How the Health Care System is Failing the L.A. Homeless Community
On a recent summer afternoon, a homeless man stood under a clear, blue sky in Santa Monica and adjusted the radio that is tied to his grocery cart.
Squinting into the sun, Laurence Harvey Lockhart Jr. smiled to reveal several missing teeth. Smiling is what helps him get through the numerous physical aches and pains of life on the streets—and so does singing. On request, he puffs out his chest to belt out the classic gospel song “I Love You Lord” by Charlie Pride.
“By his grace, we still stand,” said Lockhart, grateful for his mobility.
A few years ago, Lockhart was panhandling on a Los Angeles highway entrance “running across the street to get some dollars” when a driver ran him over, he said. A team of surgeons was able to salvage his right leg, implanting a temporary metal plate in his knee that they would remove once the bones healed.
Like many homeless people, Lockhart not only struggles to get appropriate medical care—once they find their way to a hospital or clinic, receiving sufficient care after they leave and need follow up care is a challenge. One of the most crucial, yet lacking elements in this system is proper after care.
This deficiency has manifested in the numerous patient dumping cases across the county. Homeless patients are dropped off on the streets, vulnerable and injured, after being discharged from hospitals. Local officials have fought the practice with fines—and Los Angeles hospitals have paid millions of dollars in fines over the past decade. Just last month, Silver Lake Medical Center was ordered to pay a $550,000 settlement for dumping hundreds of patients—over 750 of these patients who were homeless and mentally ill—over several years. The incident was the eighth in a string of dumping cases settled in the last five years.
In response to the public outrage the case inspired, California Senator Ed Hernandez has authored a bill that he hopes will decrease—if not put an end to—patient dumping. This bill will require hospitals to hire more social workers to create plans for continued care and communicate with shelters before transferring patients.
Los Angeles: The Patient Dumping Capital
While many hospitals in the U.S. have been under fire for dumping homeless patients on the street, Los Angeles has seen the most incidents since 2006—when the story of Carol Anne Reyes, who was dumped outside of the Union Rescue Mission, drew national attention. From 2006 to 2018, seven hospitals in L.A. were taken to court for improperly discharging and releasing homeless patients to the streets. Many of these homeless patients had severe, or chronic conditions and still required care. Each of these facilities has been ordered to pay a settlement to the city of L.A., but this does not seem to have stopped the problem.
“One of my primary objectives with Senate Bill 1152 is to get hospitals and homeless services providers to work more closely together so that homeless patients are not discharged under unsafe conditions or dropped off at a shelter that doesn't have the ability to care for them,” Hernandez said in a statement.
If passed, it's estimated the University of California Medical Center hospitals will have to pay millions of dollars to properly staff their facilities, according to a fiscal analysis of the bill. The legislation has passed the Senate and is slated to be heard in an Assembly committee on August 15.
There are past laws that have changed the way homeless people receive care—but typically apply to how everyone is treated. President Ronald Reagan signed federal legislation in 1986 that was designed to prevent hospitals from refusing to screen patients that the American College of Emergency Physicians calls “financially undesirable” patients.
There is another aftercare issue homeless people face—like many patients, they are often given prescriptions that need to be filled to treat their ailments. Because of the financial costs, many homeless individuals like Myron Bryant are left without sufficient medication, a means of transportation to the hospital and a place to find shelter from harsh weather conditions.
The 53-year-old's severe arthritis inhibits his ability to walk. “If I was in a better housing situation, I'd be able to make appointments on time and stuff like that, but it's just difficult without housing.” He navigates the streets of Santa Monica with a wheelchair and cane. Bryant smiles pleasantly through his small, frameless glasses as beads of sweat form on his brow. He has insurance which allows him to see a primary care physician and provides medication that he keeps in a pink and maroon suitcase. However, Bryant said getting quality medication for their ailments is a big issue for the homeless.
An alternative means of care has emerged via non-profit clinics that provide a spectrum of preventive and primary care to prevent homeless people from slipping through the cracks. Though the clinics are committed to serving the homeless community for free, they are not able to solve all the problems that homelessness presents.
Hospitals lack recuperative care beds—like a bed that Lockhart could have used to recover in after the knee surgery he still needs—and that causes a lot of problems, said Dr. Lisa Abdishoo, President & CEO of Los Angeles Christian Health Centers. Clinics are regarded as an alternative option to make up for this shortage, but have their own struggles providing recuperative beds. “Sometimes people end up coming through our doors—perhaps as a result of a dumping situation—and we want to get them to recuperative care,” Abdishoo said. “But we have less priority getting a recuperative bed than a hospital.”
Up to 65,000 patients a year visit Abdishoo's clinic for services ranging from dentistry to therapy. There is also a licensed pharmacy to ensure everyone has affordable, readily available medication. While the clinic can provide homeless patients some measure of guaranteed access to their prescriptions, this promise cannot extend beyond their walls, where the very condition of being homeless exacerbates risks like stolen medications. Refills are not easy to guarantee because of insurance companies' policies and restrictive measures, said Los Angeles Christian Health Centers' physician Dr. Young Kim.
“It's difficult for those patients because once their medications are stolen, we can refill the medications for the patients, but the insurance companies will allow only one early refill,” he said. “If their medication were to be stolen twice in less than a year, they're left without their medications for an extended period of time.”
In addition to the barriers to access, Abdishoo believes the healthcare system doesn't understand the homeless community.
“People in certain healthcare settings don't realize that there's a culture of homelessness,” she said. “The key is being sensitive to the individual's needs, not making assumptions about them, and asking a lot of questions.”
It's a change that is still slow in the making. Despite the combined efforts of clinics, a large number of patients are grappling with insufficient after care, as Rev. Andy Bales, CEO of the Los Angeles Union Rescue Mission, has witnessed in his 30 years of social service. In 2006, it was Bales who identified and took in then-63-year-old Carol Ann Reyes, a patient discarded on the streets of Skid Row by Kaiser Permanente. Disoriented, she wandered the streets of Skid Row in a hospital gown until she was escorted to safety of the Mission. The incident was caught on video and resulted in a first-of-its-kind settlement that changed rules about how hospitals could discharge patients. Yet, problems have persisted.
Though the Mission is the city's largest homeless center, sheltering about 1,300 men, women and children every day, Bales said its services have limits.
“Even in our permanent supportive housing when someone needs 24-hour care—nursing care, we have to have them exit and go to a place that provides nursing care.” he said.
The overwhelmingly large population of homeless patients have hospitals struggling to deal with the intake of homeless, Bales said. Clinics must fight for more public funding to provide services, or rely solely on donations.
An attitude change is what is really needed, Bales said, both in the county's policy and its population's way of thinking. The first step in the homeless health crisis is getting the population off the streets, as the promise of shelter is sure to alleviate illnesses.
“There are 53,000 people experiencing homelessness in California and there's only 12 to 13,000 beds in Southern California—I'd say L.A. County,” he said. “If you are in the hospital and you're gonna experiencing homelessness, where would the hospitals send them? So it's not all the hospital's fault now. It's the fact that we allow 75 percent of our people experiencing homelessness to be on the streets.”
A greater sense of accountability must exist on the part of the city and its governance, Bales said. The population of homeless people living on the streets in L.A. is staggering when compared to other cities. “They just make sure nobody is on the streets.” he said. “And that's the attitude that L.A. needs to develop.”