Medicaid Expansion: Chronically Homeless Adults Will Need Targeted Enrollment And Access To A Broad Range Of Services

By Jack Tsai, Robert A. Rosenheck, Dennis P. Culhane and Samantha Artiga
Health Affairs, September 2013

Prior to health reform, eligibility for Medicaid was limited to low-income people in certain categories, including children, pregnant women, parents with dependent children, people who qualified as disabled, and elderly adults. The Medicaid expansion in 2014 extends eligibility to low-income, nonelderly, nondisabled adults without dependent children—often called “childless adults”—who were historically excluded from the program.

Among other people who could gain coverage under the Affordable Care Act’s Medicaid expansion are the estimated 1.2 million people across the country who are homeless in a given year, including roughly 110,000 chronically homeless adults. Given their low incomes, many currently uninsured or underinsured homeless adults will gain from the Medicaid expansion a new pathway to coverage and new health care opportunities.


The Medicaid expansion under the Affordable Care Act will likely increase coverage options and provide broader access to care for many chronically homeless adults who are uninsured or rely solely on state or local assistance programs. Moreover, states that expand Medicaid may experience offsetting cost savings, as chronically homeless adults who previously relied on state and local assistance transition to Medicaid. Conversely, in states that do not expand Medicaid coverage, poor uninsured adults will not gain a new coverage option, and many will likely remain uninsured and continue to face barriers to accessing needed care.

The findings of this study illustrate the broad and varied health care needs of chronically homeless adults. Ensuring access to preventive and mental health services is particularly important for addressing the needs of this population, and the services available to this group should include case management and other supportive services, such as help with housing.

For those states that expand Medicaid, many of the chronically homeless will have an opportunity to obtain health care coverage – much needed in this vulnerable population. However, these individuals face many hurdles in both initial enrollment and maintaining enrollment in Medicaid. Many will still be without adequate coverage. This is unfortunate since we could have eliminated the coverage problem by establishing a single payer national health program – enroll once and it is for life. We could still do that.

For more information on health care for the homeless, see the website of National Health Care for the Homeless Council: