As of November 2014, 28 states are implementing the option to expand Medicaid through the Affordable Care Act, which allows adults with incomes at or below 138% of the federal poverty line ($16,105 for an individual or $27,310 for a family of three) to obtain coverage. This expansion option opens up new opportunities for a variety of at-risk and disenfranchised populations, perhaps none of whom are more vulnerable than the more than 600,000 individuals who are homeless nationwide.
To gain insight into the early impacts of the Medicaid expansion on the homeless community, the National Health Care for the Homeless Council and the Kaiser Commission on Medicaid and the Uninsured jointly conducted focus groups over a three-month period in 2014. These focus groups brought together staff and community partners at federally qualified health centers (FQHCs) that serve individuals experiencing homelessness. The focus groups occurred at five different sites, four of which were located in states that have chosen to expand Medicaid (Albuquerque, NM; Baltimore, MD; Chicago, IL; and Portland, OR), and one of which that has not expanded (Jacksonville, FL).
Although the findings from these groups are preliminary, they give insight into the potential benefits expanded Medicaid can have on behalf of homeless individuals, as well as raise important considerations for policy makers and providers to consider when moving forward in accessing these services. The following chart illustrates some of the key takeaways from the group:
In addition to the benefits contained in the chart, Focus group participants in the expansion states emphasized that homeless individuals are now more empowered to participate in decisions related to their health care as a result of gaining coverage. A provider in Albuquerque, NM, stated, “The other thing that is a little bit more intangible is the excitement that [homeless] patients feel in the choices that they have. They’re feeling quite empowered, they’re extraordinarily excited when they hear the types of things that they now have access to.”
However, despite the ample benefits resulting from Medicaid expansion, the focus groups raised important considerations for service providers serving the homeless in expansion states. One-on-one assistance with the application process is key for enrolling homeless individuals, particularly given their limited experience with health insurance and other enrollment barriers, including limited literacy, lack of access to the internet, and confusion about coverage options. Maintaining coverage and educating homeless individuals on how to use coverage is also a critical factor in shifting care patterns and reducing emergency room use. A provider in Baltimore, MD, aptly stated, “There needs to be an educational piece, because a lot of [homeless] people haven’t had primary care maybe ever and don’t even really know what it means to have a routine visit with a provider to get those preventative services.” A worker in Portland noted, “It’s not only about making sure that we have the appointment, the important part is making sure they get to the appointment.”
In addition, Medicaid expansion should not be considered the only solution to meet the needs of homeless individuals. Focus group participants pointed to the importance of continuing to address social determinants of health, including poverty, hunger, lack of housing, and unemployment to support improved access to care and health outcomes and reduce health costs. During one focus group, an administrator in Baltimore said, “We can write prescriptions, we can send referrals, get people into specialty services, but if we are actually able to house people that’s the best way to improve their health.”
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