Homelessness makes you sick: Medicaid expansion and health care for the homeless


Homelessness is intimately tied to the health of an individual. Through expansion of the Medicaid program in 2014 ,the Affordable Care Act (ACA) provides a policy framework for Medicaid coverage of individuals under 65 years of age with incomes up to 133 percent of the federal poverty level (FPL), which includes many who are experiencing homelessness. This expansion, in conjunction with programs serving those experiencing homelessness, such as Health Care for the Homeless (HCH) in Baltimore, Maryland, part of the National Health Care for the Homeless Council (NHCHC), provides relief to a vulnerable population who cannot afford the high cost of health care. HCHs have successfully provided vital health care to those experiencing homelessness. Prior to the ACA, HCHs relied on grants and independent contributions to fund services. HCHs in states that expanded Medicaid can now be reimbursed for services, thereby expanding health care and supportive services to this vulnerable population.Medicaid Coverage Gap_KFFSource: The Henry J. Kaiser Family Foundation

With the federal government matching state spending, 31 states have expanded Medicaid under the ACA. However, Texas rejected Medicaid expansion with devastating results. Nationally, 2.9 million individuals fall into the Medicaid coverage gap in states that have not expanded Medicaid, with 26% of those individuals residing in Texas.

As affordability and underlying determinants pose obstacles to accessing care, advocating on behalf of the vulnerable and uninsured should be a priority. For an exaJustice_HCH Baltimore_2mple, the NHCHC kicked off the 2014 ‘Got Medicaid?’ campaign to lobby support and create awareness among grantees and the general public. As the campaign grows, efforts must be focused urgently in Texas with the state’s large proportion of uninsured individuals. Raising public awareness about the health consequences of being uninsured and the fiscal implications of not expanding Medicaid will help persuade voters and pressure law-makers to adopt Medicaid expansion. By doing so, health service organizations, such as Health Care for the Homeless in Houston, TX, can reach further with essential health care and supportive services to transform communities.




4 Responses to “Homelessness makes you sick: Medicaid expansion and health care for the homeless”

  1. edlinpatrick Says:

    This is a great topic; however a difficult one to address in a conservative state such as Texas. In response to the PPACA, the governor of Texas outlined the following arguments: 1 sustainability given eventual costs to the State, and 2 increased power of federal government thereby limiting autonomy of the state to be innovative.

    The argument above did not focus on addressing the main arguments against Medicaid expansion rather focused on a small subpopulation with little political power. If the call to action is to expand Medicaid, the argument should focus on demonstrating how Medicaid expansion programs have curbed medical spend and produced economy. The argument presented focused on the homeless who hold little political capital in comparison to large republican community in Texas.

    Showing both the anticipated fiscal gains Texas stands to earn from Medicaid expansion and alleviating concerns around state autonomy by highlighting the positive relations Texas and CMS have built through the Medicare-Medicaid demonstration may be a more effective approach.

    Sites related to the topic:


    • raymondbelarmino Says:

      Thanks for the insightful assessment. I appreciate your comment about focusing on the fiscal impacts and benefits of Medicaid. Drawing on this element to convince law makers in Texas to adopt Medicaid expansion would certainly be a worthwhile pursuit. As the other commenters recognized, the costs associated with emergency department visits by uninsured patients experiencing homelessness are substantial. Many of these visits can be avoided with primary care coverage. I imagine focusing attention on the relationship between CMS and the state would be helpful as a supplemental strategy. However, in today’s emotionally charged political environment, highlighting the human element and the associated health disparities of homelessness for the general public to pressure law-makers could be an effective strategy. I appreciate the challenge to “expand” the scope.

  2. petertwyugmailcom Says:

    Great post, great topic. I can certainly understand why those who are fiscally conservative might oppose health care/medicaid expansion to the homeless. They might argue, for instance, that this is an undue strain on taxpayers; recipients of such largesse will abuse the system; it is not sustainable; and that people will not be motivated to improve their situation if they are receiving handouts. However, as a health care provider, my perspective is that the current system needs fresh ideas such as this in order to improve the care provided to our citizens and to decrease the current astronomical costs of healthcare in the US.

    Homeless citizens face myriad obstacles towards improving their lives. With regard to healthcare, they do not have easy, quality access to primary providers. As such, they do not benefit from preventative healthcare. There is little debate that appropriate preventative healthcare for prevalent diseases is cheaper in the long run. It is better to nip a common, expensive disease in the bud or keep it quiescent as opposed to dealing with its severe and more expensive complications. Even if the cost of prevention versus treatment ends up as equivalent as some studies might indicate, then we as a society might as well favor prevention as it improves quality of life.

    Furthermore, because they do not have access to primary care, they use the emergency room as a means of obtaining all care–this typically encompasses medical conditions that would not be deemed emergent or even urgent. They can do this because laws such as EMTALA mandate that emergency physicians treat them regardless of insurance status. Studies have shown that care for a medical issue that is treatable by a primary care provider is 320-728% higher in the E.R. The problem is compounded as, once stabilized with regard to the acute medical issue, the homeless patient is then discharged only to have the problem occur again…and again…and again…at an extreme cost that is ultimately paid for by taxpayers.

    Just as many cities are finding that providing homes to the homeless is cost-saving in the long run, so too will we find that providing healthcare to this population improves their health and our bottom line.

    1. http://www.newsweek.com/health-prevention-worth-money-86075
    2. http://www.nejm.org/doi/full/10.1056/NEJMp0708558#t=article
    3. https://www.acep.org/news-media-top-banner/emtala/
    4. http://www.ncbi.nlm.nih.gov/pubmed/22128684
    5. http://www.centerforhealthjournalism.org/resources/lessons/million-dollar-homeless-patient
    6. http://www.sfchronicle.com/bayarea/article/Housing-homeless-to-pay-off-in-long-run-budget-7953339.php

  3. rpalleg1 Says:

    Thanks for posting on this interesting topic. As an emergency medicine physician, I can certainly attest to the strain “frequent flyers” such as homeless patients have on the system as they often present with a non emergent chronic issue. As stated above, their care often falls in the safety net of the ER which comes at great cost. Chronic conditions like alcoholism and the myriad of complications that arise from it, often come hand in hand with homelessness and are only treated in a cursory way in the ER, if at all. And if and when, for example, the chronic liver failure or recurrent alcohol withdrawal turns into serious and costly hospital stays from life threatening sequelae like bleeding or seizures, the cost is exponentially higher. Not to mention the expense of inappropriate ambulance rides to the ED by alcohol-dependent homeless individuals. I agree that arguing with the economics of health care for the homeless as a weapon may be the best way to persuade your audience.

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