Sewing Up the Hole in the Safety Net: Hope for the Hard-To-Reach Homeless Through Medicaid Expansion

If you went and asked for the simplest explanation of Medicaid from a group of perfect strangers, the consensus could very well be: “health insurance for poor people.”

While that may be true, it does not paint nearly enough of the picture. Childless adults without a qualifying disability are not eligible, regardless of their income. Moreover, in order to gain eligibility because of a qualifying disability, an arduous waiver process is necessary.  So, try putting yourself in the shoes of a homeless, childless substance abuser. What now?

In 1997, Massachusetts attempted to answer that question with the MassHealth Medicaid Expansion Program. While not specifically aimed at the hard-to-reach homeless population, the program expanded eligibility to any individual that fell below 133 percent of the federal poverty level (FPL), regardless of disability or childlessness. Considering that substance abuse disproportionately affects the homeless population in the US and is costly for society when those seeking care are uninsured, this program offered the possibility of substantial improvements to healthcare for the homeless.

In a recent edition of the American Journal of Public Health, Drs. Julia Zur and Ramin Mojtabai of the Johns Hopkins Bloomberg School of Public Health examine the program’s effects on the rate of enrollment amongst Massachusetts’ substance-abusing homeless. They collected data on all substance abuse treatment admissions among housed and homeless individuals who were 18 or older in Massachusetts, 17 other states, and the District of Columbia between 1992 and 2009 – a total of 7.5 million records. This population sample was limited to individuals who were receiving Medicaid benefits at the time of their admission and those who were uninsured. Drs. Zur and Mojtabai then compared the rates of Medicaid enrollment in Massachusetts against the 17 other states and DC in order to quantify the effect of the expansion in that state.

When eligibility requirements widened, the increase in Medicaid enrollment among the homeless seeking substance abuse treatment was profound. The study revealed that the Medicaid rolls in Massachusetts increased 21 percent immediately following the implementation of the MassHealth Medicaid Expansion Program. Over the 12-year period from implementation to 2009, the average annual increase in enrollment was over five percent.

When comparing Medicaid enrollment among the Massachusetts homeless seeking substance abuse treatment against the controlled populations of the 17 other states and DC, it was clear that the rise in enrollment in Massachusetts was due specifically to the MassHealth program. Additionally, both homeless and non-homeless adults were equally affected by the policy, showing that the expansion was surprisingly equitable across the board.

What Drs. Zur and Mojtabai found offers hope that the Affordable Care Act’s Medicaid expansion, which is set to take place in January 2014, will benefit the hard-to-reach homeless citizens seeking substance abuse treatment in the states that have opted into the program. As of October 22, 2013, there are 26 states set to go ahead with widening their Medicaid eligibility guidelines to all individuals under the age of 65 that have incomes at or below 133 percent of the FPL. Based on the Massachusetts experience, expansion appears to have the potential to relieve at least some of the financial burden of healthcare for local and state governments.

By far, the most important revelation of this study is that the 2014 Medicaid expansion provides sturdy stitching in our social safety net by improving the health and well being for some of the most vulnerable individuals in our society, taking one more step toward ensuring that there is a level beneath which no one can fall.

Feature Photo/cc: (Stephan Geyer)