risk of homelessness — who have been identified as frequent users of multiple systems and continue to have poor health outcomes. The goal of these pilots is to improve beneficiary health and well-being by coordinating health, behavioral health, and social services.
CHCF is ready to be part of the effort to shed light on how, and how well, such concepts work and to help scale what has already been shown to work for this complex, vulnerable population. It’s important not to buy into the false dichotomy of creating services without housing or housing without services. We recognize that both are essential to ending chronic homelessness. At CHCF our mission is to make health care work, especially for those who are not well-served by our current system. The men, women, families, and children who are poor and who today do not have stable, humane housing may be homeless, but they are not faceless or hopeless. They are our call to action.
Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also cochaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco. It was the first time a local government in the US attempted to provide health care for all of its constituents.
In February 2018, Sandra was appointed by Governor Jerry Brown to the Covered California board of directors. She also serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and on the UC Regents Health Services Committee. Sandra is an assistant clinical professor at the UCSF School of Medicine. She practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016.
Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.