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At the Intersection of Health, Health Care and Policy

doi: 10.1377/hlthaff.2013.0228

, 32, no.9 (2013):1552-1559 Health Affairs


And Access To A Broad Range Of Services
Medicaid Expansion: Chronically Homeless Adults Will Need Targeted Enrollment
Jack Tsai, Robert A. Rosenheck, Dennis P. Culhane and Samantha Artiga
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By Jack Tsai, Robert A. Rosenheck, Dennis P. Culhane, and Samantha Artiga
Medicaid Expansion: Chronically
Homeless Adults Will Need
Targeted Enrollment And Access
To A Broad Range Of Services
ABSTRACT Homeless adults may gain access to health services under the
Affordable Care Acts Medicaid expansion, which takes effect in 2014.
This study analyzed the health coverage, health status, and health
services use of 725 chronically homeless adults with disabilities in eleven
cities in the United States. Nearly three-quarters of the chronically
homeless adults in this study with incomes below the threshold for the
Medicaid expansion were not enrolled in Medicaid. Fifty-three percent
were uninsured or relied solely on state or local assistance, and
21 percent had other coverage that included Department of Veterans
Affairs health care. The findings on differences in health status and
service use across groups suggest that the Medicaid expansion offers
important opportunities to increase coverage and access to care for
chronically homeless adults. There may be potential savings for states
that expand Medicaid, as people transition from state and local assistance
to more comprehensive services under Medicaid. Targeted outreach and
assistance to enroll eligible homeless people will be necessary. A broad
range of physical and mental health services will be required, including
case management to coordinate services.
T
he Affordable Care Act created a
framework for one of the most im-
portant changes to the US health
care system in history. One of the
acts main components is the ex-
pansion of Medicaid coverage to include people
under age sixty-five with incomes of up to
138 percent of the federal poverty level (in
2013, $15,856 for an individual), beginning
in 2014.
Prior to health reform, eligibility for Medicaid
was limited to low-income people in certain cat-
egories, including children, pregnant women,
parents with dependent children, people who
qualified as disabled, and elderly adults. The
Medicaid expansion in 2014 extends eligibility
to low-income, nonelderly, nondisabled adults
without dependent childrenoften called
childless adultswho were historically exclud-
ed from the program.
Although the Affordable Care Act originally
expanded Medicaid in all states, the 2012
Supreme Court decision on the act effectively
made implementation of the expansion a state
option.
1
As of the end of July 2013, twenty-six
states had decided to participate in the expan-
sion, thirteen had decided to opt out, and eleven
remained undecided or were pursuing alterna-
tive models.
2
Coverage for adults who are newly
eligible under the Medicaid expansion will be
completely federally funded until 2016.
States are considering a wide array of factors
as they decide whether or not to implement the
expansion, including its impacts on coverage
and costs.
2
States may have to ramp up resources
to enroll people in Medicaid and will have to pay
doi: 10.1377/hlthaff.2013.0228
HEALTH AFFAIRS 32,
NO. 9 (2013): 15521559
2013 Project HOPE
The People-to-People Health
Foundation, Inc.
Jack Tsai (Jack.Tsai@yale.edu)
is a core investigator for the
Veterans Affairs New England
Mental Illness, Research,
Education, and Clinical Center
and an assistant professor of
psychiatry at the Yale
University School of Medicine,
in West Haven, Connecticut.
Robert A. Rosenheck is a
senior investigator for the
Veterans Affairs New England
Mental Illness, Research,
Education, and Clinical Center
and a professor of psychiatry
and public health at the Yale
University School of Medicine.
Dennis P. Culhane holds the
Dana and Andrew Stone Chair
in Social Policy at the
University of Pennsylvania, in
Philadelphia.
Samantha Artiga is associate
director of the Kaiser
Commission on Medicaid and
the Uninsured, in Washington,
D.C.
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a small portionof the expenses for newly eligible
adults after 2016.
3,4
At the same time, there are
potential advantages for the states to expanding
Medicaid. For example, the expansion would
provide offsetting savings in spending for ser-
vices the states would otherwise provide to un-
insured people, and building on state-funded
efforts with federal dollars would save states
and localities billions of dollars.
5
Among other people who could gain coverage
under the Affordable Care Acts Medicaid expan-
sion are the estimated 1.2 million people across
the country who are homeless in a given year,
including roughly 110,000 chronically homeless
adults.
6
Giventheir lowincomes, many currently
uninsured or underinsured homeless adults will
gain from the Medicaid expansion a new path-
way to coverage and new health care opportuni-
ties.
7,8
Despite these impending changes and
the often complex health conditions and needs
of chronically homeless adults,
9,10
there has been
no recent comparison between the chronically
homeless adults currently enrolled in Medicaid
and those newly eligible for Medicaid under
health reform in the states that will implement
the expansion.
This study was intended to provide insights
into the characteristics and health needs of
chronically homeless adults with disabilities
who are likely to be eligible for Medicaid follow-
ing the programs expansion in 2014. Specifi-
cally, the study examined the health coverage,
sociodemographic characteristics, healthstatus,
and health service use of chronically homeless
adults with incomes below the threshold in the
Medicaid expansion. It also compared those
currently enrolled in Medicaid to those who
are uninsured, rely solely on state or local assis-
tance, or are covered by other insurance such as
Veterans Affairs (VA) health care. The results
may inform planning efforts among states that
decide to participate in the Medicaid expansion.
Study Data And Methods
Program Description Data were obtained on
725 chronically homeless adults with incomes
below the threshold for the Medicaid expansion
who participated in the Collaborative Initiative
to Help End Chronic Homelessnessan eleven-
site federally supportedhousinginitiativefrom
2004 to 2009.
11
The initiative provided adults
who were chronically homeless with permanent
housing and supportive primary health care
and mental health services. A person who was
chronically homeless was defined as an unaccom-
panied homeless individual with a disabling
condition who has either been continuously
homeless for 1 year or more or has had at least
four episodes of homelessness in the past 3
years.
11(p2)
Sample The program originally enrolled 756
participants, but the analyses in this study were
limited to the 725 participants who were under
age sixty-five and had a monthly income of less
than$1,246whichequates toanannual income
of $14,945 for an individual (or 138 percent of
the federal poverty level, the eligibility threshold
for the Medicaid expansion, in2009). This study
focused on the assessments of the participants
at baseline, when they enrolled in the program.
Measures Assessments of participants socio-
demographic chracteristics, health insurance
coverage, health status, and health care use
were conducted by local clinical staff designated
as program evaluation assistants at each of the
programs sites. These staff were knowledgeable
about Medicaid eligibility rules as well as avail-
able state and local assistance programs. They
conducted face-to-face interviews with partici-
pants using various self-report measures.
Health insurance coverage was assessed by
asking participants, During the past three
months, were you covered by any of the follow-
ing health insurance programs? and then ask-
ing them to respond yes or no to each of the
following forms of coverage: Medicaid, Medi-
care, VA, state or local medical assistance, pri-
vate insurance, some other health insurance, or
no health insurance.
Histories of homelessness were based on par-
ticipants reports of the age at which they first
became homeless, the total number of years they
had been homeless, and the total number of
years they had been incarcerated. Participants
were also asked how many days in the previous
three months they had stayed in their own apart-
ment, room, or house; stayed in an institution
(a halfway house, residential program, hospital,
or jail or prison); and been homeless (stayed
outdoors or in shelters, vehicles, or abandoned
buildings).
Health status was assessed with the twelve-
item Short-Form Health Survey;
12
a ten-item
rating scale for observed psychotic behavior;
13
the mean score of the psychoticism, depression,
and anxiety subscales of the Brief Symptom
Inventory;
14
and the alcohol and drug subscales
of the Addiction Severity Index.
15
Psychiatric di-
agnoses were based on participants reports.
Medical conditions reported by participants
were drawn from a list of twenty-three con-
ditions.
16
To assess health care use, participants were
asked detailed questions about the number
and type of medical, mental health, and sub-
stance abuse treatment visits they had made
during the previous three months. Visits were
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separated into emergency department, in-
patient, outpatient medical, outpatient mental
health, and outpatient substance abuse visits.
Inpatient medical, mental health, and substance
abuse visits were combined into a single in-
patient category because of the low counts in
each individual category.
The number of medical conditions for which
participants were treated in the previous three
months, out of the conditions on the list
16
that
they reported having, was their number of medi-
cal conditions treated. Participants reported
whether or not they had had one or more pre-
ventive procedures from a list of fourteen, had
discussed with a physician one or more of four
health behaviors (smoking, alcohol consump-
tion, diet, and exercise), and had had one or
more of three health tests (HIV/AIDS, hepatitis
C, and tuberculosis) in the previous year.
Last, participants were asked to respond yes
or no when asked if they had had any trouble
paying for health care in the previous three
months.
Data Analysis Participants were divided into
the following four mutually exclusive groups
based on their reported health insurance cover-
age: those with Medicaid; those with no health
insurance; those receiving state or local assis-
tance only; and those with other health insur-
ance, including VAhealth care. Participants who
reported multiple types of coverage were cate-
gorized as covered by Medicaid, if they had that
coverage; by state or local assistance, if they had
that but not Medicaid; and by other health in-
surance, if they hadneither Medicaidnor state or
local assistance. The rationale for this categori-
zation was that Medicaid generally offers more
comprehensive coverage than state or local as-
sistance, and people with other health insurance
may be less likely than others to enroll in
Medicaid after the expansion.
Participants in each of the four groups were
compared on sociodemographic characteristics,
histories of homelessness, health status, and
health care use with chi-square tests, analysis
of variance, and multinomial logistic regression
and analysis of covariance (differences in pro-
gram site and sociodemographic characteristics
were controlled for). Before tests of difference,
we conducted a log transformation on depen-
dent variables with non-normal distributions.
Post hoc group comparisons were conducted
with Fishers least significant difference test
and pairwise chi-square tests. Given the number
of comparisons and the inflated probability of
type 1 errors (the incorrect rejection of a true
null hypothesis), significance was 0.01 for all
analyses. The online Appendix provides addi-
tional details about the study methods.
17
Limitations The study sample came from
eleven cities participating in a federally sup-
ported housing initiative for chronically home-
less adults with disabilities. Thus, it may not be
representative of chronically homeless adults
without disabilities or of other cities across
the country. The data came from the period
200409, and conditions and characteristics of
homeless populations may have changed since
that time.
In interpreting our results, it is important to
consider the variation by state in eligibility for
Medicaid before the passage of the Affordable
Care Act. In all but one of the study states, eligi-
bility for adults was generally very limited. The
exception was NewYork, which expanded cover-
age to adults with incomes up to the federal
poverty level during the study period. All of
the states covered adults with disabilities
through Medicaid. However, experience sug-
gests that homeless people face serious chal-
lenges in qualifying through this pathway be-
cause of the difficulty they have in acquiring
medical documentationof their disability so that
they can qualify for Supplementary Security
Income and then Medicaid.
7
The study presents a cross-sectional compari-
son, so causality and stability of these findings
are not conclusive. Nearly all of the measures,
including insurance coverage, were based on
self-report, and their validity cannot be con-
firmed. However, there is some evidence that
adults with severe mental illnesses are able to
accurately and reliably report their health ser-
vice use,
18
illness history,
19
and health status.
20
Study Results
Of the sample of 725 chronically homeless
adults with incomes below the threshold for
the Medicaid expansion, more than three-quar-
ters had some form of insurance. Of those with
insurance, 226 (31.17 percent) were covered by
state or local assistance, 185 (25.52 percent)
were covered by Medicaid, and 153 (21.10 per-
cent) were covered by some other health insur-
ance (Exhibit 1). Among those who reported
other forms of health insurance, 79.74 percent
had VA health care, 12.50 percent had Medicare,
5.92percent hadprivateinsurance, and9.80per-
cent had some other health insurance. Of those
enrolledinMedicaid, 11.35percent alsoreported
receiving state or local assistance.
Characteristics And Histories Of Home-
lessness The sample was racially diverse and
consisted mostly of single males in their forties
who had less than a high school education and a
monthly income of less than $400 (Exhibit 1).
On average, these adults first became homeless
Medicaid Expansion
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in their early thirties, had been homeless for
more than eight years in their lifetime, and
had been homeless for more than fifty days in
the previous three-month period.
There were a few significant differences be-
tween the chronically homeless adults with
Medicaid and those who were uninsured or re-
ceiving state or local assistance. Those receiving
state or local assistance wereyounger, weremore
likely to be white, and had lower incomes than
Medicaid enrollees (Exhibit 1). Inaddition, com-
pared to Medicaid enrollees, those with no in-
surance were younger, were less likely to be vet-
erans, and had lower incomes. There were no
significant differences in homeless histories be-
tween those with Medicaid and those who were
uninsured or receiving state or local assistance.
Reflecting the fact that most of the people in
the other insurance group reported having ac-
cess to VA health care, members of the other
group were significantly more likely than those
in other groups to be veterans (Exhibit 1). They
also were generally older, were more likely to be
male and white, and had more years of educa-
tion. With respect to recent homeless history,
those with other health insurance had also spent
fewer days in their own place in the previous
three months than those without health insur-
ance and those on Medicaid.
Health Status And Health Care Use There
was a high prevalence of both physical and men-
tal health conditions among the people in the
sample (Exhibit 2). Most of the participants
reported multiple medical conditions and high
rates of psychiatric disorders, particularly sub-
stance use disorders. Compared to the national
average scores of 50 for both physical and
mental health on the twelve-item Short-Form
Health Survey
12
scores that have a standard de-
viation of 10the total sample reported worse
health. The samples average score for mental
health was 39, which is more than one standard
deviation below the national average.
After we controlled for characteristics of the
program site and sociodemographic charac-
teristics of the study participants, we found
few differences in health status across coverage
groups. However, chronically homeless adults
with no health insurance were 1116 percent
less likely than those with any coverage to report
having schizophrenia. Those with other health
insurancethe groupcontainingthe largest pro-
portion of veteranswere more likely than the
members of any other group to report having
post-traumatic stress disorder. There were no
other significant differences on health status
across groups, including the number of medical
conditions. There were differences on some in-
dividual medical conditions, as shown in the
online Appendix.
17
To examine suppression effects, we repeated
these analyses without controlling for differenc-
es in site and sociodemographic characteristics.
We found nearly no differences in health status
across groups, except that people with no health
insurance had higher physical scores on the
Short-Form Health Survey
12
than those with
Medicaid and reported fewer medical problems
Exhibit 1
Sociodemographic Characteristics And Homeless Histories Of Chronically Homeless Adults, By Health Insurance Status
(1) Medicaid
(n = 185)
(2) No
insurance
(n = 161)
(3) State or
local assistance
only (n = 226)
(4) Other
health insurance
a
(n = 153) Column comparison
Characteristic
Mean age (years) 46.91 42.54 44.65 48.27 1; 4 > 2; 3****
Male (%) 74 78 68 89 4 > 1; 3****
White (%) 26 36 44 44 3; 4 > 1***
Education (years) 11.82 11.33 11.74 12.36 4 > 2***
Married (%) 1 1 1 1
b
Veteran (%) 23 7 15 81 4 > 1 > 2; 4 > 3****
Monthly income ($)
c
546.53 227.88 272.48 474.83 1 > 4 > 2; 1 > 3****
History of homelessness
Age when first homeless (years) 33.50 30.54 30.59 35.91 4 > 2; 3****
Lifetime years homeless 8.72 7.41 8.63 7.64
b
Lifetime years incarcerated 3.14 2.89 3.22 2.04
b
Days in own place, past 3 months 8.19 6.57 5.29 3.22 1; 2 > 4***
Days in institution, past 3 months 13.88 14.68 17.48 15.73
b
Days homeless, past 3 months 53.14 53.96 55.71 59.17
b
SOURCE Authors analysis. NOTE Column comparisons are among numbered columns.
a
Includes Veterans Affairs health care.
b
No significant differences among numbered
columns.
c
A log transformation was conducted on these variables before group differences were tested. ***p < 0:01 ****p < 0:001
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than those with any coverage. Participants re-
ceiving state or local assistance had higher
Brief SymptomInventory scores
14
than members
of all other groups, reflecting greater subjective
distress.
The total sample reported using a wide range
of health services during the previous month,
with the highest use reported for outpatient
mental health and substance abuse services
(Exhibit 3). On average, study participants indi-
cated that 53 percent of their total number of
reported medical conditions had been treated.
In addition, these chronically homeless adults
reported receiving an average of seven out of
fourteen specified preventive procedures and
discussing three out of four identified health
behaviors with a physician in the previous year.
Lastly, 29 percent of the total sample reported
problems paying for care during the previous
three months.
After we controlled for differences in site and
sociodemographic characteristics, we found no
significant differences in reported health care
use between Medicaid enrollees and those with
any other formof coverage. However, there were
significant differences in reported health care
use between those who did not have insurance
and those who did (Exhibit 3). The group with-
out insurance reported less use of outpatient
medical services and preventive procedures than
all of the other groups. In examining the four-
teen preventive procedures individually, those
without insurance were significantly less likely
to have had each procedure, except the hearing
screening and colonoscopy.
Chronically homeless adults without health
insurance also reported less use of inpatient
services than those with Medicaid coverage or
state or local assistance (Exhibit 3). And they
reported less use of emergency department ser-
vices thanthose withMedicaid, as well as less use
of outpatient substance abuse services and dis-
cussing fewer health behaviors with a physician,
compared to those with other health insurance.
Moreover, participants without health insur-
ance were more likely to report having trouble
paying for their health services than those with
coverage. In fact, they were more than three
times as likely as Medicaid enrollees to report
this problem (63 percent versus 20 percent).
Nearly all of these results remained the same
when we did not control for differences in site
and sociodemographic characteristics. The ex-
ceptions were that people without health insur-
Exhibit 2
Health Status Of Chronically Homeless Adults, By Health Insurance Status
(1) Medicaid
(n = 185)
(2) No
insurance
(n = 161)
(3) State or
local assistance
only (n = 226)
4) Other
health insurance
a
(n = 153)
Column
comparison
Psychiatric diagnoses (%)
Alcohol use disorder 46 55 58 50
b
Drug use disorder 56 55 49 50
b
Schizophrenia 23 8 19 24 1; 3; 4 > 2***
Bipolar disorder 15 19 24 17
b
Post-traumatic stress disorder 3 7 7 14 4 > 1; 2; 3***
Major depression 29 30 29 22
b
Development disability 13 11 9 7
b
Scores on:
Brief Symptom Inventory
c
1.44 1.43 1.73 1.46
b
Observed psychosis scale
d
0.27 0.17 0.22 0.19
b
SF-12
e
physical 43.37 47.24 44.58 44.49
b
SF-12
e
mental 40.43 38.22 38.24 38.73
b
ASI
f
alcohol scale 0.11 0.14 0.13 0.11
b
ASI
f
drug scale 0.06 0.05 0.05 0.05
b
Medical conditions
Number
g
4.23 3.01 4.10 4.09
b
SOURCE Authors analysis. NOTES Column comparisons are among numbered columns. Column comparison tests of difference controlled for site of the Collaborative
Initiative to Help End Chronic Homelessness (see Note 11 in text) and participants age, sex, race or ethnicity, education, veteran status, and monthly income.
a
Includes Veterans Affairs health care.
b
No significant differences among numbered columns.
c
Mean score of the psychoticism, depression, and anxiety subscales of
the Brief Symptom Inventory. Scores range from 0 to 4, with higher scores indicating more subjective distress. See Note 14 in text.
d
Scores range from 0 to 3,
with higher scores indicating more exhibited psychotic behaviors. See Note 13 in text.
e
Scores on the twelve-item Short-Form Health Survey (SF-12) range from 0
to 100, with a score of 50 representing the normal level of functioning in the general population and higher scores indicating better health. See Note 12 in text.
f
Scores on the Addiction Severity Index (ASI) range from 0 to 1, with higher scores indicating more serious substance use. See Note 15 in text.
g
From a list of
twenty-three medical conditions. See Note 16 in text. ***p < 0:01
Medicaid Expansion
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ance reported less use of emergency department
services than those receiving state or local assis-
tance, and those without health insurance re-
ported less use of outpatient substance abuse
services than those with other health insurance.
Discussion
This study provides an opportunity to examine
the sociodemographic characteristics, health
needs, and health care use of chronically home-
less adults who will likely be eligible for the
Medicaid expansion under the Affordable Care
Act in 2014. The findings contribute to a better
understanding of the healthneeds of chronically
homeless adults with disabilities that may help
informplanning and implementation efforts for
that expansion.
We found that nearly three-quarters of chroni-
cally homeless adults with income below the
threshold for the Medicaid expansion were not
enrolled in Medicaid, including 53 percent who
were uninsured or relied solely on state or local
assistance. The Medicaid expansion could in-
clude coverage for a substantial number of these
uninsured or underinsured chronically home-
less adults. Importantly, with the expansion,
chronically homeless adults who now rely on
local or state assistancethe largest group in
the study samplemay transition to Medicaid
for its more comprehensive health services
7,21
in states that implement the expansion.
Eligibility for Medicaid does not necessarily
result in enrollment in the program, especially
for peoplelike the chronically homelesswho
face multiple enrollment barriers.
7
Certainly, it is
likely that a number of participants in this study
whoreportednoinsurance coverage may already
have been eligible for Medicaid but remained
unenrolled. Past experience suggests that target-
ed outreach and direct assistance will likely be
required to successfully enroll eligible homeless
adults in the Medicaid expansion.
For example, providers serving homeless pop-
ulations report that many homeless adults are
disengaged from and distrustful of public sys-
tems and that they face multiple challenges to
Medicaid enrollment, including language and
literacy barriers and lack of transportation, sta-
ble contact information, and documentation.
7
Moreover, service providers note that overcom-
ing these barriers often requires gradual and
targeted relationship building to establish trust
and rapport, together with one-on-one assis-
tance through every step of the enrollment
process.
The participants in this study reported serious
physical and mental health conditions, suggest-
ing that chronically homeless adults have a wide
variety of healthneeds that require a broadrange
of health care services. Chronically homeless
adults who received state and local assistance
were largely similar to Medicaid enrollees in re-
ported health status and health care use pat-
terns, suggesting that states and localities
could potentially experience savings from the
Exhibit 3
Health Care Use Of Chronically Homeless Adults, By Health Insurance Status
(1) Medicaid
(n = 185)
(2) No
insurance
(n = 161)
(3) State or
local assistance
only (n = 226)
(4) Other
health insurance
a
(n = 153)
Column
comparison
In the past month, number of days of:
Inpatient services
b
0.40 0.22 0.42 0.33 1; 3 > 2***
Emergency department services 0.53 0.39 0.58 0.43 1 > 2***
Outpatient medical services 0.57 0.35 0.64 0.56 1; 3; 4 > 2***
Outpatient mental health services 4.75 3.41 3.40 3.24
c
Outpatient substance abuse services 8.21 2.79 3.70 5.58 4 > 2***
In the past three months, number of:
Medical conditions treated 2.63 1.22 2.07 2.22 1; 4 > 2****
In the past year, number of:
Preventive procedures
d
7.92 5.49 7.09 7.52 1; 3; 4 > 2****
Health behaviors discussed with physician
e
3.56 2.85 3.44 3.54 1; 4 > 2***
Health tests
f
2.00 1.72 1.96 1.97
c
In the past 3 months, trouble paying for:
Health care (%) 20 63 19 21 2 > 1; 3; 4****
SOURCE Authors analysis. NOTES Column comparisons are among numbered columns. Column comparison tests of difference controlled for site of the Collaborative
Initiative to Help End Chronic Homelessness (see Note 11 in text) and participants, age, sex, race or ethnicity, education, veteran status, and monthly income.
a
Includes Veterans Affairs health care.
b
A log transformation was conducted on these variables before differences were tested.
c
No significant differences among
numbered columns.
d
The number ranged from 0 to 14.
e
The number ranged from 0 to 6.
f
The number ranged from 0 to 3. ***p < 0:01 ****p < 0:001
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decreaseduse of state andlocally fundedservices
if these people transitioned to Medicaid. Savings
will be particularly substantial for adults who are
made newly eligible by the expansion, since
coverage for newly eligible individuals will be
100 percent federally funded until 2016, after
which federal funding decreases to 90 percent
over time.
7
Chronically homeless adults who were un-
insured reported fewer health problems than
Medicaid enrollees, but they still reported a
broad range of physical and mental health con-
ditions. Compared to Medicaid enrollees, they
reported significantly less use of care, including
preventive services, and markedly greater prob-
lems in affording care. These findings could re-
flect better health status among this group, but
they may also reflect undiagnosed and untreated
conditions, given the participants limited use of
health care services and reported difficulties in
affording care.
An important randomized controlled study
of Medicaid expansion in Oregon showed that
Medicaid coverage increased health care use,
including various screening procedures; im-
proved self-reported health; and reduced finan-
cial strain.
22
These findings, taken together with
the results of our study, suggest that enrolling
uninsured chronically homeless adults in Med-
icaid could improve their access to treatment
and preventive services and that these adults will
require a broad range of services.
It may be particularly important to provide
case management or care coordination services
for chronically homeless adults, given their
range of health care needs and problems.
6
Moreover, access to preventive and primary care
will be one key to identifying conditions in
homeless adults early, preventing them from
worsening over time, and controlling the adults
health care costs. Basic preventive procedures
such as measuring blood pressure, cholesterol,
and glucose levelswere often found to be lack-
ing in this population.
Conclusion
The Medicaid expansion under the Affordable
Care Act will likely increase coverage options
and provide broader access to care for many
chronically homeless adults who are uninsured
or rely solely on state or local assistance pro-
grams. Moreover, states that expand Medicaid
may experience offsetting cost savings, as chron-
ically homeless adults who previously relied
on state and local assistance transitionto Medic-
aid. Conversely, in states that do not expand
Medicaid coverage, poor uninsured adults will
not gain a new coverage option, and many will
likely remain uninsured and continue to face
barriers to accessing needed care.
The findings of this study illustrate the broad
and varied health care needs of chronically
homeless adults. Ensuring access to preventive
and mental health services is particularly im-
portant for addressing the needs of this popula-
tion, and the services available to this group
should include case management and other
supportive services, suchas help withhousing.
The Collaborative Initiative to Help End
Chronic Homelessness Funders Group
representing the Department of Housing
and Urban Development, the Department
of Health and Human Services, and the
Department of Veterans Affairs
provided essential support and guidance
to the authors evaluation of the
initiative. The evaluation has been
completed, and the federal government
is no longer involved. The views
presented here are solely those of the
authors and do not represent the
position of any federal agency or of the
US government.
Enrolling uninsured
chronically homeless
adults in Medicaid
could improve their
access to treatment
and preventive
services.
Medicaid Expansion
1558 Health Affai rs SEPTEMBER 201 3 32: 9
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NOTES
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