Achieving public health goals through Medicaid expansion: opportunities in criminal justice, homelessness, and behavioral health with the Patient Protection and Affordable Care Act.

States are currently discussing how (or whether) to implement the Medicaid expansion to nondisabled adults earning less than 133% of the federal poverty level, a key aspect of the Patient Protection and Affordable Care Act. Those experiencing homelessness and those involved with the criminal justice system--particularly when they struggle with behavioral health diagnoses--are subpopulations that are currently uninsured at high rates and have significant health care needs but will become Medicaid eligible starting in 2014. We outline the connection between these groups, assert outcomes possible from greater collaboration between multiple systems, provide a summary of Medicaid eligibility and its ramifications for individuals in the criminal justice system, and explore opportunities to improve overall public health through Medicaid outreach, enrollment, and engagement in needed health care.

Barriers to COVID-19 Prevention Measures Among People Experiencing Homelessness with Substance Use Disorder or Serious Mental Illness.

People experiencing homelessness (PEH) are at disproportionate risk of becoming infected and having severe illness from coronavirus disease 2019 (COVID-19), especially when residing in congregate settings like homeless shelters. Behavioral health problems related to substance use disorder (SUD) and severe mental illness (SMI) may have created additional challenges for PEH to practice prevention measures like mask wearing, physical distancing, handwashing, and quarantine and isolation. The study objective was to understand the perceived barriers PEH face regarding COVID-19 non-pharmaceutical prevention strategies and identify recommendations for overcoming barriers. From August-October 2020, qualitative phone interviews with 50 purposively selected behavioral health professionals across the United States serving PEH with SUD or SMI were conducted. Professionals described that PEH faced barriers to prevention that were structural (e.g., access to necessary resources), behavioral (related to SUD or SMI), or related to the priority of other needs. Recommendations to overcome these barriers included providing free prevention resources (e.g., masks and hand sanitizer), providing education about importance of prevention strategies, and prioritizing access to stable housing. Interviews took place before COVID-19 vaccines were available, so barriers to vaccination are not included in this paper. Findings can help support tailored approaches during COVID-19 and future public health threats.

Ill, itinerant, and insured: the top 20 users of emergency departments in Baltimore city.

The purpose of this study was to document the clinical and demographic characteristics of the 20 most frequent users of emergency departments (EDs) in one urban area. We reviewed administrative records from three EDs and two agencies providing services to homeless people in Baltimore City. The top 20 users accounted for 2,079 visits at the three EDs. Their mean age was 48, and median age was 51. Nineteen patients visited at least 2 EDs, 18 were homeless, and 13 had some form of public insurance. The vast majority of visits (86%) were triaged as moderate or high acuity. The five most frequent diagnoses were limb pain (n = 9), lack of housing (n = 6), alteration of consciousness (n = 6), infection with human immunodeficiency virus (HIV) (n = 5), and nausea/vomiting (n = 5). Hypertension, HIV infection, diabetes, substance abuse, and alcohol abuse were the most common chronic illnesses. The most frequent ED users were relatively young, accounted for a high number of visits, used multiple EDs, and often received high triage scores. Homelessness was the most common characteristic of this patient group, suggesting a relationship between this social factor and frequent ED use.

Behavioral Health Providers' Experience with Changes in Services for People Experiencing Homelessness During COVID-19, USA, August-October 2020.

The COVID-19 pandemic caused disruptions in behavioral health services (BHS), essential for people experiencing homelessness (PEH). BHS changes created barriers to care and opportunities for innovative strategies for reaching PEH. The authors conducted 50 qualitative interviews with behavioral health providers in the USA during August-October 2020 to explore their observations of BHS changes for PEH. Interviews were transcribed and entered into MAXQDA for analysis and to identify salient themes. The largest impact from COVID-19 was the closure or limited hours for BHS and homeless shelters due to mandated "stay-at-home" orders or staff working remotely leading to a disconnection in services and housing linkages. Most providers initiated telehealth services for clients, yielding positive outcomes. Implications for BHS are the need for long-term strategies, such as advances in communication technology to support BHS and homeless services and to ensure the needs of underserved populations are met during public health emergencies.

Impact of Social Isolation during the COVID-19 Pandemic on Mental Health, Substance Use, and Homelessness: Qualitative Interviews with Behavioral Health Providers.

The United States is experiencing a syndemic of homelessness, substance use disorder, and mental health conditions, which has been further exacerbated by the COVID-19 pandemic. Although it is expected that mitigation strategies will curb community transmission of COVID-19, the unintended consequences of social isolation on mental health and substance use are a growing public health concern. Awareness of changing mental health and substance use treatment needs due to the pandemic is critical to understanding what additional services and support are needed during and post-pandemic, particularly among people experiencing homelessness who have pre-existing serious mental illness or substance use disorder. To evaluate these effects and support our understanding of mental health and substance use outcomes of the COVID-19 pandemic, we conducted a qualitative study where behavioral health providers serving people experiencing homelessness described the impact of COVID-19 among their clients throughout the United States. Behavioral health providers shared that experiencing social isolation worsened mental health conditions and caused some people to return to substance use and fatally overdose. However, some changes initiated during the pandemic resulted in positive outcomes, such as increased client willingness to discuss mental health topics. Our findings provide additional evidence that the social isolation experienced during the pandemic has been detrimental to mental health and substance use outcomes, especially for people experiencing homelessness.

Homelessness and the Public's Health: Legal Responses.

This commentary addresses public health issues underlying homelessness and related law, policy, and advocacy options. After framing public health issues for affected individuals and the community, legal and policy approaches and related barriers are assessed. Major topics include deficits in housing availability, the role of state-based Medicaid programs, criminalization of homelessness, and the use of emergency declarations seeking to address particular issues related to homelessness in select states and localities.