By Theo Schall


On November 13, the Henry J. Kaiser Family Foundation’s Commission on Medicaid and the Uninsured released a report on the Early Impacts of the Medicaid Expansion for the Homeless Population. Medicaid expansion was a major milestone in President Obama’s health care reform, though for political reasons, only some states took part. The Kaiser Commission’s report compares the experiences of healthcare providers who work with the homeless in states that expanded Medicaid to those in states that didn’t expand. The results are striking, if somewhat obvious: homeless individuals’ insurance rates went up dramatically in states that expanded Medicaid while they stayed just about flat in states that didn’t. The study site in Baltimore saw the rate of insurance among its clients rise from 51% in January 2012 to 87% in July 2014.



This trend is tremendously important for healthcare providers who specialize in helping the homeless population and for parts of the medical system, like emergency rooms, that disproportionately treat the homeless. People experiencing homelessness visit emergency departments at a very high rate – around 72 annual visits per 100 homeless and marginally housed individuals, according to a recent analysis. That’s about three times more visits than among people with secure housing. Since the passage of the Emergency Medical Treatment and Active Labor Act in 1986, nearly all American hospitals are legally required to medically screen and treat anyone who arrives at an emergency department suffering from an acute condition, so the cost of visits from uninsured people has had a major impact on hospitals nationwide. Increasing insurance coverage among the uninsured will benefit hospitals with emergency departments by allowing them to bill for the services they provide.



For clinics and specialists who work only with the homeless population, a higher rate of insurance among their clientele has the potential to completely change how their practices are funded. A Baltimore Business Journal reporter visited Healthcare for the Homeless in January, in the midst of this dramatic increase in rates of coverage, and described a mailroom packed with Medicaid enrollment packets. Without insurance reimbursements, charitable clinics and social service organizations are dependent upon grant funding, which requires a dedicated grant-writing staff and can be inconsistent year-to-year. In January, Healthcare for the Homeless had already seen its primary funding source shift from grants to insurance reimbursement, allowing it to expand its services and more confidently plan for the future.



The true beneficiaries of this expansion are marginally-housed and homeless individuals themselves. Anecdotes from the Kaiser Commission’s report describe individuals finally being able to receive oncology testing, substance abuse treatment, and even surgeries that allowed them to return to work. The biggest challenge faced by many people who seek help from low-cost clinics is the sheer complexity of intersecting problems: many people experiencing homelessness also have a history of substance abuse and a mental health diagnosis. Seeking help with food, housing, physical health, mental health, and addictions may require a person to go to several different social welfare organizations, all of which will have different rules, pay structures, and requirements. While improving access to healthcare doesn’t “fix” poverty or food insecurity, it does make the tangle of problems faced by many marginalized people simpler and can increase their chances at living healthy, fulfilling lives.



Those of us who live in well-populated areas inevitably walk past homeless people on a regular basis, sometimes offering a token gift of money or food, but usually ignoring any attempts at interaction. It’s a painful reality of contemporary life, but the situation is not intractable. We can end street homelessness. Supporting legislation that offers the homeless population access to healthcare is a step towards a society where no one’s pleas for assistance go unheard.

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Theo Schall

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