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The need for AB 369: the Street Medicine Act would allow street medicine physicians to do far more than dismantle bureaucratic barriers, it would save lives
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The need for AB 369: the Street Medicine Act would allow street medicine physicians to do far more than dismantle bureaucratic barriers, it would save lives
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Content
The need for AB 369
The Street Medicine Act would allow street medicine physicians to do far more than dismantle
bureaucratic barriers. It would save lives.
by
Lauren Merola
A Thesis Presented to the
FACULTY OF THE USC ANNENBERG SCHOOL FOR COMMUNICATION AND
JOURNALISM
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
SPECIALIZED JOURNALISM
December 2021
Copyright 2021 Lauren Merola
ii
TABLE OF CONTENTS
Abstract ........................................................................................................................................iii
Introduction....................................................................................................................................1
Chapter 1: The origin of street medicine.......................................................................................6
Chapter 2: Public reactions to the unhoused.................................................................................8
Chapter 3: Street medicine as preventative care........................................................................13
Chapter 4: The USC street medicine team’s involvement...........................................................15
Chapter 5: AB 369 supporters and opposers..............................................................................17
Chapter 6: A hopeful future for unhoused patients......................................................................18
References..................................................................................................................................20
iii
ABSTRACT
California has a homeless population of over 151,000, 72% of whom are unsheltered,
meaning they live on the street (Rosenheck and Lam, 1997). Los Angeles, specifically, has one
of the largest homeless populations in the United States. As of 2019, Los Angeles had an
estimated 59,000 unhoused people (Oreskes, 2020). In 2020, the Greater Los Angeles
Homeless Count showed 66,436 homeless people living in Los Angeles County, a 12.7% rise
from 2019 (Los Angeles Homeless Services Authority, 2020). More pressing than the number of
homeless people in Los Angeles is the number of them that are dying from treatable conditions.
The life expectancy of unhoused people is 30 years shorter than those housed and the
unhoused are more likely to fall ill from preventable diseases like respiratory disorders, skin
disorders and infectious diseases (Salit, Kuhn, Hartz, Vu and Mosso, 1998). The homeless
population also have less access to health care, as 73% of unhoused people insured under
Medi-Cal have never seen their assigned healthcare provider (Kamlager and Ashtari,
2021). Barriers like transportation, mailing addresses and stolen Medi-Cal Benefits Identification
Cards prevent the homeless from meeting their assigned doctor and, thus, receiving the care
they are qualified for. To combat this, street medicine doctors have taken to the streets and
bridges of Los Angeles to treat homeless patients where they can, and want to, be treated. AB
369, a new bill proposed to the California Congress, aims to insure street medicine work and
extend Medi-Cal presumptive eligibility to the unhoused, allowing them to receive Medi-Cal
services and referrals from all licensed primary care providers, including street medicine
doctors, regardless of who their assigned physician is. Currently, only prescriptions and referrals
written by the assigned Medi-Cal doctor are covered by insurance, but with the passage of AB
369, street medicine doctors will be allowed to write life-saving, insurance-covered scripts and
referrals for their homeless patients.
Neda Ashtari was conducting a physical exam on a patient when she noticed a bumpy,
irregular skin lesion on his arm. Ashtari called over the attending physician, Dr. Mary Marfisee,
to take a look. After a few seconds of examining the lesion, Marfisee pulled Ashtari to the side.
“It’s cancer,” Marfisee told Ashtari. “But we can’t do anything about it.”
The two couldn’t refer the patient to a dermatologist or oncologist. They could not find his
assigned primary physician through Medi-Cal. The patient did not know who his listed doctor
was or where his health insurance card was because he did not know to what address Medi-Cal
sent it.
This patient was homeless and, like many others, had Medi-Cal benefits but no access
to them, because he didn’t have a mailing address so he didn’t know who his assigned primary
care physician was. Instead, he received care from Ashtari and other street medicine volunteers
and doctors on the streets of Los Angeles.
Unfortunately, this is one of many patients Ashtari couldn’t help. Even with street-based
doctors, many bureaucratic barriers interfere.
Instead of adding to the worries Ashtari and Marfisee’s patient thought about on a daily
basis, like food supply, shelter and guarding his belongings against theft, the two did not tell him
about the cancerous lesion. Since Ashtari and Marfisee couldn’t find his assigned Medi-Cal
physician and the patient couldn’t afford private insurance, the medical team was stuck. They
didn’t want to add on to the burdens he already encountered daily.
“It was deeply, deeply traumatic,” Ashtari said as she considered the ethical dilemma.
California has a homeless population of over 151,000, 72% of whom are unsheltered,
meaning they live on the street (Rosenheck and Lam, 1997). As of 2019, Los Angeles has an
estimated 59,000 people experiencing homelessness, higher than any city in the United States
(Oreskes, 2020). There was no 2021 homeless count due to the COVID-19 pandemic. In 2020,
the Greater Los Angeles Homeless Count showed 66,436 people in Los Angeles County
1
experiencing homelessness, a 12.7% rise from the 2019 point-in-time count (Los Angeles
Homeless Services Authority, 2020).
Other experts believe that figure is low.
Gabrielle Johnson, a clinical assistant professor of family medicine at the University of
Southern California, believes between 90,000 and 100,000 people are unsheltered in Los
Angeles County (Keck School of Medicine of USC). Johnson said people living in bridges and
out of sight are rarely counted in the point-in-time count, or the one-day, Los Angeles Homeless
Services Authority homeless count (Los Angeles Homeless Services Authority, 2020).
“Homeless counts identify an RV as one person,” Johnson said. “But what you don't
know is there's a family of six living in that RV.”
Due to poverty and conditions on the streets, the unhoused have higher rates of physical
health conditions and behavioral needs compared to the general population, leading to a life
expectancy 30 years shorter than the housed population. A report for the charity Crisis found
that the unhoused are nine times more likely to commit suicide than the rest of the population
and three times more likely to die as a result of traffic accidents (BBC, 2011). Unhoused people
also battle preventable illnesses, like respiratory disorders, skin disorders and infectious
diseases (Salit, Kuhn, Hartz, Vu and Mosso, 1998). However, accessing health care to prevent
and treat these illnesses and injuries is incredibly difficult. Seventy-three percent of the
unhoused who are insured under Medi-Cal have never seen their healthcare provider (Kamlager
and Ashtari, 2021).
Other street medicine teams in Los Angeles, like the USC Keck School of Medicine’s
team, have stepped in to help.
Johnson is the lead nurse practitioner on USC Keck’s Service Planning Area 3 (SPA 3)
team, covering Pasadena to Pomona, where Johnson said 6,000 unhoused people live.
2
USC’s second street medicine team is led by the director of street medicine Brett
Feldman. Feldman’s team works out of the LAC+USC hospital — a 600-bed, USC-affiliated
public hospital near Boston Heights. From there, they follow discharged, homeless patients to
the streets for ongoing check-ups and medical care.
Joseph Becerra, Feldman’s team community outreach worker who was once homeless,
relates his team’s work in the hospital to that of the cardiology wing. Patients who have heart
problems are sent to a cardiologist for a consultation. Similarly, homeless patients are sent to
Becerra to consult with. After they’re discharged, Becerra and the team — usually composed of
a physician, nurse and outreach worker — meet the patients at their street location for
check-ups.
“My job has a lot of different avenues,” Becerra said in December. “Not only am I in
charge of navigating our patients in L.A., but I also make sure our team is OK in the areas that
we go. I know who’s involved in the area, like the gangs, the people, the culture and the
community.”
SPA 3, however, is geographically bound, finding patients on the street and in
encampments as opposed to meeting them at a hospital and following them to the streets for
check-ups.
Both teams provide primary care for acute illness and chronic conditions like high blood
pressure and diabetes, dispense medications, obtain blood work, provide samples needed for
survival and make sure patients get drug and alcohol counseling, treatment for mental illness,
hospital consultative services and more.
Often, both teams run into roadblocks that prevent proper treatment. If a patient needs
an MRI, X-ray or any type of specialty care, Johnson said companies that insure Medi-Cal are
reluctant because the request isn’t coming from the patient’s assigned doctor.
3
“I put an order in through the scanner, which I have the right to do [in] my job, and the
insurance company says, ‘But who are you?’” Johnson said. “‘We're not going to pay for it
because, who are you in relation to the patient? And that patient has already been given a
primary care doctor.’ So 12 miles away from where we are right now, we have to figure out how
to get that patient inside of that primary care doctor to have that doctor put in the same order I
just put in for the insurance to pay for it.”
If Johnson can find the patient’s assigned care provider, she said it often takes weeks to
get the patient seen. If she’s lucky, the patient can get an appointment in three weeks.
Enter AB 369: The Street Medicine Act.
AB 369 proposes to extend Medi-Cal presumptive eligibility to the unhoused, allowing
them to receive Medi-Cal services and referrals from all licensed primary care providers
regardless of who their assigned doctor is.
“This [bill] is going to cut out a lot of that,” Johnson said. “You no longer will need a
patient to be seen by their impaneled primary care doctor to get access to health care. A lot of
times the claims are denied because the insurance company says, yet again, ‘Why are you
seeing them when they have a primary care doctor?’ That is the No. 1 thing that the [new] bill
would be helpful in reducing: All the time [wasted] running around, calling the insurance
company, figuring out who their primary is and getting the appointment.”
The bill passed in the California Senate Appropriations on August 26 (California
Legislative Information, 2021). The Senate Committee estimates about 130,000 homeless
people would qualify for the new services presented by AB 369 (Portantino, 2021).
4
The proposed law grows directly out of the experiences of street medicine teams.
Ashtari, who volunteered with the UCLA Student-Run Homeless Clinic, collaborated with
Marfisee and Feldman to write it.
Ashtari is a third-year medical student at UCLA getting her master’s degree in public
policy and was a legislative aide for California State Senator Sydney Kamlager. When she was
given the opportunity to present a bill to the senator, she remembered another moment on the
streets from two years earlier.
So she called Dr. Marfisee.
“Do you remember that patient who we wanted to get glasses for, and we just couldn’t?”
Ashtari asked Marfisee. “How can you change the law so that he could have gotten his
glasses?”
Marfisee told Ashtari that in order to have helped that patient, any physician would have
to be able to refer the patient to a specialist, not just the specific, assigned Medi-Cal primary
care provider.
That is the core of the Street Medicine Act: To allow street medicine doctors to write
insurance-covered scripts and referrals for their homeless patients. Currently, only prescriptions
and referrals written by the assigned Medi-Cal primary care provider are covered by the
insurance.
In the simplest terms, assigned primary care physicians under Medi-Cal are being paid
to not treat their homeless patients, and street medicine doctors aren’t compensated for doing
just that.
Jehni Robinson, USC Keck chair of the department of family medicine, said a patient on
the street who needs an X-ray, labs or imaging currently won’t be able to get either.
“All that has to be approved by their primary care physician, who might not even know
them,” Robinson said. “This act allows us to order the care the patient needs without going
through the process of tracking down the primary care physician.”
5
AB 369 aims to fix the growing pains of street medicine, which, as a type of health care,
was born nearly three decades ago.
The origin of street medicine
It was winter in Pittsburgh in 1992 and Dr. Jim Withers was attending to a homeless
patient at a hospital. Withers said the patient refused treatment and left the hospital against
medical advice, where, outside, he froze to death.
It was then that Withers realized people can live in different realities. He said before that
incident, he didn’t understand how his good intentions and medical tools weren’t enough to help
everybody.
“It wasn’t going to do anything for this patient unless I found a way to meet him where he
was,” Withers said. “There’s a whole frontier under bridges here in Pittsburgh. I needed to flip
the power dynamic upside down.”
Thus, street medicine — the concept — was born.
Withers gave the power back to the patients by meeting them in their most comfortable
environments. He found an unhoused person to take him around the city to do check-ups and
rounds on other unhoused people.
Withers didn’t tell the hospital or his malpractice carrier. To seem more trustworthy to the
people on the streets, he didn’t dress like a doctor. For an entire year, he helped people heal
where they wanted to. Withers set out to ensure no other marginalized person froze on his
watch and developed a practice that, eventually, had nurses volunteering and pairing off with
unhoused patients, too. They kept records, tracked their patients and developed the unknown
territory that was street medicine in the 1990s.
Withers founded the Street Medicine Institute in 2009, which Feldman is also the vice
chair of. All of Withers’ accomplishments came from what he called “a giant leap of faith into
your own self-reinvention.”
6
Inevitably, the idea of street medicine migrated west, reaching USC Keck School of
Medicine in 2017, when USC recruited Feldman to start the program in the most heavily
populated homeless city in the United States (Clay, 2019).
The street medicine team saw great success. In its first year, it decreased hospital
readmissions for its patients by 75% (LeBlanc, 2020). Eventually, the roadblocks and waiting
times of Medi-Cal became more clear.
Ashtari saw it, too.
When Ashtari started her presentation of AB 369 to Kamlager, the state senator was
immediately on board. For her, seeing Black homeless women, especially, hits close to home.
“I'm from Los Angeles and also a Black woman, and the statistics are pretty jarring and
stark about the homeless population, not just in the state of California, but in Los Angeles
County,” Kamlager said. “Fifty-two percent of the folks who are experiencing homelessness are
Black in this county… As someone who has gone down to Skid Row, has talked with folks who
are homeless and who looked into the eyes of women that look like me, doing something to fix
this is both important and personal.”
In the current Medi-Cal system, all eligible people must enroll in a managed care plan,
unless they qualify for an exemption, by filling out an information packet received in the mail.
The packet explains the health plans available in the county and how to enroll in their plan of
choice. If they do not fill out the form and mail it back within 30 days of getting Medi-Cal
approval, the state chooses a primary physician for them.
But what if you don't have a mailing address?
Most unhoused people are assigned a doctor due to the nature of the system but do not
have a secure address to receive mail. Even when they are able to get the packet or
7
identification card, leaving their belongings to travel to an appointment makes them vulnerable
to theft, Ashtari said.
Medi-Cal covers most medically necessary care, including doctor and dentist
appointments, prescription drugs, vision care, family planning, mental health care and drug or
alcohol treatment. To access this care, patients need to show their Medi-Cal Benefits
Identification Card (BIC). Health care and dental providers need the BIC to provide services and
to bill Medi-Cal.
But what if your BIC gets stolen?
“I.D. cards are frequently stolen on the street,” Ashtari said. “Under existing law, you’re
not allowed to see your provider without an I.D. card. What our bill does is remove that barrier.
We waive the I.D. requirements for somebody experiencing homelessness because we see this
as a very significant barrier to people getting care when their cards are being stolen and sold for
$250.”
Feldman said another obstacle standing in the way of unhoused people and health care
is the fare for public transportation, and more often, public scrutiny.
Public reactions to the unhoused
When CeeCee, an unhoused female in Los Angeles, uses the bus to go anywhere, she
said people stare. It’s easier for her doctors to come to her because, at her encampment, she
doesn’t have to subject herself to ridicule and embarrassment she can receive elsewhere.
“They’re better than anything else,” CeeCee said of the street medicine team.
CeeCee first became Feldman’s patient after being admitted to the LAC+USC hospital
for an infected puncture wound in her hand sustained from recycling copper for money. CeeCee
has Medi-Cal insurance but no way of using it.
8
Johnson , too, saw the humiliation of her patients, saying she endures a fraction of what
her patients get.
If one of Johnson’s patients is going to the dentist, or a specialty doctor, she said she
has the luxury of getting in the Uber with the patient and going with them. But housed patients
don’t hold back in the waiting room.
“Sometimes I’ll hear, ‘Why do you even do this? They’re just drug addicts. You’re wasting
your time,’” Johnson said.
At the core of the Street Medicine Institute and the USC Keck street medicine program is
the belief that every human deserves health care (Street Medicine Institute, 2019). This idea
isn’t always the most popular among housed people, who often believe people choose to be
homeless or live on the streets as a result of drug use.
“It’s the biggest lie in the world,” Becerra said.
He said females who become homeless are usually victims of theft, assault or rape. To
combat this, Becerra said unhoused females stay up all night to protect themselves in the dark,
during peak crime hours.
But a dangerous cycle ensues.
“Instead of falling asleep, you use drugs to stay up,” Becerra said. “If you’re driving down
Skid Row during the day, you probably see the homeless sleeping because they’re up all night
trying to prevent themselves from becoming a victim.”
What starts as a way to protect oneself can turn into a problem. Understanding the
lengths people can go to in order to survive on the street motivates the whole team to help.
“I rode the bus with a patient once, and the people on it talked about him like he wasn’t
there,” Johnson said. “The bus driver said, ‘Oh my god, he is so dirty. Do you claim him?’
“Claim him?” Johnson remembered thinking. “What is wrong with you? This is my friend
Bart.”
9
Bart is a 59-year-old former patient of the USC Keck School of Medicine street medicine
team. According to Rachel Kent, the team’s former occupational therapy fellow, Bart spent about
a month in the hospital for health complications. After being released from LAC+USC hospital,
the team went to check on Bart.
When he saw the street medicine team approaching him, Bart, who struggles to talk for
long, said he felt “comfortable” and “excited.”
They noticed a growth on his throat from surgery complications and got him admitted
back to their home base. Bart had a tracheotomy. He also has osteoarthritis, causing harsh back
pain.
As of May, Bart was placed in a Los Angeles-based board and care, sharing a house
with other formerly homeless individuals. Board and care homes are a sort of residential care
community, with a nurse checking in on the house every day to a few times a week.
Two light blue-grey stucco houses are separated by a cement yard, all fenced in.
Walkers, wheelchairs and scattered chairs and tables fill the space between the two homes. In
the back house is Bart’s room. In the small room are two bunk beds and Bart’s hospital bed.
While the board and care may seem like a better option than the streets, providing Bart
with indoor plumbing, a bed and a house nurse, Bart missed the relationships and community
he built miles away from where his house is.
“This is all right,” Bart said. “I’m not going to stay here forever.”
10
Street View from Bart’s board and care, taken May 19 in Studio City. (Photo by Lauren Merola)
A provided bed at night covers the foundational layer of Maslow’s Hierarchy of Needs, a
psychological idea suggesting people are motivated to fulfill basic needs before meeting other,
more sophisticated needs, like friendship or safety (Cherry, 2021).
One of the street medicine team’s patients, who lives on Skid Row, was beaten by her
boyfriend, causing her to go blind. She is still in that same abusive relationship. All the same,
she further depends on the boyfriend to be her safety net. She needs someone to see what she
can’t and to protect her from getting raped, beaten or stolen from.
“You don’t know how many times she’s told me, ‘I’d rather get raped by the same man
every night than a different man,’” Feldman said.
When it comes to health care, medications are also targeted.
In March, Mercedes, a woman living on Skid Row, woke up to find her medications
missing.
“I woke up and they were gone,” she said.
11
If AB 369 passed and Mercedes’ medication was stolen, as a patient of a street medicine
team, she could immediately have her medications replaced to remain medically stable and
avoid more expensive hospital care.
Mercedes – wearing orange leggings, two different shoes and a navy and red sweatshirt
with a big “USA” logo printed on the chest – said she has two daughters and a nephew to look
after. When asked what she needs, without hesitation, Mercedes said housing, “right now.”
Ashtari, Johnson, Feldman and Beccera all agree: No one they treat wants to be
homeless.
The focus of the homeless population has been on housing. In March 2020, the
California Department of Social Services established Project Roomkey in response to the
COVID-19 pandemic (California Department of Social Services, 2020). The goal was to provide
non-congregate shelter for the unhoused and minimize strain on the healthcare system. Motels
and hotels were rented to provide emergency and temporary housing.
Kamlager said the focus of housing pushes issues – like mental and physical health – to
the side.
“I think we, quite frankly, don't see homeless people,” Kamlager said. “I think California,
collectively, we've been focused on housing and shelter, we've been focused on just getting
people out of our eyesight. We haven't been thinking about mental health. We haven't been
thinking about physical health. We haven't been thinking about the homeless communities and
cultures that have developed just because folks have been homeless for so long and those
become very complicated and nuanced ecosystems that require something deeper than just to
put someone in a shelter. We haven’t been focusing on the whole person.”
Kamlager said government policies haven’t catered to how homeless people take care of
themselves, just where they do it.
“For a long time, we weren't even thinking about how folks were being bathed and
cleaned and accessed sanitary napkins and how homeless families were managing school and
12
education. None of those things, because the primary focus, I think, has been on housing,
because when you see someone who's homeless, you see that they got all their stuff out on the
corner. You don't see someone is sick, they haven't taken their vitamins this morning or haven't
taken that blood pressure pill. We haven't really been focused on health care.”
With Project Roomkey, people exposed to COVID-19 or who had health complications
that put them at high risk were given priority for shelter. Preventative measures like this,
ultimately, make healthcare cheaper. If AB 369 passes, it too can serve as proactive care rather
than reactive care, as it does now.
Street medicine as preventative care
According to a study in the National Library of Medicine, homeless patients stay in the
hospital about 4.1 days, or 36%, longer than housed patients (Salit, Kuhn, Hartz, Vu and Mosso,
1998). The cost of the additional days per discharge averaged $2,414. The report cited trauma,
respiratory diseases, infectious diseases and skin disorders, “many of which are potentially
preventable medical conditions.”
When an unhoused person goes to the emergency room, the care is almost 800% more
expensive than it is for a housed person. The days spent in care are about 130% more
expensive than a housed person.
Despite this, Kamlager’s concern is funding. She said her hope is that the ongoing
expenses of paying for healthcare are not a deterrent for insurance companies, despite paying
for preventative care being cheaper in the long run.
“If healthcare is a right, it’s a right regardless of whether you’re housed or not,” Kamlager
said.
She added there’s money left on the table, with so many unhoused (73%) not using the
Medi-Cal benefits they’re eligible for.
13
For the street medicine teams, authenticity is at stake. Becerra said the more money
brought into the organization, the less likely people are to be altruistic.
Johnson agrees. She said there’s always the worry that expanding the program and
adding more funding will affect the authenticity of the work, but that street medicine is hard to
do, and unless someone has the heart for it, they’re unlikely to get into it for the money.
Robinson, however, said the issues of fraud and abuse in the health care system are
always things to keep an eye on, but the lack of healthcare access to the homeless outweighs
potential dangers to the system.
“It’s an injustice that people don’t have access to basic health care, that people are dying
20-30 years earlier than others,” Robinson said. “When you think about the lives lost, the
injustice, the waste of paying people for care when our patients never reach those providers… I
can think of nothing better for our society as a whole than to get the 60,000+ people
experiencing homelessness the basic health care they need.”
Street medicine doctors and policymakers are fighting for just that.
“One of the biggest problems in the legislature right now, is you have a lot of people
who’ve never experienced poverty writing laws for people who are poor,” Ashtari said.
As someone who is enrolled in Medi-Cal, Ashtari said she ran into the roadblocks of
booking a doctor’s appointment, even as a 26-year-old woman fluent in English.
“As someone who’s been on Medi-Cal my whole entire life, I can tell you I have literally
been in the process of filing a lawsuit against a managed care plan because I could not get
care,” Ashtari said. “For six months I tried to make a doctor appointment with Medi-Cal. With all
my resources, my two laptops and phone, it took me six months because they don’t answer the
phone.”
Imagine, she said, how much longer it would have taken if she didn't have an address or
a cell phone. Ashtari was so passionate about the issue that she spearheaded AB369 herself.
14
The USC street medicine team’s involvement
Before he ran USC's street medicine team for the Keck School, Feldman had 14 years of
experience practicing street medicine in Pennsylvania. He has been practicing in Los Angeles
County for roughly four years. He founded two street medicine programs, one in Allentown, Pa.,
and the other for USC.
The team splits into groups of three and delegates which team attends to which patients.
They start with street rounds early in the morning before finishing their day at the LAC+USC
Hospital for consultations.
LAC+USC Hospital in Los Angeles. (Photo by Lauren Merola)
While he works on the streets, Feldman waits for AB 369 to pass. Feldman said he was
working on something similar in Pennsylvania before he moved to California, but did not know
who to talk to about bringing it to the state legislature.
When Ashtari called him, everything fell into place.
15
“I’ve wanted to do this for years,” Feldman said.
The SMI quickly sponsored the Street Medicine Act after Feldman brought it to the
board. The SMI’s mission to inspire and equip communities worldwide to provide street
medicine services to the rough-sleeping, another name for the unhoused (Street Medicine
Institute).
“You become a part of their ecosystem,” Withers said. “They embrace you and cherish
you and you begin to see as an outsider how awful it is and how callous people can be.”
Feldman said his patients are spit on, urinated on and aggressively yelled at.
The grassroots movement caused Withers to call together top doctors and street
medicine volunteers from around the world. His first meeting in India was with Dr. Jack Preger, a
health care champion for “pavement dwellers” in Calcutta, who convinced Withers to bring
together Street Medicine pioneers and spark a global movement. He called the meeting of street
medicine leaders the Street Medicine Symposium.
An entire industry’s name stemmed from one meeting.
Now, if AB 369 passes, the profession will have grown so that it is insured and can truly
provide the care needed. Currently, USC’s street medicine team is funded by USC, donors and
partners at LAC+USC, Robinson said.
“Street medicine stands between the reality of the hospital healthcare system and rough
sleepers,” Withers said. “People are dying on the streets and treating them is worth paying for.”
In early September 2020, Feldman met a homeless woman — whose name he did not
disclose — who had a large, cancerous growth on her nose. She knew it was there, but the
woman wasn’t able to get health care. She was too concerned with threats to her safety to worry
about it, or the coronavirus pandemic.
After the diagnosis, Feldman asked if the woman was interested in receiving treatment.
Street medicine is patient-led and prioritizes humility, allowing the patient to set the agenda,
Feldman said. After the woman agreed to treatment, Feldman found a dermatologist willing to
16
see her. But because of insurance issues, it was going to take a minimum of six weeks to get
her seen.
“There are all kinds of bureaucratic barriers in the healthcare system that prevent her
from being seen,” Feldman said. “In the meantime, she’s now aware that she has this cancer
and is still living outside.”
AB 369 supporters and opposers
Among the other sponsors of AB 369 are Health Net, Good RX, Los Angeles Mayor Eric
Garcetti, Dean of UC Riverside Medical School Dr. Deborah Deas and Los Angeles, Kern and
Alameda counties.
The California Department of Health Care Services (DHCS) and the Department of
Finance both oppose AB 369.
“Finance is opposed to this measure because this bill creates new General Fund costs
for DHCS that are not included in the state’s fiscal plan,” the department wrote in a bill analysis
brief. “Additionally, the Administration is implementing a series of programs aimed at improving
health care for individuals experiencing homelessness. Lastly, the presumptive eligibility
program for persons experiencing homelessness required in this bill is duplicative of the existing
Hospital Presumptive Eligibility program.”
The Hospital Presumptive Eligibility (HPE) program provides qualified individuals
immediate access to temporary, no-cost Medi-Cal while applying for permanent Medi-Cal
coverage (California Department of Health Care Services, 2021). HPE and AB 369 don’t
overlap. HPE doesn’t cater to the unhoused or allow street medicine doctors to order insured
scripts and services on the street.
Currently, there are about 50 supporters from California organizations and counties.
Kamlager hopes it will pass in September.
17
“We have to pass this bill because of Sean and Star and their three children who
deserve to have access to care just like anyone else,” Kamlager said. “Because of women like
Tina, who has been homeless for thirty-nine years on Skid Row and deserves to be able to see
a doctor on a regular basis to talk to her about her ailments and her cancer. Because of Dennis,
who's also homeless on Skid Row and deserves to see a doctor to talk about his thyroid
condition.”
A hopeful future for unhoused patients
About two years ago, Ashtari met a patient who was recently released from prison,
where his eyeglasses and identification were stolen. There is no process for enrolling
ex-convicts into Medi-Cal, so the patient had no way of affording new eyeglasses. He had no
way of getting to the DMV to fill out an I.D. card form. He had no way of being able to even see
such a thing.
“How can we expect this man to go pick himself up by his bootstraps and find a job and
make a living when he barely crosses the street without getting hit by a car?” Ashtari said.
Ashtari said she started medical school thinking she could make a difference in people’s
lives, but when attending to her poor-sighted patient, she realized she couldn’t.
Her mind naturally moved to the next step: paying for the patient’s glasses herself.
Quickly, Ashtari realized how unrealistic that’d be. She’d been told before about a growing-up
moment she’d experience as a medical student, where she’d realize she couldn’t personally buy
everything for every patient.
This was that moment, the one Withers experienced 30 years ago.
“It really takes away this idealistic image of doctors being able to solve everything and
heal the world because you realize so much of medicine does not happen in a medical clinic,
but through policies,” Ashtari said. “Policies like the ones we’re trying to change.”
18
With the future passage of the Street Medicine Act, next time, Ashtari and Marfisee can
not only tell the unhoused patient he has a cancerous lesion.
They can help him heal.
19
References
“15th Annual International Street Medicine Symposium.” Street Medicine Institute. Street
Medicine Institute, October 20-23, 2019.
https://www.streetmedicine.org/assets/docs/ISMS%2015%20Final%20Full%20Program
%20for%20Print.pdf.
“2020 Greater Los Angeles Homeless Count Results.” 2020 GREATER LOS ANGELES
HOMELESS COUNT RESULTS. Los Angeles Homeless Services Authority, June 12,
2020.
https://www.lahsa.org/news?article=726-2020-greater-los-angeles-homeless-count-result
s.
“AB-369 Medi-Cal Services: Persons Experiencing Homelessness.” California Legislative
Information, n.d.
https://leginfo.legislature.ca.gov/faces/billVotesClient.xhtml?bill_id=202120220AB369.
Cherry, Kendra. “How Maslow's Famous Hierarchy of Needs Explains Human Motivation.”
Verywell Mind, March 19, 2021.
https://www.verywellmind.com/what-is-maslows-hierarchy-of-needs-4136760.
Clay, Joanna. “USC's Street Medicine Team Brings the Hospital to the Homeless.” USC News,
August 27, 2019.
https://news.usc.edu/159333/usc-street-medicine-team-homeless-health-care/.
“Homeless People Die 30 Years YOUNGER, Study Suggests.” BBC News. BBC, December 21,
2011. https://www.bbc.com/news/uk-16272120.
Hospital Presumptive Eligibility Program. California Department of Health Care Services, March
23, 2021. https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/HospitalPE.aspx.
Kamlager, Sydney, and Neda Ashtari. “AB 369 – Street Medicine Act: Bringing Care to the
Street.” Los Angeles: Sydney Kamlager, 2021.
Kamlager, Sydney. “Department of Finance Bill Analysis.” Los Angeles: California Senate, n.d.
“Keck School Faculty.” Keck School of Medicine of USC, n.d.
https://keck.usc.edu/faculty-search/gabrielle-johnson/.
Keck Street Medicine, n.d. https://sites.usc.edu/streetmedicine/.
LAHSA Homeless Count. Los Angeles Homeless Services Authority, n.d.
https://www.lahsa.org/homeless-count/.
LeBlanc, Laura. “During Pandemic, Street Medicine Is First Line of Defense for People Living on
the Streets.” Keck School of Medicine of USC, May 11, 2020.
https://keck.usc.edu/during-pandemic-street-medicine-is-first-line-of-defense-for-people-li
ving-on-the-streets/.
Oreskes, Benjamin. “L.A. County Is Counting Homeless People This Week. Here's Everything
You Need to Know.” Los Angeles Times. Los Angeles Times, January 21, 2020.
20
https://www.latimes.com/california/story/2020-01-21/homeless-count-los-angeles-county-
faq.
“Our Vision & Mission.” Street Medicine Institute, n.d.
https://www.streetmedicine.org/our-vision-mission.
Portantino, Anthony. “Senate Committee on Appropriations.” Los Angeles: California Senate,
2021.
“Project Roomkey/Housing and Homelessness COVID Response.” California Department of
Social Services, 2020.
https://www.cdss.ca.gov/inforesources/cdss-programs/housing-programs/project-roomke
y.
Rosenheck, R, and JA Lam . “Client and Site Characteristics as Barriers to Service Use by
Homeless Persons with Serious Mental Illness.” Europe pmc, March 1, 1997.
http://europepmc.org/article/med/9057243.
Salit, S A, E M Kuhn, A J Hartz, J M Vu, and A L Mosso. “Hospitalization Costs Associated with
Homelessness in New York City.” The New England journal of medicine. U.S. National
Library of Medicine, June 11, 1998. https://pubmed.ncbi.nlm.nih.gov/9624194/.
21
Abstract (if available)
Abstract
California has a homeless population of over 151,000, 72% of whom are unsheltered, meaning they live on the street (Rosenheck and Lam, 1997). Los Angeles, specifically, has one of the largest homeless populations in the United States. As of 2019, Los Angeles had an estimated 59,000 unhoused people (Oreskes, 2020). In 2020, the Greater Los Angeles Homeless Count showed 66,436 homeless people living in Los Angeles County, a 12.7% rise from 2019 (Los Angeles Homeless Services Authority, 2020). More pressing than the number of homeless people in Los Angeles is the number of them that are dying from treatable conditions. The life expectancy of unhoused people is 30 years shorter than those housed and the unhoused are more likely to fall ill from preventable diseases like respiratory disorders, skin disorders and infectious diseases (Salit, Kuhn, Hartz, Vu and Mosso, 1998). The homeless population also have less access to health care, as 73% of unhoused people insured under Medi-Cal have never seen their assigned healthcare provider (Kamlager and Ashtari, 2021). Barriers like transportation, mailing addresses and stolen Medi-Cal Benefits Identification Cards prevent the homeless from meeting their assigned doctor and, thus, receiving the care they are qualified for. To combat this, street medicine doctors have taken to the streets and bridges of Los Angeles to treat homeless patients where they can, and want to, be treated. AB 369, a new bill proposed to the California Congress, aims to insure street medicine work and extend Medi-Cal presumptive eligibility to the unhoused, allowing them to receive Medi-Cal services and referrals from all licensed primary care providers, including street medicine doctors, regardless of who their assigned physician is. Currently, only prescriptions and referrals written by the assigned Medi-Cal doctor are covered by insurance, but with the passage of AB 369, street medicine doctors will be allowed to write life-saving, insurance-covered scripts and referrals for their homeless patients.
Linked assets
University of Southern California Dissertations and Theses
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Merola, Lauren
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The need for AB 369: the Street Medicine Act would allow street medicine physicians to do far more than dismantle bureaucratic barriers, it would save lives
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Publication Date
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AB 369,Brett Feldman,California,Congress,COVID-19,Gabrielle Johnson,homeless population,Homelessness,Insurance,Jehni Robinson,los angeles,Mary Marfisee,Medi-Cal,Neda Ashtari,OAI-PMH Harvest,rough sleeping,street medicine,Street Medicine Act,Sydney Kamlager,UCLA,USC
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AB 369
Brett Feldman
COVID-19
Gabrielle Johnson
homeless population
Jehni Robinson
Mary Marfisee
Medi-Cal
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rough sleeping
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Street Medicine Act
Sydney Kamlager