Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. 4. Group 1: Poor Enough But Not Eligible for Medicaid


Under current conditions, people in Group 1 are often the least well-served among the chronically homeless population in many communities. This group includes some people with very high levels of unmet health needs, because they have limited access to health care or treatment services because they are uninsured, or they may be disaffiliated from formal care systems, having tried them and decided to avoid them. Many are adults with chronic substance use disorders, who have not been eligible for SSI since January 1, 1997. At that time, a change in federal law and SSI regulations began disallowing primary diagnoses of substance abuse as well as of conditions to which substance use “contributes materially.”6

As a result, as of 2011, a large number of chronically homeless people have been ineligible for Medicaid in most states. A few states have used a Medicaid 1115 waiver to expand coverage to those who are not “categorically eligible,” including those whose substance use disorder is their primary diagnosis. These policies put the people affected into this paper’s Group 2, discussed below.

Nearly all people in Group 1 will become eligible for Medicaid in 2014, or sooner in states that are moving more quickly to expand eligibility. It is thus important to understand who they are and what their health and behavioral health needs might be.

Within this group, the target or priority populations for PSH may include:

  • Very vulnerable homeless people living on the streets or in emergency shelters for many years--particularly those who have serious long-term substance abuse problems and health conditions or risks associated with substance abuse (including liver disease and cold-weather injuries).

  • Uninsured homeless patients being discharged from hospitals (sometimes with stays in medical respite).

  • Frequent users of hospital emergency rooms, avoidable hospital inpatient care or readmissions, detoxification services, emergency response teams, and other costly services.

  • Homeless people with recent or past histories of incarceration, some of whom may cycle among jails and shelters.

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