We have made great strides in increasing the number of people with health insurance in the US through the Affordable Care Act. However, an emerging healthcare provider shortage disproportionately impacts some of the most vulnerable populations and rural communities. The COVID-19 public health emergency stretched the capacity of our entire healthcare system to the limits, overwhelming the healthcare workforce. Many have left the healthcare industry altogether because of the intense demands of the job, which has resulted in an overall workforce shortage. Yet the number of people in need of quality healthcare keeps growing. For example, the need for behavioral health services has increased dramatically for both children and adults. Additionally, the opioid epidemic has led to increased investment in substance abuse treatment as a medical, not just social, intervention.
Rural communities struggle to meet health-related social needs
Traditional healthcare providers, such as physicians, clinics, and hospitals, are trying to meet the expanding need. They are also trying to address the root causes of many health conditions by addressing external factors, such as housing and food insecurity, which are commonly referred to as Health-Related Social Needs (HRSN). The Centers for Medicare and Medicaid Services (CMS) describes HRSNs as “an individual’s unmet, adverse social conditions that contribute to poor health outcomes. These unmet needs, when unmet, can drive lapses in coverage and access to care, higher downstream medical costs, worse health outcomes, and perpetuation of health inequities, particularly for children and adults at risk for poor health outcomes and individuals in historically underserved communities.”
Unhoused people are particularly affected
Although social elements affect everyone’s health, the unhoused are at particular risk for poor health outcomes due to external factors. Without stable housing, access to healthy foods, and safety, unhoused individuals may develop new chronic conditions, such as diabetes or hypertension, or face more severe conditions, such as hypothermia or malnutrition. Some suggest that 50% of unhoused individuals develop mental health conditions due to homelessness, contrary to the common belief that those with mental health issues become homeless. Unfortunately, a growing number of people cannot find affordable housing, and the unhoused population includes families with young children, senior citizens, and veterans, as well as single adults. As communities across the nation see a rise in the unhoused population, the need for healthcare services for the unhoused has also increased.
How community-based organizations step up
No one understands these needs better than community-based organizations (CBOs), such as homeless shelters, food banks or food pantries, and other social services organizations. They have always played a critical role in providing a safety net to those in our communities who need help. Not only do CBOs provide individuals with basic safety and necessities during times of crisis, they may be the only trusted source for many whose family, friends, the government, and the healthcare system have turned them away. Even with public healthcare insurance like Medicaid or Medicare, unhoused individuals often delay getting care until they are very sick and end up in the emergency room. Once discharged, it is difficult for them to receive the follow-up care they need, which contributes to worsening conditions and ending up in the emergency room months later. This cycling in and out of the ER damages long-term health and adds significant costs to the healthcare system, affecting all of us.
Fortunately, because they are already trusted and known resources in their community, CBOs are now offering their clients behavioral health services and substance abuse treatment, as well as assisting them in finding permanent housing. Starting in 2022, non-profit organizations providing housing assistance and sheltering services could seek funding through the new California Advancing and Innovating Medi-Cal (CalAIM) program, administered under California’s Medicaid program. CalAIM is an initiative sponsored and funded by the CA Department of Health Care Services (DHCS) and the federal Centers for Medicare and Medicaid Services (CMS) to pay for services that address health-related social needs, such as housing instability, homelessness, and food insecurity to improve overall health outcomes. This innovative funding vehicle brought CBOs into the traditional healthcare system, allowing for more integrated and holistic care.
Why we care
A1M Solutions is based in Chico, California, in rural Butte County. Our years of experience as a contractor to federal and state governments supporting healthcare programs like Medicaid and Medicare provide the basis for our understanding of just how critical these programs are to many people in the U.S. We recognized early on how vital initiatives like CalAIM are in improving health outcomes and addressing HRSNs for the most vulnerable populations in our communities.
In Butte County, demand for shelter and housing navigation services has increased year over year. In the last five years, it has skyrocketed due to the loss of housing caused by the 2018 Camp Fire, 2021 Dixie Fire, and the recent 2024 Park Fire. The combination of ongoing natural disasters and the economic and health impacts of COVID-19 has exacerbated an already dire situation in Butte County, where 18.3% of residents live in poverty and housing vacancies remain at less than 1%.
A1M’s core mission is to support underserved and disadvantaged communities. For nearly two years, we’ve provided pro-bono assistance to help CBOs in Butte County and surrounding areas enroll in the CalAIM program and become Medi-Cal providers in their communities.
A long journey to stable funding
Unfortunately, CBOs must overcome steep challenges in their journey to become CalAIM providers. The discovery of where to begin, coupled with stringent requirements to enroll, places an unnecessary burden on CBOs that need more resources to invest in the process. Time and resources needed to devote to the process are scarce when organizations that run full-service shelters like True North Housing Alliance (TNHA) are providing over 120,000 meals a year and operating a shelter 24/7, 365 days a year.
After nearly two years of ups and downs on their path to becoming a CalAIM provider, TNHA is now providing services and receiving reimbursement for housing tenancy services, navigation services and day habilitation as a Medi-Cal provider in the CalAIM program. The true impact of a program like CalAIM on a largely rural county like Butte is much bigger than it may seem.
Community benefits go beyond the dollars
Despite the challenges, the CalAIM program is saving lives and improving the overall health and well-being of our community. With stable funding from CalAIM for more diversified services, TNHA assisted 68% of the known unhoused population in Butte County and connected over 200 unhoused individuals to permanent housing. Services such as CalAIM Housing Tenancy and Sustaining Services have helped avoid returns to homelessness county-wide. Over 120 clients received at least one CalAIM Community Support service through TNHA in the first year of CalAIM operations.
Because TNHA now has a sustainable source of funding through CalAIM, it is easier to get funding from other sources, such as lines of credit from banks. Staff gained confidence and expertise in providing the necessary information to successfully apply for and obtain new grants at the state level. With the additional funding, TNHA has been able to expand support services and look for new approaches to addressing the housing gap in the community. The additional funding has also allowed the organization to expand full-time staff and provide employment stability to existing staff rather than worry about meeting payroll every pay period. As a result, CalAIM has not only helped the TNHA organization and the clients it serves but has also helped bring funds into the local economy.
Given the short- and long-term impact to individuals, the healthcare system, and the local economy, we would like to see more investments in the success of CBOs as a critical solution to the healthcare provider shortage. A1M’s purpose is to continue bridging the gap between CBOs and the federal and state governments through policy translation and empathetic stakeholder engagement. Successful programmatic and systemic change is possible, and we look forward to what the future holds as our healthcare system continues to evolve and mature.
Photo by Shane Rounce on Unsplash
