One Bay Area Health Plan Is Breaking Health Insurance Boundaries. California May Follow Suit
This is the third in a three-part series about housing and healthcare. Listen to parts one and two here.
“Happiness comes to mind. I can only speak for myself. I'm happy. I have my life back.”
I meet Kojo Nsoah outside of Home Sweet Home, an assisted living facility in Daly City. He’s wearing all-black, even his Raiders hat and his mask match his outfit.
Nsoah’s out front in his electric wheelchair, waiting for a group van. He lives at Home Sweet Home, but likes to spend his days at an adult day health care facility down the coast in Half Moon Bay.
The van pulls up at 8:30 a.m. on the dot. He gets aboard, the driver straps him in, and he turns on his iPad to play games or watch horror movies for the hour-long drive. This has been his routine for almost six years, ever since he made his way out of homelessness. That chapter of Nsoah’s story begins around 15 years ago in Washington DC. He had just graduated from law school and was working as a paralegal, studying for the bar.
“That's when it happened. It seemed like I just lost my mind,” he says.
He had what he describes as a psychotic break. He stopped going to work, and started living in parks in Washington D.C. One day, he saw a picture of the Golden Gate Bridge and decided he was going to move to the Bay Area. Nsoah collected enough money for a one way bus ticket and made it out to San Francisco.
“I was out there 10 years, and I woke up one morning — I was sleeping at the Chinese park up the hill — that's where I had the stroke.”
He was 50 years old. An ambulance rushed him to the hospital and he spent a year recovering in a nursing home in Daly City. Until, he says, they gave him his medicine and dropped him off in a wheelchair in front of a shelter in downtown San Francisco.
“I had a rude awakening when they put me out at a homeless shelter. I didn't expect that,” he says.
So he says he became defiant. He didn’t want to live at a shelter. He didn’t have a good understanding of his stroke, but he knew couldn’t take care of himself on the street or in a shelter. The stroke had paralyzed one side of his body. He was at his wit’s end.
“I walked all the way to Market Street, and I was down there for a couple of nights before I stopped the police car and told them that I felt suicidal.”
They took him to a mental health ward at San Francisco General Hospital and he eventually ended up back in the nursing home in Daly City. It’s a cycle that often continues for many people aging on the street — emergency room to nursing home to street to emergency room. But during this stay, he got lucky and landed a spot in a pilot program with San Mateo County’s public health plan. One that was designed, in part, to stop this endless revolving door.
The Health Plan of San Mateo is unique among public health plans because they run both Medi-Cal (the state program for low income people) and Medicare (the federal program for seniors).
Amy Scribner works with the health plan, and says only six other counties in the state cover both plans in this way. That’s because doing so means dealing with more requirements from the state, and more scrutiny from the federal government. It’s just more work. But, there’s a big benefit.
“The idea was really transitioning folks from nursing homes back into the community through wraparound services and supports.”
This started in 2014, around the same time Kojo Nsoah found himself in a San Mateo County nursing home for the second time, and didn’t really need to be there. And back then, Amy Scribner was seeing a lot of individuals in the same situation –– people with physical and mental limitations ending up in overcrowded nursing facilities because they had no where else to go. Plus, a large nursing home in the county was slated to close and threatened to displace a lot of people.
“One of the things that happens when somebody goes to a skilled nursing facility who is on Medi-Cal, even if it's short term, if they are renting an apartment their money ends up after 90 days going to the nursing home. They can't pay their rent. So a lot of people get evicted and end up in long term care because they lost their housing while they were in there. And so can't get out because they're homeless, right. Nobody wants to discharge somebody from a nursing home back to the streets,” she says.
So, the plan decided to cover things not normally covered by Medi-Cal or Medicare. They can’t legally pay rent, but they can pay for security deposits and for people to help with things like Section 8 vouchers, for example.
“Here in San Mateo County, we have recognized it as an important thing for our members and for our community. And so we have taken on the burden, the financial burden of the program,” Amy Scribner says.
In Kojo Nsoah’s case, he pays for his rent with his social security check. Almost everything else at Home Sweet Home is covered by the Health Plan of San Mateo –– a payment not traditionally covered under Medicare or Medi-Cal.
The plan also covers a case manager who connects him to other services to keep him living as independently as possible and keep him out of a nursing home. While this all sounds pretty expensive for the health plan, financially, it ends up saving state money long term. An independent evaluator found that there’s a 30-35% cost savings from moving people out of nursing homes and back into the community. But, Amy Scribner also thinks about it as an investment in the person.
“They're not just a health care number. They are a person that we're trying to serve.”
This particular program only goes until the end of this year. It was designed, in part, to demonstrate to California whether providing services in this way could be successful. In January, it will be folded into a new state initiative, called CalAIM.
The idea is to have Medi-Cal be more responsive, more flexible to people with those conditions that are outside of the traditional medical world, says Sharon Rapport, a policy advisor with the Corporation for Supportive Housing.
She says there will be a lot of changes in California. Something called in-lieu of services is what could make a difference for people like Kojo Nsoah across the state. It basically does what the Health Plan of San Mateo has been doing, paying for things not traditionally covered by Medi-Cal, with the goal of keeping someone out of a nursing home if they don’t need to be there — like paying for a wheelchair ramp at home or a grab bar in shower. If someone is experiencing homelessness, the plan could pay for a housing navigator, or a security deposit. If they end up in the hospital, it could pay for a respite home — a place for them to recuperate so they don’t get discharged back into homelessness.
“So, instead, they go to another place that's not a hospital, but it's a place where they can have a bed, maybe nursing services, a case manager to help them line up housing when they leave,” Rapport says. It’s similar to what shelter-in-place hotels offered people experiencing homelessness in the worst months of the pandemic.
Sharon Rapport says it is a good start in recognizing the wide range of things that make someone healthy, but she wants the state to go further for people experiencing homelessness. At this point, in lieu of services are only optional, and plans can pick and choose which services they want to cover or narrow eligibility. Plus, most insurance plans don’t have clear data on which of their members are experiencing homelessness.
Kojo Nsoah will still get the same services covered and paid for by his health plan. Though in other places the transitions may not be as smooth. Plans across the state are in the process of confirming which services they’ll cover through CalAIM, and Homeless advocates hope housing is high on the list.
Nsoah says having all this support around housing gives him the ability to think more about his health.
“It's great. I mean. I've never lived in a place like this before. It is great to have a nurse on staff. They have activities you can do, or leave me alone.”
And when he gets to adult day health care, he takes occupational and physical therapy classes. He wheels his chair into a circle of other seniors, the teacher removes his legs from his wheelchair and bands them together for extra support.
When it’s time to begin, Nsoah and the rest of the class mime the teacher as she moves her hands and feet in a circular motion, or taps her heels on the ground. He tells me it’s something that just a decade ago, he would never have been able to picture himself doing.
“I had a stroke. I think I was doing well, but I wasn't. You know, looking back at it, I wasn't. I wasn't doing well at all.”
Now that he has stable housing and his other basic needs covered, for the first time in years, he says he’s finally been able to put a finger on how he is feeling.
Angela Johnston reported this series while participating in the USC Annenberg Center for Health Journalism‘s 2021 California Fellowship.