Is Medicaid expansion an effective health policy tool to target chronic homelessness?

Photo: @nate_dumlao

By Jessica Hsu

Though the United States is one of the most economically prosperous countries in the world, at least half a million Americans on any given day continue to experience homelessness. COVID-19 has further exacerbated this issue, increasing the number of persons who have had to experience homelessness and bringing into question whether the US has the necessary and sufficient resources to address the prevalence of homelessness.

In the article Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness in the Journal of Health Politics, Policy and Law, HMP Governance Lab Collaborators Charley Willison, Amanda Mauri, Phillip Singer and co-author Denise Lillvis from the State University of New York at Buffalo explore the effects of Medicaid expansion on persons experiencing chronic homelessness.

Medicaid primarily serves to provide health coverage for people who have low incomes. Though the program is not intended to directly address homelessness, advocates for persons experiencing homelessness argue that expanding Medicaid could provide adequate medical and housing services to target the issue of chronic homelessness.

Through two case studies, San Francisco, California, and Shreveport, Louisiana, researchers evaluated how cities approached homelessness, the challenges encountered, the effects of Medicaid on local health policies, and local political decision-making processes. They conducted interviews with stakeholders involved in policymaking and analyzed archived documents to determine the social and institutional context behind Medicaid policies in the two cities.

They found that Medicaid expansion generally failed to significantly expand the needed services and sufficiently target homelessness in these local cities. While expanding Medicaid may have the potential to increase access to medical services, problems in implementation significantly hindered its effectiveness and prevented it from achieving its goals where it was implemented.

Researchers found divergent policy goals between the state and local level, where the state-administered Medicaid program, a program that not been created specifically to address homelessness, misaligns and conflicts with local policies regarding homelessness.

Administrative burden in terms of access to Medicaid also appears to be a prevalent issue.  Eligibility criteria have increased disenrollment for people experiencing chronic homelessness, who often move between different counties and states or into and out of jail. Such criteria have also created difficulty for people who were incarcerated (but have since been discharged) to receive services. Finally, limited funding in recent years has resulted in the failure of Medicaid to establish adequate supportive medical access and housing for individuals in need of services.

The article offers important considerations for public health policymakers, examining how health policy translates practically when implemented and expanded across a city. Though Medicaid may have the capability to provide medical services and generate the necessary housing options for persons experiencing chronic homelessness, flaws within the implementation process and administrative challenges present significant obstacles to effective care.