People’s Health Solutions,
Los Angeles City and County Health Coordination for People Experiencing Homelessness
(December 1, 2021)
This report looks at the ways that the City and County of Los Angeles work together (or not) in providing health care to the homeless. http://peopleshealthsolutions.com/recent-projects The city is responsible for housing; the county is responsible for health care and social services. The county’s responsibilities are divided between four separate agencies: Department of Health Services, Department of Mental Health, Department of Public Health and Department of Social Services. The city’s responsibilities are split between the Police and Fire Departments. The city and county share governance for the Los Angeles Homeless Services Authority.
The city’s planning, zoning, building, and housing departments are a big part of the many reasons why we lack an adequate supply of affordable housing. They are not discussed in the report. The MediCal managed care system is the primary program paying for public and private health care to low income Californians, including the homeless. It too is not the subject of this report.
So what could possibly go wrong when six different government agencies and two different bodies of local government intersect in impacting the lives of homeless individuals? You might want to read the report to find out. http://peopleshealthsolutions.com/recent-projects
There are about 66,000 homeless individuals among Los Angeles County’s 10 million residents. Along with New York City, we account for 1/4th of the nation’s homeless persons. We have more than our fair share of homeless for two basic reasons: not enough housing and not enough affordable housing.
Homelessness skyrocketed in our nation due to a number of overlapping issues. Starting in the 60’s, we de-institutionalized the nation’s and our state’s mental hospitals and failed to invest in community mental health services for the people with serious mental illnesses returned to the community from institutional confinement. Beginning in the 70’s and 80’s, continuing in the 90’s, we shredded the nation’s safety net programs, particularly those programs providing income support and public housing. In the 80’s and 90’s we incarcerated vast numbers of African American men for long periods for “drug crimes”; their felony convictions disabling their ability to secure employment upon release from prison. In the 2007-08 financial meltdown, large numbers of people lost their homes to foreclosures due to some truly reprehensible and irresponsible bank and savings and loan practices. Rent and home prices skyrocketed in cities with strong economic growth and insufficient housing stock. We did not build enough housing to meet the demands of the state, the county and the city’s growing population. Finally, rather than build a sufficient supply of permanent supportive housing, we instead circulated and re-circulated the homeless through the criminal justice and local jail system, deploying law enforcement to solve our unresolved social problems of homelessness, further impairing their ability to get and retain work for themselves and their family members.
On the other more positive side, the nation and the state of California implemented the ACA (Affordable Care Act); we have vastly strengthened the health care system for the homeless. It provides coverage and pays for care to homeless and working poor individuals at risk of homelessness, people who were not previously eligible for coverage. It extends coverage for behavioral health, including mental health and substance abuse treatments, which have long been a particularly serious and underfunded weakness in California’s health system. The state and the county have creatively used federal Medicaid waivers to provide a range of supportive services to those homeless with medical conditions that put them at high risk of hospitalizations and emergency care. The county and the city have passed Propositions H and HHH to provide funding to finance, build and provide housing and supportive services for the homeless.
The report identifies key issues that still need lots of work here in LA:
· The lack of an adequate supply of affordable interim and permanent supportive housing
· The silos and bureaucratic barriers for housing, health, and social services programs
· The high mobility and housing instability of the homeless is not a good fit with the health and social service programs.
· Racism and profit motives in the health system
· Stigma and public misperceptions of the homeless.
Some of these require a little more detail to understand and appreciate. For example, about 1/4th of the homeless have serious mental illness or severe substance abuse. That is the public image of the homeless, not the homeless people sleeping in their cars or vans and going to work every day. “It makes people feel scared, and they burn their way into people’s imagination, [but what the public] certainly never sees [is] the 18,000 people who are sleeping in their cars, and who bought the cheapest gym membership so they could shower in the morning, so they could get to work clean. You know, they’re not seeing those folks. But they do see the people who are in the grip of comorbid disorders.”
Many of the homeless are people of color; African American men are particularly over-represented among the homeless. “I’m going to just explicitly say black people have an issue with the way stigma impacts us. We have an issue with the way that there’s been medical practices to purposefully cause harm and damage our reproductive systems and things like that.”
The modern medical system is very poorly designed to provide care to people living on the streets. “Key informants acknowledged how people often need same-day drop-in services that don’t fit with the dominant medical paradigm, which requires advance appointments and referrals within specific networks. As one service provider explained, agencies offering walk-in services “stand a greater chance of staying connected and linked to their homeless patients, as compared to a sort of normal brick and mortar behavioral health service facility [that] operates on a scheduled basis [where you] have a therapy session once a week, [and] if you don’t make that appointment, sorry, we’ll see you next week. That just doesn’t work [for] homeless individuals.”
The homeless not only don’t have a fixed home address, but they are often being moved about by the police, the sanitation department, fear of violence, or whatever. “I think the difficulty is that people experiencing homelessness are so spread out. We [have] mobiles that go to the shelters. And so they’ve established kind of a medical home, to some extent, for folks who are at the same shelters or store their belongings at the same place,” said leadership of a homeless health provider. “But I think there is a significant percentage of folks experiencing homelessness that are at encampments, and I think those are particularly difficult. The penetration rate is much more difficult, the consistency rate, they’re constantly being forced to move by law enforcement, you know, their stuff is being thrown away, and they have to find a new place. It’s really hard to keep up with them.”
The multiple program silos are not only difficult for the homeless individual to navigate; they create enormous barriers to effective care of the homeless for their service providers as well. “We have, you know, 40 to 50 different contracts [and for] every different funding stream, there’s a different contract number. We do a lot of our integrated medicine between our work with the DMH and DHS. It still feels like it’s splintered, and there’s more coordination that we can do,” said leadership of a culturally-specific homeless health care provider. “I think a lot of the times, it’s funding streams. I think DHS and DMH have done a good job of making that process a little less cumbersome. But I think [providers] have a lot of funding streams with a lot of different requirements that vary from funder to funder.”
Data sharing has enormous potential to improve the delivery of health care and rental assistance to the homeless, but it faces severe obstacles. A homeless individual could have information about their health and housing needs on file with multiple different agencies: Department of Health Services, Department of Mental Health, Department of Public Health, Department of Social Services, and their managed care plan. Yet, due to privacy and confidentiality rules, an individual’s data and information cannot be readily shared among the different providers of vital services to them.
Outcomes and accountability must become the key measurements and the basis for payment or reimbursement, rather the numbers of clinic visits or hospital procedures. “A final theme arising from interviews was the potential to accelerate a reduction in homelessness by shifting from a focus on program activities to housing and health outcomes. The effectiveness of Brilliant Corners, the agency that manages housing placements for the County’s Flexible Housing Subsidy Pool, were attributed to a focus on doing “whatever it takes” to achieve positive results for people with some of the greatest health needs.”
“They’re effective because they manage for results,” said one key informant of these two agencies. “Brilliant Corners is really, really good at finding what housing there is [because] they get paid based on successful placements. Whereas everybody in the [continuum of care] gets paid for their activities. So you may have six different LAHSA outreach workers who encounter the same person, and they have six successful encounters. But the person is exactly the same person... basically I do my activity, then I throw them over to the next person. And there’s nobody responsible for the failure of that connection, which happens all the time...so what makes the Housing for Health thing work, I think, is that results [are] what they want. But there’s no reward for activity. And it took me a long time to learn this, but it’s really important not to confuse activity with accomplishment in whatever field you’re in.”
Lucien Wulsin
12/15/25