Medicaid Expansion May Boost Homeless Individuals’ Access to Care

Medicaid expansion might ensure that homeless individuals receive access not only to healthcare coverage, but also to the care that they need, a Health Affairs study found.

“Our results provide evidence of substantial pent-up demand for health care among a population experiencing homelessness in Arkansas that gained health insurance coverage as a result of Medicaid expansion,” the researchers explained.

The study followed over 1,200 Arkansans who did not have stable housing after Medicaid expansion as well as 2,100 individuals who were continuously enrolled on Medicaid. The researchers compared the groups’ inpatient hospital admissions and emergency department visits from 2010 through 2016.

“To our knowledge, our findings represent the first evidence of the association between ACA Medicaid expansion and health services use for people experiencing homelessness,” the study stated.

The demographics of the two Medicaid groups were distinct in certain aspects, the researchers acknowledged. The population of homeless individuals was mostly white, middle-aged (35 to 49 years old), and male. In contrast, the non-homeless Medicaid population was mostly white, young (19 to 34 years old), and almost entirely female (94.3 percent).

The researchers found that when the Affordable Care Act’s Medicaid expansion went into effect in 2014, emergency department visits escalated among homeless beneficiaries.

Emergency department visits were already on an incline for this community. That increase continued through the first quarter of the year of Medicaid expansion. After the first quarter of 2014, however, emergency department visits for homeless Arkansans trended downward.

In contrast with the more than seven percentage point increase over the baseline trend for the homeless Medicaid population, emergency department visits dropped slightly after Medicaid expansion for the non-homeless Medicaid group.

During 2015, the second year after Medicaid expansion, emergency department utilization dropped by 2.4 percentage points for the homeless population. The slightly downward trend continued for those in the non-homeless Medicaid group.

In 2016, three years after Medicaid expansion, emergency department utilization dropped 12.2 percentage points from the baseline trend for homeless Arkansans on Medicaid. By the end of this decline, the rates were similar to what the homeless population had seen before Medicaid expansion.

Meanwhile, those in the non-homeless Medicaid group continued to see a slight decline in emergency department utilization.

Inpatient hospitalizations saw a spike among the homeless population when Medicaid expansion went into effect. In 2014, the inpatient hospitalization rate increased by 3.9 percentage points over the baseline trend in this population. Otherwise, inpatient hospitalizations for the homeless group of beneficiaries declined.

“Again, we observed no departure from the baseline trend for the traditional Medicaid population in any of the postexpansion periods in our sample,” the researchers stated.

Whereas in the continuously enrolled Medicaid group both measures remained steady despite Medicaid expansion, the homeless community saw a rapid increase in medical attention in inpatient and emergency settings immediately following Medicaid expansion.

“This finding supports the conclusion that changes in health services use for people experiencing homelessness were the result of gaining Medicaid coverage and not due to modifications to claims processing or reporting coinciding with Medicaid expansion in Arkansas or another unmeasured confounding factor,” the researchers found.

“We thus interpret our findings as evidence of pent-up demand for acute care among people experiencing homelessness who gained Medicaid coverage after expansion in Arkansas.”

Providing healthcare coverage for individuals without stable housing is a persistent challenge in the US. The problem is urgent, as the need for healthcare services is high among homeless individuals. Nearly one in five homeless individuals has a severe mental illness, a White House report discovered, emphasizing the demand for behavioral and mental healthcare resources.

Some experts have recommended repurposing Medicare Advantage special needs plans to better support the needs of the homeless community.

Proponents of this approach, such as LA Care health plan, have argued that special needs plans would better be able to deliver mental healthcare as well as addiction treatment, healthcare-related transportation, street healthcare and other Medicare Advantage supplemental offerings through Medicaid managed care organizations.

As of early January 2021, this proposal has not yet been tested.

Other payers have tried to support the housing unstable community’s healthcare access by offering housing solutions.

The University of Pittsburgh Medical Center (UPMC) Health Plan’s Cultivating Health for Success program took this approach, partnering with a local housing and urban development business to deliver healthcare to the homeless community. The program placed homeless individuals in permanent housing and paired this with intensive case management.

The program served 51 members in its first five years and demonstrated savings of more than $6,300 per member.

The research published in Health Affairs could add a new solution to payers’ toolboxes as healthcare leaders seek to care for this underserved population. Medicaid expansion has proved critical to expanding access to emergency healthcare for other populations.