As noted in the Introduction, chronically homeless peoples 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 papers 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 states 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 peoples Medicaid enrollment come from the 100,000 Homes Campaign (http://www.100khomes.org), 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 persons likelihood of dying on the streets in the near future. It asks more than 30 questions about a persons 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 Grounds 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.
2.1. Likely Size of Each Group
These estimates cover a broad range, in part reflecting the different populations surveyed. Variation is also influenced by differences in methods used to collect data and among states or communities in the availability of housing and supports for people with SMI who might otherwise experience long-term homelessness. The best guess of group size, given the paucity of evidence, is that Group 1 could be as large as half the chronically homeless population or as small as 20 percent, while Group 3 could be as large as 70-80 percent of that population or as small as 40-50 percent (HUD, 2011; Poulin et al., 2010).
2.2. Likelihood of Being in Permanent Supportive Housing
In comparison to group membership in the overall population of chronically homeless people, group membership of tenants in PSH appears to be somewhat skewed toward those in Group 3, although the skew may not be very large in some jurisdictions.
A 2008 survey of all PSH programs in the District of Columbia (DC) found that 79 percent of tenants had SMI (Burt and Hall, 2009), while similar surveys of three states and three counties in 2007 found that 60 percent of PSH residents had SMI (Burt, 2008a).5 A separate survey of Ohio PSH indicated that more than 90 percent of PSH tenants had a mental illness, and most also had a co-occurring substance abuse problem. Data from PSH programs reporting through Homeless Management Information Systems to the 2010 Annual Homeless Assessment Report to Congress, however, show a substantially lower prevalence of mental illness among PSH residents --43 percent (HUD, 2011). Variations reflect, among other factors, the policies of different jurisdictions in the commitment of their public mental health systems to helping people eligible for their services to move into PSH.
|EXHIBIT 1. Differentiating Access to Medicaid-Reimbursed Health Care Among Three Groups of People*
||Implications for Group Membership and Scope of Health and Behavioral Health Services Likely Covered by Medicaid
|Q 1. Income low enough to meet requirements?
||Not eligible for Medicaid. In some cases people may become eligible for Medicaid services if they meet other eligibility criteria and spend down some of their income by paying a share of costs for Medicaid-covered services.
|Yes ask Q2
||In 2011, the median income cutoff for Medicaid across the 50 states and DC was 64% of the federal poverty level (Heberlein, Brooks, and Guyer, 2011). In 2014, the ACA will make all people with incomes at or below 133% of poverty eligible on the basis of income. This will include virtually all homeless people. Medicaid coverage for these newly eligible people may be offered through benchmark benefit packages that offer at least essential benefits. Services covered by benchmark benefit packages are usually more limited than regular Medicaid as to type and intensity/frequency. Some services needed by chronically homeless people, particularly services delivered outside of doctors offices, clinics, or hospitals, may not be covered.
|Q2. Meet requirements for Medicaid eligibility on basis of disability or other categorical eligibility criteria?
||GROUP 1 Not Eligible for Medicaid in most states, where Medicaid is available to single adults only if they are in a group with categorical eligibility (e.g., disabled or elderly, or pregnant). Exceptions include Medicaid eligibility now in states that decided to implement ACA eligibility provisions more quickly or have waivers to serve people who are not categorically eligible.
|Yes ask Q3
||Medicaid-eligible. Usually people meet this requirement by establishing eligibility for SSI, which also provides an income source. Otherwise they must meet the same disability criteria as for SSI, but assessment is by a Medicaid eligibility office, not the SSA; it usually takes less time and is not as difficult, but does not include any cash benefit.
|Q3. Meet requirements for specialized mental health services, as established by the medical necessity criteria specified in a states Medicaid Plan for these services.
||GROUP 2 Qualify for Medicaid, but not for specialized mental health services. Medicaid service coverage for people in this group, who have categorical eligibility, is more comprehensive than the benchmark benefits or essential benefits that will become available to Group 1 in 2014 and are available to some people in some states now. However, Group 2 people are unlikely to be eligible for extensive behavioral health services or care coordination for people with multiple health needs.
||GROUP 3 Qualify for Medicaid, and for specialized mental health services. Medicaid-eligible, and also qualify for specialized mental health services plus the same full Medicaid benefits available to those in Group 2. Many state Medicaid programs have authorized rehabilitation services for eligible clients, whether homeless or not, that come closest to meeting the needs of chronically homeless people and formerly homeless people residing in PSH. State and county mental health agencies often target as their clients the population eligible for these specialized mental health services. The services can and often do cover intensive and extensive treatment and supportive services to stabilize symptoms and help clients recover/move toward stable community residence. Persons in this group will most likely have SSI or Social Security Disability Insurance already, but if not, providers will be able to help them get it.
|* These categories apply to any adults seeking Medicaid eligibility, including the chronically homeless people on whom this study focuses.