Interview with Director of Street Medicine Brett Feldman Who Breaks Down Bill AB-369 That Is Before California’s State Senate
AB-369 is the first and only bill of its kind. This seemingly small piece of legislation could prevent someone from dying on the streets, writhing in agony from a treatable disease. It could provide early detection for cancer, heart disease, and other ailments that become increasingly more life-threatening with time. Depending upon its application, the bill could save a life or a hundred thousand lives or more.
It is currently on the table of California’s State Senate, along with your taxpayer dollars. If passed, AB-369, often referred to as the “street medicine bill,” could save county and city funds along with those lives mentioned above. Today, we sat down with Physician’s Assistant Brett Feldman to discuss this piece of groundbreaking legislation and how it could alter the course of community medicine.
Invisible People: I’d like to start by thanking you on behalf of Invisible People for your dedication to promoting health in the homeless community. And from a personal standpoint, as a formerly homeless person and a breast cancer survivor, I find your mission, your life’s mission, honorable, touching, and important. My job is to express the level of importance to our readers. And with that angle in mind, I have put together a short series of questions introducing our readers to the street medicine bill AB-369.
So firstly, for our readers who might not be familiar with you and your work, could you please explain the street medicine bill along with your credentials and your role in the program itself?
Brett Feldman: I’m Brett Feldman. I’m a physician’s assistant, and I’m the Director of a division of street medicine for the Keck School of Medicine of USC. And I’m also the vice-chair of the Street Medicine Institute, which is an international organization that provides technical assistance to about 140 programs around the world, about 28 of which are in the state of California.
In street medicine, we recognize that people experiencing homelessness just can’t access health care the way that housed people do for many, many reasons. These reasons are both personal and environmental, but the environmental reasons are very often overlooked. We believe it’s our duty to leave our offices and go to them, these vulnerable members of the homeless community, first to deliver a tender love and then to provide the same quality healthcare on the street that they would expect in a brick-and-mortar clinic.
Invisible People: Can you explain how that works?
Brett Feldman: Sure. All of the care is delivered on-site. We dispense medications, draw labs, do Ultrasounds, EKGs, and we do point of care. In short, we do as much as we possibly can outside. So, those are pretty much the basics of street medicine.
Invisible People: Can you briefly explain the bill, AB-369, and its purpose?
Brett Feldman: AB-369 came to be because homelessness poses problems healthcare previously couldn’t solve. There are a few things that the bill does, but the core problem that it’s trying to solve is one of recognition. This bill recognizes the reality of the people on the street whose healthcare is adversely affected by their unmet needs for basic survival. To give you some perspective, these individuals might not know where their next meal is coming from, where they’re going to sleep tonight, if they’re going to be safe doing those things, etc. And until those basic needs are met, it’s really hard to begin to think about other things like the need for basic healthcare.
The vast majority of the people we go out and see are enrolled in Medi-Cal. When you’re enrolled in Medi-Cal, you’re assigned to a PCP, a primary care physician. All of the wonderful Medi-Cal benefits can really only be accessed through that PCP. So, your medications, labs, diagnostic studies, durable medical equipment like wheelchairs, specialty referrals and more, are all accessed through that PCP.
If you don’t have access to your PCP, then you also don’t have access to your benefits. So, for our patients, 94% of the people that we serve are enrolled in Medi-Ca. But only 27% have ever seen their PCP within our brick-and-mortar clinic. That number would be higher because of how we identify people within a hospital system.
There was one study that was done from the street level and showed only 8% had seen a doctor in a brick-and-mortar clinic.
As you can see, there’s this huge gap between benefit eligibility, which the vast majority are eligible for, and benefit access, where the vast majority are not able to access those benefits. Bill AB-369 makes it, so that street medicine healthcare providers become what they call direct access providers, meaning that they don’t need to be officially signed through Medi-Cal as their PCP.
We also are not categorized as specialists, meaning that we don’t need a referral to see them. So, they can exactly, as it sounds, directly access us, and we can directly access their benefits. So that the moment we see them, we can immediately prescribe medications or order labs. If they need a wheelchair, we can order that without having to wait a few months in order to change their impanelment, which is what we were doing before.
Invisible People: Before this, how long would a patient have to wait?
Brett Feldman: It would usually take two months.
Invisible People: What are some of the other things the street medicine bill does?
Brett Feldman: The bill makes street medicine providers direct access providers so that we can access their benefits for them and order things they need. The second thing it does is that it forces Medi-Cal and Medicaid to recognize the street as a legitimate place to deliver health care.
So everything that we’re doing is reimbursable. It’s already reimbursable through Medi-Cal, but because of where we’re doing it, where the patients are, it’s not reimbursable. So, we’re not able to bill and get paid for the services that we provide. The result is that we don’t have a sustainability plan.
Invisible People: Why is it crucial for these organizations to recognize the street as a legitimate place to provide healthcare?
Brett Feldman: Every other medical practice is able to exist because they can bill for services rendered, and we can’t do that. Due to our unique position, we have to fight to exist and fight to survive with philanthropy and grants and all these things. Also, we must provide things for our patients for free because we can’t access their benefits. We’re not only trying to find sustainable funding for us. We’re trying to support our patients as well.
The Street Medicine Act recognizes the street as a legitimate place to deliver care. In doing so, it also recognizes the people we serve as having a legitimate right to life because they really do depend on us coming to them and providing care in their environment in order to survive.
Invisible People: How long have you been providing street medicine to the homeless community?
Brett Feldman: I started in Allentown, Pennsylvania, in 2007 and then came to LA in 2018. My wife Corinne, who is a PA and also does street medicine, was just completely blown away by the enormity of the crisis in LA. We were inspired to move out here and do what we could to help.
The crisis is so big that we knew that it couldn’t be just us. We knew that we had to be able to create a pipeline of providers ready to do this work and also train and equip others. And doing it through USC was the perfect way to build that foundation because it is such a robust academic institution.
Invisible People: The general public is well aware of the public health risks posed by COVID-19. But what are some other issues they might be less aware of in that sphere?
Brett Feldman: Aside from COVID, there are a lot of other health risks that have to do with the state of homelessness, not the people who are experiencing it. Please bear in mind that you and I would have the same issues if we were homeless, as homelessness is a health crisis. For example, a friend of mine, Dr. Liz Fry, published a study that looked at open defecation.
As it turns out, what happens when we don’t provide enough toilets for people who are sleeping outside and we force them to practice open defecation, because everybody who is alive and human has to defecate, found that about a third of the stool samples have some sort of infectious diarrhea in them. There are a few reasons why that’s so prevalent- one of which is a lack of access to refrigeration. Another is a lack of access to a reliable food source.
So when somebody comes by and drops off a tray of food, and they don’t know where their next meal will come from after that tray, even if the tray is sitting in the heat, they’ll probably eat it longer than they really should. This makes them more likely to get food poisoning. There are definite health risks posed by forcing people to stay outside. The answer is not to push them somewhere but rather look to resolve their homelessness.
Invisible People: What are some ways in which this program could save taxpayers money?
Brett Feldman: The vast majority of people are eligible and enrolled in Medi-Cal. Many of the programs, especially in LA and San Francisco, are currently being funded by the counties and some of the cities. The way things are set up now, the people are being funded two ways: they’re being funded through the state with Medi-Cal and also by the county and the city. The bill essentially alleviates cities and counties from their need to cover these medical costs. This shifts the bill back where it belongs- to the insurance companies and frees up taxpayer dollars in the process.
So, if AB- 369 passes, the counties and the cities can take the money they are currently using for street medicine and use it to help somewhere else.
Invisible People: What are some ways in which this program saves lives?
Brett Feldman: People experiencing homelessness are much sicker than the general population. Their mortality rate is ten times higher than that of the average housed population. For unsheltered individuals, it is three times higher than that of the sheltered population. Their utilization of healthcare services leans much more towards urgent and emergency services. With street medicine, we’ve shown that we can increase access to primary care by over 250%.
We tracked the hospital readmission rate for 30 days from the patients experiencing homelessness. Of those individuals not seen by street medicine, over 30% came back within 30 days. When we see them, that number plummets to less than 10%.
*Important Note: Street Medicine Has the Dual Benefit of Saving Lives and Saving Taxpayer Dollars.
Invisible People: Could you describe a typical day of practicing street medicine?
Brett Feldman: In street medicine, we operate through walking rounds. There’s a philosophical reason why we don’t work out of an RV, but we have a pickup truck and backpacks. So, we all meet up at this fast-food restaurant across the street from the hospital in the morning. We do our rounds early before folks have really gotten up and are moving around, going about their day.
We do our best to make a schedule like you would in a traditional medical practice. There are patients that we plan to see that day, but we also believe that we need to take care of their communities. We don’t stack patients up to such an extent that if we see somebody that we want to help, we’re unable to. We make sure our schedule has enough flexibility to prioritize the unique needs of the whole community.
For example, we might go to one encampment and have a patient. Then, just like other medical practices, we get referrals, and word-of-mouth referrals, except our referrals are from one tent to the next. So, they might say, “Hey, you know, you think I’m bad you gotta go see Bob three tents down. He’s really bad.”
In this sense, we see ourselves as taking care of the community versus just individual patients. We usually do that until about two o’clock, and then we work on some case management. And sometimes we have consults in the hospital where if somebody is identified as experiencing homelessness and expected to be discharged back outside, we go into the hospital and see them and then follow them on the street when they’re discharged.
Invisible People: What are some of the most common ailments and illnesses you see?
Brett Feldman: The most common things we see are similar to what you would expect from the general population, except we usually see homeless people in much more advanced states.
The most common diagnosis that we see is congestive heart failure. That’s very difficult to treat on the street because we typically give people diuretics or water pills, and they work to keep their fluid down. But the problem is that if they don’t have consistent access to food and water, it’s difficult to get the dose right. If they take too much, they can go into kidney failure. If they take too little, they go into heart failure. So you have to follow them very closely.
We also see a lot of lung disease and chronic obstructive pulmonary disease. One of the things that we treat that is more common in our population than the general population is definitely wounds. We see a lot of wounds and do a high level of wound care on the street. It’s difficult to keep them clean and dry. Mental health and substance abuse is not the primary thing we see, but it does exist within the community.
Invisible People: Are there any patients you have met who stand out in your mind? If so, what was their story, and how did they impact your worldview?
Brett Feldman: There are so many! I’ve been able to stay in this work so long because I’m inspired every day by them. They’ve completely changed my worldview since I’ve started. Here’s a story of one patient that immediately comes to mind as changing my worldview:
His name was Craig, and I met him through the hospital console service. He came in with belly pain and was exactly 50 years old, which is the age that you would get your first colonoscopy to screen for colon cancer. But he already had metastatic colon cancer everywhere and had been living in this drainage pipe for three years. He decided that he did not want treatment. He just wanted to be made comfortable.
And we just couldn’t bear to see him go back to the drainage pipe.
So I had arranged with the inpatient hospice for him to go there, and they agreed. It was very unusual because, typically, you need some sort of support, like respiratory support team support, and the life expectancy in an inpatient hospice unit is usually shorter. Although it was a terminal diagnosis, he had a few months to live. They also said he could come and go and keep his freedom if he wanted it. So, I went back, you know, triumphantly and tell him the thing that I, that we, had arranged for him.
And he said that he didn’t want to go. I said, “why not?”. He said because you said that the people in there are gonna die within a week. That means they need the bed more than I do, and so I’ll go back to my drainage pipe. And so we saw him there, in the drainage pipe, for the next few months. The thing that really stuck with me was that even in his suffering, he was able to recognize someone else’s suffering that, that might even be greater than his, and he was willing to make a real sacrifice for the benefit of somebody else. His level of self-sacrifice was to the point that he was willing to live outside, even longer with a cancer diagnosis. That encounter was years ago, and it still inspires me today.
Invisible People: How often do you encounter homeless individuals whose terminal status could have been avoided if they had been diagnosed sooner?
Brett Feldman: More often than is comfortable to talk about, because it’s just so, it’s just so common. Boston Healthcare for the Homeless published what was really a sentinel study on mortality rates for people experiencing homelessness, and cancer was the number three cause for mortality in people experiencing homelessness.
I just don’t think people think about that as a cause, which is tragic. If we believe that screening is valuable – colonoscopies, mammograms, you know, all of these screening tools that the rest of the population gets – if we believe that’s valuable, then it also needs to be applied to people experiencing homelessness. It is really negligent to leave the current system the way it is, knowing that they can’t access it, even if they’re eligible for it.
Invisible People: In a video with Invisible People, you spoke on the importance of prioritizing homeless patients, comfort over your own. Do you think that applies to members of the housed community across the board who are seriously considering the relationship between healthcare and homelessness, perhaps for the first time?
Brett Feldman: Most of the solution to homelessness comes down to if we’re willing to take responsibility for our community. And if we’re willing to stand in solidarity with the people in our community who are suffering. The first thing you have to do is recognize people experiencing homelessness as members of the community. If you continue to view them as others, people that are not like you and will never be like you, it’s easy to discard them and throw them away and, say, remove them from our community.
But if we, if you start with the idea that they are part of the community already, you’re less likely to want to remove them. You’re more likely to want to take care of them.
Part of the reason we’re successful is that we’re willing to share in the suffering of our patients for us to feel a little bit uncomfortable to provide them some comfort. It’s not enough to just give out of our excess, you know, to go into your closet and just give whatever you don’t want anymore. We all have a responsibility to do what’s right for the people who are suffering the most. And that has to involve some sort of sacrifice for us.
Dear Readers, according to a study conducted by the University College of London, one-third of all fatalities occurring within the homeless population result from treatable diseases. Time is running out to support this bill. If it is successful in California, it could have significant implications all across the nation. Don’t let it die when human lives hang in the balance.
Check out our Invisible Stories mini-documentary featuring Director of Street Medicine Brett Feldman and the importance of Street Medicine: