At the Intersection of Health, Health Care and Policy
doi: 10.1377/hlthaff.2013.0228
, 32, no.9 (2013):1552-1559 Health Affairs
And Access To A Broad Range Of Services Medicaid Expansion: Chronically Homeless Adults Will Need Targeted Enrollment Jack Tsai, Robert A. Rosenheck, Dennis P. Culhane and Samantha Artiga Cite this article as:
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Culhane, and Samantha Artiga Medicaid Expansion: Chronically Homeless Adults Will Need Targeted Enrollment And Access To A Broad Range Of Services ABSTRACT Homeless adults may gain access to health services under the Affordable Care Acts Medicaid expansion, which takes effect in 2014. This study analyzed the health coverage, health status, and health services use of 725 chronically homeless adults with disabilities in eleven cities in the United States. Nearly three-quarters of the chronically homeless adults in this study with incomes below the threshold for the Medicaid expansion were not enrolled in Medicaid. Fifty-three percent were uninsured or relied solely on state or local assistance, and 21 percent had other coverage that included Department of Veterans Affairs health care. The findings on differences in health status and service use across groups suggest that the Medicaid expansion offers important opportunities to increase coverage and access to care for chronically homeless adults. There may be potential savings for states that expand Medicaid, as people transition from state and local assistance to more comprehensive services under Medicaid. Targeted outreach and assistance to enroll eligible homeless people will be necessary. A broad range of physical and mental health services will be required, including case management to coordinate services. T he Affordable Care Act created a framework for one of the most im- portant changes to the US health care system in history. One of the acts main components is the ex- pansion of Medicaid coverage to include people under age sixty-five with incomes of up to 138 percent of the federal poverty level (in 2013, $15,856 for an individual), beginning in 2014. Prior to health reform, eligibility for Medicaid was limited to low-income people in certain cat- egories, 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 childrenoften called childless adultswho were historically exclud- ed from the program. Although the Affordable Care Act originally expanded Medicaid in all states, the 2012 Supreme Court decision on the act effectively made implementation of the expansion a state option. 1 As of the end of July 2013, twenty-six states had decided to participate in the expan- sion, thirteen had decided to opt out, and eleven remained undecided or were pursuing alterna- tive models. 2 Coverage for adults who are newly eligible under the Medicaid expansion will be completely federally funded until 2016. States are considering a wide array of factors as they decide whether or not to implement the expansion, including its impacts on coverage and costs. 2 States may have to ramp up resources to enroll people in Medicaid and will have to pay doi: 10.1377/hlthaff.2013.0228 HEALTH AFFAIRS 32, NO. 9 (2013): 15521559 2013 Project HOPE The People-to-People Health Foundation, Inc. Jack Tsai (Jack.Tsai@yale.edu) is a core investigator for the Veterans Affairs New England Mental Illness, Research, Education, and Clinical Center and an assistant professor of psychiatry at the Yale University School of Medicine, in West Haven, Connecticut. Robert A. Rosenheck is a senior investigator for the Veterans Affairs New England Mental Illness, Research, Education, and Clinical Center and a professor of psychiatry and public health at the Yale University School of Medicine. Dennis P. Culhane holds the Dana and Andrew Stone Chair in Social Policy at the University of Pennsylvania, in Philadelphia. Samantha Artiga is associate director of the Kaiser Commission on Medicaid and the Uninsured, in Washington, D.C. 1552 Health Affai rs SEPTEMBER 201 3 32: 9 Medicaid Expansion by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from a small portionof the expenses for newly eligible adults after 2016. 3,4 At the same time, there are potential advantages for the states to expanding Medicaid. For example, the expansion would provide offsetting savings in spending for ser- vices the states would otherwise provide to un- insured people, and building on state-funded efforts with federal dollars would save states and localities billions of dollars. 5 Among other people who could gain coverage under the Affordable Care Acts Medicaid expan- sion are the estimated 1.2 million people across the country who are homeless in a given year, including roughly 110,000 chronically homeless adults. 6 Giventheir lowincomes, many currently uninsured or underinsured homeless adults will gain from the Medicaid expansion a new path- way to coverage and new health care opportuni- ties. 7,8 Despite these impending changes and the often complex health conditions and needs of chronically homeless adults, 9,10 there has been no recent comparison between the chronically homeless adults currently enrolled in Medicaid and those newly eligible for Medicaid under health reform in the states that will implement the expansion. This study was intended to provide insights into the characteristics and health needs of chronically homeless adults with disabilities who are likely to be eligible for Medicaid follow- ing the programs expansion in 2014. Specifi- cally, the study examined the health coverage, sociodemographic characteristics, healthstatus, and health service use of chronically homeless adults with incomes below the threshold in the Medicaid expansion. It also compared those currently enrolled in Medicaid to those who are uninsured, rely solely on state or local assis- tance, or are covered by other insurance such as Veterans Affairs (VA) health care. The results may inform planning efforts among states that decide to participate in the Medicaid expansion. Study Data And Methods Program Description Data were obtained on 725 chronically homeless adults with incomes below the threshold for the Medicaid expansion who participated in the Collaborative Initiative to Help End Chronic Homelessnessan eleven- site federally supportedhousinginitiativefrom 2004 to 2009. 11 The initiative provided adults who were chronically homeless with permanent housing and supportive primary health care and mental health services. A person who was chronically homeless was defined as an unaccom- panied homeless individual with a disabling condition who has either been continuously homeless for 1 year or more or has had at least four episodes of homelessness in the past 3 years. 11(p2) Sample The program originally enrolled 756 participants, but the analyses in this study were limited to the 725 participants who were under age sixty-five and had a monthly income of less than$1,246whichequates toanannual income of $14,945 for an individual (or 138 percent of the federal poverty level, the eligibility threshold for the Medicaid expansion, in2009). This study focused on the assessments of the participants at baseline, when they enrolled in the program. Measures Assessments of participants socio- demographic chracteristics, health insurance coverage, health status, and health care use were conducted by local clinical staff designated as program evaluation assistants at each of the programs sites. These staff were knowledgeable about Medicaid eligibility rules as well as avail- able state and local assistance programs. They conducted face-to-face interviews with partici- pants using various self-report measures. Health insurance coverage was assessed by asking participants, During the past three months, were you covered by any of the follow- ing health insurance programs? and then ask- ing them to respond yes or no to each of the following forms of coverage: Medicaid, Medi- care, VA, state or local medical assistance, pri- vate insurance, some other health insurance, or no health insurance. Histories of homelessness were based on par- ticipants reports of the age at which they first became homeless, the total number of years they had been homeless, and the total number of years they had been incarcerated. Participants were also asked how many days in the previous three months they had stayed in their own apart- ment, room, or house; stayed in an institution (a halfway house, residential program, hospital, or jail or prison); and been homeless (stayed outdoors or in shelters, vehicles, or abandoned buildings). Health status was assessed with the twelve- item Short-Form Health Survey; 12 a ten-item rating scale for observed psychotic behavior; 13 the mean score of the psychoticism, depression, and anxiety subscales of the Brief Symptom Inventory; 14 and the alcohol and drug subscales of the Addiction Severity Index. 15 Psychiatric di- agnoses were based on participants reports. Medical conditions reported by participants were drawn from a list of twenty-three con- ditions. 16 To assess health care use, participants were asked detailed questions about the number and type of medical, mental health, and sub- stance abuse treatment visits they had made during the previous three months. Visits were SEPTEMBER 201 3 32: 9 Health Affai rs 1553 by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from separated into emergency department, in- patient, outpatient medical, outpatient mental health, and outpatient substance abuse visits. Inpatient medical, mental health, and substance abuse visits were combined into a single in- patient category because of the low counts in each individual category. The number of medical conditions for which participants were treated in the previous three months, out of the conditions on the list 16 that they reported having, was their number of medi- cal conditions treated. Participants reported whether or not they had had one or more pre- ventive procedures from a list of fourteen, had discussed with a physician one or more of four health behaviors (smoking, alcohol consump- tion, diet, and exercise), and had had one or more of three health tests (HIV/AIDS, hepatitis C, and tuberculosis) in the previous year. Last, participants were asked to respond yes or no when asked if they had had any trouble paying for health care in the previous three months. Data Analysis Participants were divided into the following four mutually exclusive groups based on their reported health insurance cover- age: those with Medicaid; those with no health insurance; those receiving state or local assis- tance only; and those with other health insur- ance, including VAhealth care. Participants who reported multiple types of coverage were cate- gorized as covered by Medicaid, if they had that coverage; by state or local assistance, if they had that but not Medicaid; and by other health in- surance, if they hadneither Medicaidnor state or local assistance. The rationale for this categori- zation was that Medicaid generally offers more comprehensive coverage than state or local as- sistance, and people with other health insurance may be less likely than others to enroll in Medicaid after the expansion. Participants in each of the four groups were compared on sociodemographic characteristics, histories of homelessness, health status, and health care use with chi-square tests, analysis of variance, and multinomial logistic regression and analysis of covariance (differences in pro- gram site and sociodemographic characteristics were controlled for). Before tests of difference, we conducted a log transformation on depen- dent variables with non-normal distributions. Post hoc group comparisons were conducted with Fishers least significant difference test and pairwise chi-square tests. Given the number of comparisons and the inflated probability of type 1 errors (the incorrect rejection of a true null hypothesis), significance was 0.01 for all analyses. The online Appendix provides addi- tional details about the study methods. 17 Limitations The study sample came from eleven cities participating in a federally sup- ported housing initiative for chronically home- less adults with disabilities. Thus, it may not be representative of chronically homeless adults without disabilities or of other cities across the country. The data came from the period 200409, and conditions and characteristics of homeless populations may have changed since that time. In interpreting our results, it is important to consider the variation by state in eligibility for Medicaid before the passage of the Affordable Care Act. In all but one of the study states, eligi- bility for adults was generally very limited. The exception was NewYork, which expanded cover- age to adults with incomes up to the federal poverty level during the study period. All of the states covered adults with disabilities through Medicaid. However, experience sug- gests that homeless people face serious chal- lenges in qualifying through this pathway be- cause of the difficulty they have in acquiring medical documentationof their disability so that they can qualify for Supplementary Security Income and then Medicaid. 7 The study presents a cross-sectional compari- son, so causality and stability of these findings are not conclusive. Nearly all of the measures, including insurance coverage, were based on self-report, and their validity cannot be con- firmed. However, there is some evidence that adults with severe mental illnesses are able to accurately and reliably report their health ser- vice use, 18 illness history, 19 and health status. 20 Study Results Of the sample of 725 chronically homeless adults with incomes below the threshold for the Medicaid expansion, more than three-quar- ters had some form of insurance. Of those with insurance, 226 (31.17 percent) were covered by state or local assistance, 185 (25.52 percent) were covered by Medicaid, and 153 (21.10 per- cent) were covered by some other health insur- ance (Exhibit 1). Among those who reported other forms of health insurance, 79.74 percent had VA health care, 12.50 percent had Medicare, 5.92percent hadprivateinsurance, and9.80per- cent had some other health insurance. Of those enrolledinMedicaid, 11.35percent alsoreported receiving state or local assistance. Characteristics And Histories Of Home- lessness The sample was racially diverse and consisted mostly of single males in their forties who had less than a high school education and a monthly income of less than $400 (Exhibit 1). On average, these adults first became homeless Medicaid Expansion 1554 Health Affai rs SEPTEMBER 201 3 32: 9 by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from in their early thirties, had been homeless for more than eight years in their lifetime, and had been homeless for more than fifty days in the previous three-month period. There were a few significant differences be- tween the chronically homeless adults with Medicaid and those who were uninsured or re- ceiving state or local assistance. Those receiving state or local assistance wereyounger, weremore likely to be white, and had lower incomes than Medicaid enrollees (Exhibit 1). Inaddition, com- pared to Medicaid enrollees, those with no in- surance were younger, were less likely to be vet- erans, and had lower incomes. There were no significant differences in homeless histories be- tween those with Medicaid and those who were uninsured or receiving state or local assistance. Reflecting the fact that most of the people in the other insurance group reported having ac- cess to VA health care, members of the other group were significantly more likely than those in other groups to be veterans (Exhibit 1). They also were generally older, were more likely to be male and white, and had more years of educa- tion. With respect to recent homeless history, those with other health insurance had also spent fewer days in their own place in the previous three months than those without health insur- ance and those on Medicaid. Health Status And Health Care Use There was a high prevalence of both physical and men- tal health conditions among the people in the sample (Exhibit 2). Most of the participants reported multiple medical conditions and high rates of psychiatric disorders, particularly sub- stance use disorders. Compared to the national average scores of 50 for both physical and mental health on the twelve-item Short-Form Health Survey 12 scores that have a standard de- viation of 10the total sample reported worse health. The samples average score for mental health was 39, which is more than one standard deviation below the national average. After we controlled for characteristics of the program site and sociodemographic charac- teristics of the study participants, we found few differences in health status across coverage groups. However, chronically homeless adults with no health insurance were 1116 percent less likely than those with any coverage to report having schizophrenia. Those with other health insurancethe groupcontainingthe largest pro- portion of veteranswere more likely than the members of any other group to report having post-traumatic stress disorder. There were no other significant differences on health status across groups, including the number of medical conditions. There were differences on some in- dividual medical conditions, as shown in the online Appendix. 17 To examine suppression effects, we repeated these analyses without controlling for differenc- es in site and sociodemographic characteristics. We found nearly no differences in health status across groups, except that people with no health insurance had higher physical scores on the Short-Form Health Survey 12 than those with Medicaid and reported fewer medical problems Exhibit 1 Sociodemographic Characteristics And Homeless Histories Of Chronically Homeless Adults, By Health Insurance Status (1) Medicaid (n = 185) (2) No insurance (n = 161) (3) State or local assistance only (n = 226) (4) Other health insurance a (n = 153) Column comparison Characteristic Mean age (years) 46.91 42.54 44.65 48.27 1; 4 > 2; 3**** Male (%) 74 78 68 89 4 > 1; 3**** White (%) 26 36 44 44 3; 4 > 1*** Education (years) 11.82 11.33 11.74 12.36 4 > 2*** Married (%) 1 1 1 1 b Veteran (%) 23 7 15 81 4 > 1 > 2; 4 > 3**** Monthly income ($) c 546.53 227.88 272.48 474.83 1 > 4 > 2; 1 > 3**** History of homelessness Age when first homeless (years) 33.50 30.54 30.59 35.91 4 > 2; 3**** Lifetime years homeless 8.72 7.41 8.63 7.64 b Lifetime years incarcerated 3.14 2.89 3.22 2.04 b Days in own place, past 3 months 8.19 6.57 5.29 3.22 1; 2 > 4*** Days in institution, past 3 months 13.88 14.68 17.48 15.73 b Days homeless, past 3 months 53.14 53.96 55.71 59.17 b SOURCE Authors analysis. NOTE Column comparisons are among numbered columns. a Includes Veterans Affairs health care. b No significant differences among numbered columns. c A log transformation was conducted on these variables before group differences were tested. ***p < 0:01 ****p < 0:001 SEPTEMBER 201 3 32: 9 Health Affai rs 1555 by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from than those with any coverage. Participants re- ceiving state or local assistance had higher Brief SymptomInventory scores 14 than members of all other groups, reflecting greater subjective distress. The total sample reported using a wide range of health services during the previous month, with the highest use reported for outpatient mental health and substance abuse services (Exhibit 3). On average, study participants indi- cated that 53 percent of their total number of reported medical conditions had been treated. In addition, these chronically homeless adults reported receiving an average of seven out of fourteen specified preventive procedures and discussing three out of four identified health behaviors with a physician in the previous year. Lastly, 29 percent of the total sample reported problems paying for care during the previous three months. After we controlled for differences in site and sociodemographic characteristics, we found no significant differences in reported health care use between Medicaid enrollees and those with any other formof coverage. However, there were significant differences in reported health care use between those who did not have insurance and those who did (Exhibit 3). The group with- out insurance reported less use of outpatient medical services and preventive procedures than all of the other groups. In examining the four- teen preventive procedures individually, those without insurance were significantly less likely to have had each procedure, except the hearing screening and colonoscopy. Chronically homeless adults without health insurance also reported less use of inpatient services than those with Medicaid coverage or state or local assistance (Exhibit 3). And they reported less use of emergency department ser- vices thanthose withMedicaid, as well as less use of outpatient substance abuse services and dis- cussing fewer health behaviors with a physician, compared to those with other health insurance. Moreover, participants without health insur- ance were more likely to report having trouble paying for their health services than those with coverage. In fact, they were more than three times as likely as Medicaid enrollees to report this problem (63 percent versus 20 percent). Nearly all of these results remained the same when we did not control for differences in site and sociodemographic characteristics. The ex- ceptions were that people without health insur- Exhibit 2 Health Status Of Chronically Homeless Adults, By Health Insurance Status (1) Medicaid (n = 185) (2) No insurance (n = 161) (3) State or local assistance only (n = 226) 4) Other health insurance a (n = 153) Column comparison Psychiatric diagnoses (%) Alcohol use disorder 46 55 58 50 b Drug use disorder 56 55 49 50 b Schizophrenia 23 8 19 24 1; 3; 4 > 2*** Bipolar disorder 15 19 24 17 b Post-traumatic stress disorder 3 7 7 14 4 > 1; 2; 3*** Major depression 29 30 29 22 b Development disability 13 11 9 7 b Scores on: Brief Symptom Inventory c 1.44 1.43 1.73 1.46 b Observed psychosis scale d 0.27 0.17 0.22 0.19 b SF-12 e physical 43.37 47.24 44.58 44.49 b SF-12 e mental 40.43 38.22 38.24 38.73 b ASI f alcohol scale 0.11 0.14 0.13 0.11 b ASI f drug scale 0.06 0.05 0.05 0.05 b Medical conditions Number g 4.23 3.01 4.10 4.09 b SOURCE Authors analysis. NOTES Column comparisons are among numbered columns. Column comparison tests of difference controlled for site of the Collaborative Initiative to Help End Chronic Homelessness (see Note 11 in text) and participants age, sex, race or ethnicity, education, veteran status, and monthly income. a Includes Veterans Affairs health care. b No significant differences among numbered columns. c Mean score of the psychoticism, depression, and anxiety subscales of the Brief Symptom Inventory. Scores range from 0 to 4, with higher scores indicating more subjective distress. See Note 14 in text. d Scores range from 0 to 3, with higher scores indicating more exhibited psychotic behaviors. See Note 13 in text. e Scores on the twelve-item Short-Form Health Survey (SF-12) range from 0 to 100, with a score of 50 representing the normal level of functioning in the general population and higher scores indicating better health. See Note 12 in text. f Scores on the Addiction Severity Index (ASI) range from 0 to 1, with higher scores indicating more serious substance use. See Note 15 in text. g From a list of twenty-three medical conditions. See Note 16 in text. ***p < 0:01 Medicaid Expansion 1556 Health Affai rs SEPTEMBER 201 3 32: 9 by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from ance reported less use of emergency department services than those receiving state or local assis- tance, and those without health insurance re- ported less use of outpatient substance abuse services than those with other health insurance. Discussion This study provides an opportunity to examine the sociodemographic characteristics, health needs, and health care use of chronically home- less adults who will likely be eligible for the Medicaid expansion under the Affordable Care Act in 2014. The findings contribute to a better understanding of the healthneeds of chronically homeless adults with disabilities that may help informplanning and implementation efforts for that expansion. We found that nearly three-quarters of chroni- cally homeless adults with income below the threshold for the Medicaid expansion were not enrolled in Medicaid, including 53 percent who were uninsured or relied solely on state or local assistance. The Medicaid expansion could in- clude coverage for a substantial number of these uninsured or underinsured chronically home- less adults. Importantly, with the expansion, chronically homeless adults who now rely on local or state assistancethe largest group in the study samplemay transition to Medicaid for its more comprehensive health services 7,21 in states that implement the expansion. Eligibility for Medicaid does not necessarily result in enrollment in the program, especially for peoplelike the chronically homelesswho face multiple enrollment barriers. 7 Certainly, it is likely that a number of participants in this study whoreportednoinsurance coverage may already have been eligible for Medicaid but remained unenrolled. Past experience suggests that target- ed outreach and direct assistance will likely be required to successfully enroll eligible homeless adults in the Medicaid expansion. For example, providers serving homeless pop- ulations report that many homeless adults are disengaged from and distrustful of public sys- tems and that they face multiple challenges to Medicaid enrollment, including language and literacy barriers and lack of transportation, sta- ble contact information, and documentation. 7 Moreover, service providers note that overcom- ing these barriers often requires gradual and targeted relationship building to establish trust and rapport, together with one-on-one assis- tance through every step of the enrollment process. The participants in this study reported serious physical and mental health conditions, suggest- ing that chronically homeless adults have a wide variety of healthneeds that require a broadrange of health care services. Chronically homeless adults who received state and local assistance were largely similar to Medicaid enrollees in re- ported health status and health care use pat- terns, suggesting that states and localities could potentially experience savings from the Exhibit 3 Health Care Use Of Chronically Homeless Adults, By Health Insurance Status (1) Medicaid (n = 185) (2) No insurance (n = 161) (3) State or local assistance only (n = 226) (4) Other health insurance a (n = 153) Column comparison In the past month, number of days of: Inpatient services b 0.40 0.22 0.42 0.33 1; 3 > 2*** Emergency department services 0.53 0.39 0.58 0.43 1 > 2*** Outpatient medical services 0.57 0.35 0.64 0.56 1; 3; 4 > 2*** Outpatient mental health services 4.75 3.41 3.40 3.24 c Outpatient substance abuse services 8.21 2.79 3.70 5.58 4 > 2*** In the past three months, number of: Medical conditions treated 2.63 1.22 2.07 2.22 1; 4 > 2**** In the past year, number of: Preventive procedures d 7.92 5.49 7.09 7.52 1; 3; 4 > 2**** Health behaviors discussed with physician e 3.56 2.85 3.44 3.54 1; 4 > 2*** Health tests f 2.00 1.72 1.96 1.97 c In the past 3 months, trouble paying for: Health care (%) 20 63 19 21 2 > 1; 3; 4**** SOURCE Authors analysis. NOTES Column comparisons are among numbered columns. Column comparison tests of difference controlled for site of the Collaborative Initiative to Help End Chronic Homelessness (see Note 11 in text) and participants, age, sex, race or ethnicity, education, veteran status, and monthly income. a Includes Veterans Affairs health care. b A log transformation was conducted on these variables before differences were tested. c No significant differences among numbered columns. d The number ranged from 0 to 14. e The number ranged from 0 to 6. f The number ranged from 0 to 3. ***p < 0:01 ****p < 0:001 SEPTEMBER 201 3 32: 9 Health Affai rs 1557 by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from decreaseduse of state andlocally fundedservices if these people transitioned to Medicaid. Savings will be particularly substantial for adults who are made newly eligible by the expansion, since coverage for newly eligible individuals will be 100 percent federally funded until 2016, after which federal funding decreases to 90 percent over time. 7 Chronically homeless adults who were un- insured reported fewer health problems than Medicaid enrollees, but they still reported a broad range of physical and mental health con- ditions. Compared to Medicaid enrollees, they reported significantly less use of care, including preventive services, and markedly greater prob- lems in affording care. These findings could re- flect better health status among this group, but they may also reflect undiagnosed and untreated conditions, given the participants limited use of health care services and reported difficulties in affording care. An important randomized controlled study of Medicaid expansion in Oregon showed that Medicaid coverage increased health care use, including various screening procedures; im- proved self-reported health; and reduced finan- cial strain. 22 These findings, taken together with the results of our study, suggest that enrolling uninsured chronically homeless adults in Med- icaid could improve their access to treatment and preventive services and that these adults will require a broad range of services. It may be particularly important to provide case management or care coordination services for chronically homeless adults, given their range of health care needs and problems. 6 Moreover, access to preventive and primary care will be one key to identifying conditions in homeless adults early, preventing them from worsening over time, and controlling the adults health care costs. Basic preventive procedures such as measuring blood pressure, cholesterol, and glucose levelswere often found to be lack- ing in this population. Conclusion 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 pro- grams. Moreover, states that expand Medicaid may experience offsetting cost savings, as chron- ically homeless adults who previously relied on state and local assistance transitionto Medic- aid. 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 im- portant for addressing the needs of this popula- tion, and the services available to this group should include case management and other supportive services, suchas help withhousing. The Collaborative Initiative to Help End Chronic Homelessness Funders Group representing the Department of Housing and Urban Development, the Department of Health and Human Services, and the Department of Veterans Affairs provided essential support and guidance to the authors evaluation of the initiative. The evaluation has been completed, and the federal government is no longer involved. The views presented here are solely those of the authors and do not represent the position of any federal agency or of the US government. Enrolling uninsured chronically homeless adults in Medicaid could improve their access to treatment and preventive services. Medicaid Expansion 1558 Health Affai rs SEPTEMBER 201 3 32: 9 by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from NOTES 1 National Federation of Independent Business v. Sebelius, 567 U.S., 2012 WL 2427810 (2012 Jun 28). 2 Advisory Board Company. Beyond the pledges: where the states stand on Medicaid [Internet]. Washington (DC): The Company; 2013 Jul 26 [cited 2013 Aug 8]. Available from: http://www.advisory.com/Daily- Briefing/Resources/Primers/ MedicaidMap 3 Holahan J, Buettgens M, Carroll C, Dorn S (Urban Institute, Washington, DC). The cost and coverage implications of the ACA Medicaid expansion: national and state-by-state analysis. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2012. 4 Sommers BD, Epstein AM. Medicaid expansionthe soft underbelly of health care reform? N Engl J Med. 2010;363(22):20857. 5 Dorn S, Buettgens M. Net effects of the Affordable Care Act on state budgets. Washington (DC): Urban Institute; 2010. 6 Nardone M, Cho R, Moses K. Medicaid-financed services in sup- portive housing for high-need homeless beneficiaries: the business case. Hamilton (NJ): Center for Health Care Strategies; 2012. 7 DiPietro B, Knopf S, Artiga S, Arguello R. Medicaid coverage and care for the homeless population: key lessons to consider for the 2014 Medicaid expansion. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2012. 8 Montgomery AE, Metraux S, Culhane D. Rethinking homeless- ness prevention among persons with serious mental illness. Soc Issues Policy Rev. 2013;7(1):5882. 9 Mechanic D. Seizing opportunities under the Affordable Care Act for transforming the mental and be- havioral health system. Health Aff (Millwood). 2012;31(2):37682. 10 Ku L. Ready, set, plan, implement: executing the expansion of Medicaid. Health Aff (Millwood). 2010;29(6):11737. 11 Mares AS, Rosenheck RA. HUD/ HHS/VA Collaborative Initiative to Help End Chronic Homelessness. West Haven (CT): Northeast Program Evaluation Center; 2009. 12 Ware J Jr., Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and prelimi- nary tests of reliability and validity. Med Care. 1996;34(3):22033. 13 Dohrenwend B. Psychiatric Epidemiology Research Interview (PERI). New York (NY): Columbia University Social Psychiatry Unit; 1982. 14 Derogatis LR, Spencer MS. The Brief Symptom Inventory: administration, scoring, and procedures manual1. Baltimore (MD): Johns Hopkins University School of Medicine, Clinical Psychometrics Research Unit; 1982. 15 McLellan AT, Luborsky L, Woody GE, OBrien CP. An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. J Nerv Ment Dis. 1980;168(1):2633. 16 Brook RH, Ware JE, Davies AR, Stewart AL, Conald CA, Rogers WH, et al. Conceptualization and mea- surement of health for adults in the health insurance study. Santa Monica (CA): RAND Corporation; 1979. 17 To access the Appendix, click on the Appendix link in the box to the right of the article online. 18 Goldberg RW, Seybolt DC, Lehman A. Reliable self-report of health ser- vice use by individuals with serious mental illness. Psychiatr Serv. 2002;53(7):87981. 19 Goodman LA, Thompson KM, Weinfurt K, Corl S, Acker P, Mueser KT, et al. Reliability of reports of violent victimization and posttrau- matic stress disorder among men and women with serious mental ill- ness. J Trauma Stress. 1999;12(4): 58799. 20 Salyers MP, Bosworth HB, Swanson JW, Lamb-Pagone J, Osher FC. Reliability and validity of the SF-12 health survey among people with severe mental illness. Med Care. 2000;38(11):114150. 21 Pennucci A, Nunlist C, Mayfield J. General assistance programs for unemployable adults. Olympia (WA): Washington State Institute for Public Policy; 2009 (Contract No. 09-12-4101). 22 Baicker K, Taubman SL, Allen HL, Bernstein M, Gruber JH, Newhouse JP, et al. The Oregon experiment effects of Medicaid on clinical out- comes. N Engl J Med. 2013;368(18): 171322. SEPTEMBER 201 3 32: 9 Health Affai rs 1559 by guest on September 11, 2013 Health Affairs by content.healthaffairs.org Downloaded from