Starting in 2014, the Affordable Care Act allows states to expand Medicaid to most people earning at or below 133% of the federal poverty level (FPL), which is about $14,856 a year for an individual and $25,390 for a family of three in 2012. (To their credit, some states have gone ahead and expanded early.) This provision helps unify the current “categories” of Medicaid, where very low income children, pregnant women, adults who can prove a permanent disability, and parents in some states are eligible for Medicaid, but those without a proven disability or dependent children are not—creating a significant disparity in access to care among those at the lowest income levels. A recent Urban Institute analysis found 15 million uninsured adults will now be eligible for Medicaid, which would allow them access to the health care services needed in order to treat and manage chronic illnesses, prevent new health conditions from developing, and protect against financial ruin due to inability to pay medical bills.
A subset of the 15 million newly eligible is currently experiencing homelessness. Of the 825,000 patients seen at HRSA-funded Health Care for the Homeless projects in 2011, 62% were uninsured even though 90% had incomes below 100% FPL. Expanding Medicaid to this population is a key step to preventing homelessness among those at risk, and ending homelessness among those with significant health needs.
But eligibility does not mean enrollment. While 15 million adults will be eligible for Medicaid, the Congressional Budget Office expects only 7 million will actually enroll in 2014, and only 10 million by 2016. There are two reasons for this disparity. First, a number of states have said they do not plan to expand their Medicaid programs as the law allows, and even more have not declared an intention either way. Second, experience tells us that finding and enrolling people into assistance programs (and then keeping them enrolled) requires hands on assistance and broad public communication and outreach campaigns. Despite expansions of Medicaid for other groups in the past, there remain 4.4 million adults and almost 3 million children who are currently eligible for Medicaid, but un-enrolled.
To help address this second concern, the ACA requires states to “establish procedures for conducting outreach to and enrolling vulnerable and underserved populations, to include children, unaccompanied homeless youth, children and youth with special health care needs, pregnant women, racial and ethnic minorities, rural populations, victims of abuse or trauma, individuals with mental health or substance-related disorders, and individuals with HIV/AIDS.” Such conditions are often concentrated in homeless populations, who can be enrolled through concerted outreach efforts. Community-based organizations will be key partners in conducting needed outreach to people experiencing homelessness, enrolling them into Medicaid, and then engaging them in the care they need.
Fortunately, the Department of Health and Human Services has issued guidelines that will make enrollment easier, especially for those who are homeless. Important provisions in this guidance:
1. Applications no longer rely on paper documentation to establish identity, income and citizenship (they’ll be electronically verified through the Social Security Administration and the IRS).
2. There is no requirement for proof-of-residency or for a permanent address (a “no fixed address” option is available).
3. Enrollment is now established for 12-months, and re-enrollment requires no action by the client if nothing has changed that would jeopardize ongoing eligibility (again, SSA and the IRS can check this).
4. Applications will largely be submitted electronically with a much quicker turnaround time.
5. Applications will allow for third-party contacts (such as a family member or case manager) to be listed to facilitate better communication and prevent a loss of benefits.
These improvements will facilitate a more efficient and effective enrollment process, relieve service agencies of the need to obtain paperwork that is often non-existent and/or expensive, and give those seeking to prevent and end homelessness additional tools to help serve those most hard-to-reach. In every State, public officials and homeless interests should be in conversation regarding:
• The benefits of Medicaid,
• Effective ways to engage people experiencing homelessness,
• State-specific implementation issues, and
• Collaborations to maximize the impact of the ACA.
Agencies should identify resources for concerted outreach and enrollment efforts starting in 2013 (open enrollment starts October 2013!) and beyond, and should plan campaigns with the broadest possible participation of people who have experienced homelessness, service providers, public officials and other stakeholders.
Medicaid expansion provides an opportunity to meet urgent and long-standing needs of our poorest neighbors, but only if we exercise the option and then make it happen.