On a Wednesday morning in downtown Denver in the blazing July sun, members of STRIDE Community Health Center's street medicine team offered bottles of water, snacks, sunscreen and medical care to people experiencing homelessness.
Federal fallout As federal funding and systems dwindle, states are left to decide how and whether to make up the difference.
One person had a head injury, so the team helped him clean the wound and bandage it up.
Another person recently had surgery on his arm, so the team checked on his stitches and gave him information on medical respite housing.
The last person the team talked to needed a fresh bandage on a wound before a doctor's appointment the next day.
Most people the team interacted with just wanted some snacks and water, but STRIDE members offered sunscreen, menstrual hygiene products and first aid supplies to those they engaged with, too.
STRIDE is a federally qualified health center, or an FQHC, meaning it serves an underserved population and qualifies for enhanced reimbursements from Medicaid and Medicare. Its street medicine team treats people experiencing homelessness, which helps save everyone money, but now that work is threatened by recently passed Trump administration policies that could cut federal funding for health care.
The street medicine team at STRIDE, one of several teams doing this work in the state, travels around the five counties of the Denver metro area looking for people in need of medical attention on the streets. The idea emerged as center staff realized there was a population they still were not reaching, and started with just one person walking around with a backpack, according to Shawn Marzan, street medicine and community outreach program manager.
"If there was ever a catchphrase that works in street medicine, it is going to the people, and there really isn't anywhere that we won't go to find people," Marzan said. "We have gone to encampments, we've gone to overpasses, under bridges, in parks, in fields. There isn't a place that we won't provide care for people."
If the street medicine team was not out looking for people in need of medical care, many people experiencing homelessness would seek medical attention only in emergencies. That leads to expensive and preventable emergency room visits, according to Joanne Accardi, medical director of convenient care and street medicine at STRIDE.
"Going to the ER puts a big strain on the health care system in general, Medicaid or not," Accardi said. "When they go there, a lot of times it's stuff that we can manage here in the clinic, and it inundates the ER and then there's delays in care for people that are more acutely sick."
Marzan said one of the patients he sees regularly averaged more than 30 emergency room visits in a year for the same condition. After the first time he engaged with the street medicine team, Marzan said that patient went seven months without going to the emergency room.
Allison Draayer, business development manager at STRIDE, said emergency rooms in the metro area are familiar with the street medicine program and will let patients know to look to them for follow-up care if they are being discharged to the streets. She said their work has led to a decrease in emergency room visits.
Many people experiencing homelessness can afford medical care only if they are enrolled in Medicaid. One patient the team has interacted with had diabetes, but because he didn't have insurance coverage, he wasn't able to afford insulin from the pharmacy. He hadn't taken any insulin in about a month.
The street medicine team will help someone enroll in Medicaid on the spot, and Medicaid then reimburses STRIDE for the care they provide those patients. The nurses and medical assistants who walk around will assess a patient's needs and provide care as needed. The team also has a device that allows members to connect with a doctor for a telehealth appointment, and the doctor can see and hear everything those on the ground do.
STRIDE also partners with organizations that have expertise in housing and substance abuse recovery to ensure those the street medicine team interacts with can connect with the proper resources. Representatives with RTD will join them and hand out bus passes.
Cody Kiebler helps connect people who want to recover from substance abuse with the proper resources. Working in conjunction with the street medicine team benefits everyone involved, he said, because while he isn't equipped to provide medical care, he is better suited to navigate conversations about substance abuse for people who want to get sober.
"This provides us more access in this world and really completes that picture, because if I go out as just me doing street outreach, I don't have the energy, the effort, the ability to reach everyone we do, and I don't have the resources," Kiebler said. "This spreads the resources between different groups, different teams, how we work, different companies, as well as the care people can get. It really feels good to be part of a cool team."
Medicaid cuts put program in jeopardy
A statement from Kim Bimestefer, executive director of Colorado's Department of Health Care Policy and Financing, said changes to Medicaid following the recent passage of Republicans' policy megabill will lead to "large-scale loss of health insurance coverage for Coloradans and an extraordinary cost shift to our state that Colorado's state budget cannot absorb." With imminent cuts and changes to Medicaid eligibility, the future of programs like STRIDE's Street Medicine Team are threatened.
Without the reimbursements STRIDE gets from Medicaid and Medicare as an FQHC, running a street medicine program would be incredibly costly.
"Part of the reason why you don't see a ton of (FQHCs) doing this is because it's extremely expensive," Draayer said. "We try to run it on a very lean team ... It's very, very expensive for FQHCs to do these models, and it requires partnership. It requires people to be invested in it in order to see it succeed."
Accardi said reduced Medicaid coverage will affect everyone who needs health care, not just those covered by the program. She said emergency rooms and shelters will be more crowded as people are unable to access consistent care, and STRIDE's street medicine team would have to reduce its capacity.
"Without the funding, then we can't send as big a team out on the street, and then the patients will inevitably go back to the ER or get no treatment at all," Accardi said. "We could still see them, but then how am I going to get them their meds? We would see less patients, and they would be sicker."
Marzan said cuts to Medicaid will lead to increased wait times to get appointments and to get seen in the emergency room. Draayer said more people going to the emergency room who cannot afford it will lead to everyone's medical bills and insurance costs going up. She said community health centers like STRIDE will see increased demand, too.
"One of the best ways to invest in efficiency and eliminate waste, fraud and abuse is by investing in community health centers, because we do a lot with a little, and that's what I would also encourage people to understand," Draayer said. "We often go by the wayside, and people don't see us, but we do this work and we do it really well."
The Colorado Coalition for the Homeless also has a street medicine team, and spokesperson Cathy Alderman said the organization relies on Colorado's "presumptive eligibility" provision of Medicaid enrollment to get reimbursed for the care it provides. That means if certain factors can lead to a fair assumption someone would qualify for Medicaid, those providing care could be retroactively reimbursed once that person is enrolled.
"In a world where people both have to income-qualify for Medicaid and also demonstrate that they are complying with work requirements, that would be impossible for us to determine on the streets," Alderman said.
Marzan said the patients he works with on the streets are "some of the most caring and humble people you can meet." During summer months, he said many of them will offer their drinks to him and his team, and in the winter months, they'll offer up one of their layers for added warmth. He said he wishes more people could see "that interaction, that moment between two humans."
Accardi said Marzan and his team "have done a very good job of getting a reputation in the community with our homeless population."
"It took a while to gain the trust, but now the word is out there," Accardi said. "It's literally out there on the street, and I think that that's why we do see so many people, because we're trusted."
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