This year Congress is debating repealing and replacing the Affordable Care Act (ACA or Obamacare). As the ACA allowed states to expand Medicaid to cover all adults with income less than 138% of the federal poverty level and 32 states and the District of Columbia have expanded Medicaid pursuant to the Act and 14 million people have gained access to Medicaid coverage due to this expansion, an important part of the debate on repealing and replacing the ACA is Medicaid.
Of the more than 14 million people who have acquired health care coverage through the Medicaid expansion, hundreds of thousands of them likely are homeless individuals. According to data from the Health Resources and Services Administration, the number of homeless adults visiting a Health Care for the Homeless health center who reported having Medicaid coverage increased from 201,000 in 2013 to 311,000 in 2014 and to 356,000 in 2015. Although only 26 states implemented the expansion in fiscal year (FY) 2014 and an addition 3 states expanded coverage in FY 2015, the ACA expansion of Medicaid appears to have greatly increased the percent of homeless adults who have Medicaid coverage and concomitantly decreased the percent of homeless adults who have no medical insurance and are uninsured. Specifically, at Health Care for the Homeless health centers, the percent of homeless adults who had Medicaid coverage increased from 26.9% in 2013 to 41.6% in 2014 and 45.6% in 2015 and the percent of homeless adults who were uninsured decreased from 61.5% in 2013 to 46.0% in 2014 and to 40.0% in 2015.
Although President Trump has promised that everybody will have health insurance coverage under his health care alternative to the ACA, Republicans have proposed changing Medicaid from an entitlement program whereby the federal and state government cover the health care costs of all persons eligible for the program to a block grant program where states receive a fixed amount of money to cover health care costs. Turning Medicaid into a block grant program threatens the ability of Medicaid to cover all of the health care costs of all eligible and needy persons if the block grant funding does not increase due to inflation at all – as seen in the modification of welfare into the Temporary Assistance for Needy Families block grant program, if the block grant funding increases due to a measure of inflation instead of specifically to health care inflation, and if the block grant funding does not increase based on population increases and does not increase cyclically and with a sufficient lag during economic downturns.
Making health care funding unpredictable would likely endanger the lives of poor vulnerable people such as homeless adults and children. Almost all homeless individuals are living below the poverty line. Specifically, 87.8% of homeless and public housing patients at Health Care for the Homeless health centers reported their income was below the federal poverty level in 2015. Homeless individuals face unhealthy living situations and their lives may depend on having access to health care coverage.
Therefore, in determining how to deal with the ACA and health care across the country, Congress should maintain the Medicaid expansion and health coverage for homeless individuals. To reduce the percent of uninsured homeless adults in both states that have expanded Medicaid and in states that have not expanded Medicaid, Congress could designated homeless individuals as a group categorically eligible for Medicaid, such as elderly individuals, disabled individuals, and pregnant women.