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Can Increased Access to Health Insurance Improve Care for Homeless Populations?

The slow and steady Affordable Care Act implementation process speeds up in October. But what does it mean for our fight to end homelessness? 

The slow and steady Affordable Care Act implementation process speeds up in October. Health insurance enrollment in the new exchange programs for the 48 million uninsured Americans begins today with a March 2014 deadline. How the exchanges work, who is operating them and the benefit packages for those enrolled are different in each state. And while today’s milestone is most important for non-Medicaid beneficiaries, it offers a great opportunity to increase outreach and enrollment efforts for Medicaid eligible populations, like those experiencing homelessness, especially in states that have or will expand Medicaid to those with incomes below 138% of the federal poverty line.

The federal government has set up a new website to help navigate the exchange program– www.healthcare.gov. Starting today, October 1, individuals and families can use the site to answer a series of questions that will lead them to enrolling in either private insurance or Medicaid (if eligible). While there may be initial glitches, this website will also help people understand what subsidies they are eligible for, which will assist them with purchasing health insurance. If the person is deemed Medicaid eligible, they will be shifted to their state’s Medicaid enrollment process.

This is a long time coming and will lead to millions of Americans now having health insurance. But what does it mean for our fight to end homelessness? Plenty but it alone is not the cure.

During this push for health insurance enrollment, homeless providers and advocates should reach out to their clients. In the 24 states that are definitely expanding Medicaid , individuals who were previously unable to, will now be able to afford basic primary and preventive health services. Waiting until they are really sick and going to the emergency room will no longer serve as their primary care, they can make appointments with a doctor and then see that same doctor and a build a health record rather than retelling their story every time they see a new physician. And they may not have to worry that medical bills will bankrupt them to the point of losing their home. So with insurance comes some relief. But it’s not complete and there is much work to do.

The benefits package that comes with Medicaid coverage for those newly eligible will not be comprehensive enough for many with chronic health conditions and will not cover all services delivered within supportive housing. While some newly eligible individuals should be given access to more services, they likely should have been on Medicaid already due to a disability or serious mental illness. Those with substance use disorders, for example, will likely still have fewer benefits paid for by insurance than their mental health counterparts.

Medicaid and general insurance billing is not a simple task. States and managed care entities establish provider qualifications for delivery of specific health services and only those meeting these requirements can bill Medicaid for reimbursement. Providers may need to engage in lengthy certification processes that require improved health information systems, higher level staffing, and generally improved business practices. This is not for every provider. And it’s really a business decision. Can the provider generate enough revenue that the increased infrastructure investment is worth it? Often the answer is no. Maybe the provider does not serve enough people, maybe with client-driven, voluntary services the ability to perform billable activities is too inconsistent, or maybe the services delivered do not meet Medicaid’s criteria as eligible for reimbursement. In this case, partnerships are necessary for providers to access Medicaid reimbursement. In the meantime, no new resources are available to finance: the services a supportive housing resident may need to stay in housing, the behavioral health services because the local health care for the homeless clinic only provides primary care, or the general care coordination and daily assistance all people experiencing homelessness need if they have health conditions.

Philanthropy has a role to play as well:

  1. Assist providers as they engage in aggressive outreach since outreach and enrollment are not often Medicaid reimbursable activities.
  2. Convene meetings with state policy makers and managed care to design benefits targeted to homeless populations and connected to housing.
  3. Assist providers as they either develop capacity to bill Medicaid or create partnerships to access Medicaid.
  4. As insurance moves to managed care, demonstrate models and effectiveness of managed care organization care coordination integrating housing case management as part of health care intervention for homeless and unstably housed members.

Completing the circle – enrolling people with histories of homelessness in Medicaid that has comprehensive benefits and allows service providers to bill for reimbursement – should be the goal of every homelessness provider and champion.

Peggy Bailey is the Senior Policy Advisor for the Corporation for Supportive Housing. She is a graduate of the University of Notre Dame and has a Masters Degree in Public Affairs from the University of Texas at Dallas. 


We joined Funders Together because we believe in the power of philanthropy to play a major role in ending homelessness, and we know we have much to learn from funders across the country.

-Christine Marge, Director of Housing and Financial Stability at United Way of Greater Los Angeles

I am thankful for the local partnerships here in the Pacific Northwest that we’ve been able to create and nurture thanks to the work of Funders Together. Having so many of the right players at the table makes our conversations – and all of our efforts – all the richer and more effective.

-David Wertheimer, Deputy Director at Bill & Melinda Gates Foundation

Very often a lack of jobs and money is not the cause of poverty, but the symptom. The cause may lie deeper in our failure to give our fellow citizens a fair chance to develop their own capacities, in a lack of education and training, in a lack of medical care and housing, in a lack of decent communities in which to live and bring up their children.

-President Lyndon B. Johnson, 1964 State of the Union Address

Funders Together has given me a platform to engage the other funders in my community. Our local funding community has improved greatly to support housing first models and align of resources towards ending homelessness.

-Leslie Strnisha, Vice President at Sisters of Charity Foundation of Cleveland

Our family foundation convenes local funders and key community stakeholders around strategies to end homelessness in Houston. Funders Together members have been invaluable mentors to us in this effort, traveling to our community to share their expertise and examples of best practices from around the nation.

-Nancy Frees Fountain, Managing Director at The Frees Foundation

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