Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. 2. Three Groups Within the Chronically Homeless Population


As noted in the Introduction, chronically homeless people’s access to health and behavioral health services varies greatly depending on client characteristics, which in turn affect whether a person is eligible for Medicaid. Because this paper’s focus is the potential to have Medicaid contribute its resources to the support of people living in PSH, the analytical focus is on how client characteristics affect the likelihood of PSH tenants being eligible for Medicaid in general, and also for specialized mental health service options within Medicaid.

We approach this issue of “Who gets what?” by dividing the overall population of chronically homeless people with disabilities into three groups based on their likely Medicaid eligibility:

  • Group 1--those who do not qualify for Medicaid enrollment. Homeless people in this group are poor enough that they will qualify for Medicaid in 2014, but in 2012 they are not eligible for Medicaid in most states. A few states have expanded Medicaid eligibility for members of this group by implementing Affordable Care Act (ACA) eligibility provisions more quickly or using Medicaid waivers to serve people who are not categorically eligible.

  • Group 2--those who qualify for Medicaid, usually because they are disabled and also qualify for SSI AND who do NOT qualify for Group 3 because they do not have a serious mental illness (SMI). Some people are in this group because they qualify for Medicaid on the basis of having a disability, even though they are not SSI beneficiaries, or because they live in a state that has expanded Medicaid eligibility.

  • Group 3--those who qualify for Medicaid and also for specialized mental health services because they have a mental illness that meets a state’s medical necessity criteria for access to such services.

Exhibit 1 displays the criteria for membership in the three groups and describes the types of health and behavioral health care that Medicaid is likely to cover for each group. Section 4, Section 5 and Section 6 of this paper provides additional details on the supportive service funding sources and providers for each of the three groups.

Information about the likely size of each group within the chronically homeless population is spotty. At present, the best data available on chronically homeless people’s Medicaid enrollment come from the 100,000 Homes Campaign (, which surveys people mostly living on the streets of many cities.

These surveys use a Vulnerability Index first developed by the Boston Health Care for the Homeless Program (BHCHP). The Vulnerability Index assesses a homeless person’s likelihood of dying on the streets in the near future. It asks more than 30 questions about a person’s pattern of homelessness, illnesses and health conditions, sources and use of medical and other health care, victimization, and the like, also recording demographic characteristics and veteran status. Answers are assembled into a vulnerability score (Common Ground, 2010).

To be considered chronically homeless a person had to have been homeless for a year or more or to have had four homeless episodes in the previous 3 years. Many but not all chronically homeless people were found to be vulnerable, and vice versa.

Using information from almost 19,000 Vulnerability Surveys gathered between winter 2010 and May 2011, the 100,000 Homes Campaign found that 62 percent of those surveyed were chronically homeless, 46 percent were vulnerable, and 34 percent were both. Among the chronically homeless group, only 14 percent were enrolled in Medicaid and 48 percent said they had no insurance.

The proportion of chronically homeless people living on the streets who are enrolled in Medicaid does not tell the whole story, however. Many chronically homeless people have physical or mental disabilities that would make them eligible for Medicaid and SSI, and some have actually been beneficiaries in the past but have lost their benefits.3 Obtaining and retaining these benefits is not easy for a homeless person, or for any person applying without the assistance of trained case managers.

Data from the 100,000 Homes Campaign indicates that 63 percent of chronically homeless survey respondents were also vulnerable; as noted above, people had to report serious health problems and/or crisis health service use to be identified as vulnerable. For this group,4 only 24 percent were enrolled in Medicaid at the time they were surveyed, and 30 percent had no insurance (Common Ground, 2011). Many would probably meet criteria for an SSI or Medicaid disability determination, and thus fall into either Group 2 or Group 3.

Research is also starting to provide some evidence of the proportion of chronically homeless people who have a SMI, which potentially would make them eligible for SSI and Medicaid if not already enrolled, and place them in Group 3 rather than in Group 2. A recent study of over 3,000 chronically homeless adults in Philadelphia (Poulin et al., 2010) revealed that 75 percent had a SMI, while 45 percent of respondents to Common Ground’s Vulnerability Index surveys reported SMI (Common Ground, 2011) . Early data from the National Survey of Homeless Assistance Providers and Clients (Burt, Aron, and Lee, 2001, Table 4.1) indicated that in 1996, 45 percent of single men and 56 percent of single women had had mental health problems in the past year, while 53 percent and 65 percent of single men and women, respectively, had had mental health problems during their lifetime.

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