Jane Dotson
Homeless people in the United States face significant barriers to accessing healthcare, with unhoused patients being three times more likely to visit the emergency room than other Americans. Medicaid, a federal-state insurance program for low-income individuals, has become a crucial avenue for homeless people to access essential health and support services. While Medicare also plays a role in providing healthcare to the homeless, Medicaid's flexibility in eligibility criteria and ability to fund health-related services for the chronically homeless makes it a more prominent option. This is further emphasized by the expansion of Medicaid under the Affordable Care Act, which increased healthcare access for vulnerable populations, including the homeless. However, recent policy changes allowing states to impose work requirements for Medicaid eligibility have threatened coverage for this vulnerable group.
| Characteristics | Values |
|---|---|
| Insurance for homeless people | Medicaid |
| Who is eligible for Medicaid? | People who meet specific categorical criteria (e.g., age) and whose income and resources are within the state's threshold standards. |
| Federal policy | Generally prevents the extension of Medicaid eligibility to childless, non-disabled, non-elderly adults (except by demonstration waiver) and individuals who have primary addictive disorders. |
| Medicaid services | Surgeries, skilled nursing, and some behavioral health treatments |
| Medicaid enrollment | Enrollment has remained roughly constant nationwide since the late 1970s. |
| Medicaid and housing | Medicaid can be used to fund services for individuals experiencing chronic homelessness, particularly in Permanent Supportive Housing (PSH). |
| Medicaid expansion under the Affordable Care Act (ACA) | Intended to provide a framework for increasing health care access for vulnerable populations, including the 1.2 million who experience homelessness each year in the US. |
| Barriers to acquiring health insurance through ACA | "Not being aware if they qualify for Medicaid" was the most common and significant barrier reported by uninsured homeless persons. |
| Work requirements for Medicaid | The Trump Administration allowed states to impose work requirements on adult Medicaid enrollees other than those who are 65 or older, pregnant, or qualify due to disability. |
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What You'll Learn
Medicaid eligibility criteria for homeless people
Medicaid is a federal-state venture that financially assists states in providing medical assistance and other services to eligible low-income individuals and families. While federal policy sets broad national guidelines, states have flexibility in crafting their Medicaid programs, including eligibility criteria and services offered.
Medicaid eligibility for homeless people can vary depending on the state and specific circumstances. Here are some key considerations and pathways for Medicaid eligibility for homeless individuals:
Categorical Criteria
Medicaid eligibility typically involves meeting specific categorical criteria, such as age, disability status, or being part of a vulnerable group. For example, young adults with a history of foster care may qualify for extended Medicaid coverage in all states, regardless of income limits. Similarly, older persons with disabilities who receive SSI cash assistance may be eligible for Medicaid, although criteria may vary across states.
Financial Thresholds
Financial criteria are a critical aspect of Medicaid eligibility. States determine eligibility based on an individual's income and resources relative to the state's threshold standards. In 2014, 24 states expanding Medicaid allowed adults with incomes below approximately $15,000 to enroll in basic Medicaid benefits. However, it's important to note that income thresholds can vary across states, and specific eligibility requirements should be checked accordingly.
State-Specific Variations
Federal policy generally restricts Medicaid eligibility for childless, non-disabled, and non-elderly adults. However, states have the option to adopt eligibility pathways to extend coverage to additional low-income individuals, including those experiencing homelessness. These pathways can include waivers or specific state initiatives aimed at serving the homeless population.
Health Care for the Homeless Initiatives
The federal government funds Health Care for the Homeless projects in every state, providing primary care, mental health treatment, testing, and vaccinations. These centers are a vital safety net, offering specialized services and understanding the unique challenges faced by the homeless population. They often work closely with homelessness providers in their communities.
Medicaid Enrollment Assistance
Community clinics, public hospitals, and social workers can assist homeless individuals in enrolling in Medicaid. These frontline service agencies play a critical role in helping vulnerable populations navigate the complexities of Medicaid eligibility and enrollment. In-person assistance is available in every state to help individuals understand their options and make informed decisions about their healthcare coverage.
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Medicaid's role in providing financial access
Medicaid is a federal-state venture that financially assists states in providing medical assistance, rehabilitative services, and other support services to eligible low-income individuals and families. It is a public insurance program that provides health coverage to low-income families and individuals, including children, parents, pregnant women, seniors, and people with disabilities. It is jointly funded by the federal government and states, with the federal government providing matching payments with no pre-set limit. This means that the federal government guarantees to cover a certain percentage of costs, known as the Federal Medical Assistance Percentage (FMAP), which varies based on factors such as state income levels and specific enrollee groups.
Medicaid plays a crucial role in providing financial access to healthcare for low-income Americans, especially those experiencing homelessness. It is the major source of financing for states to provide health coverage and long-term care for this demographic. Medicaid eligibility is based on both categorical criteria, such as age, and financial criteria, with income and resources assessed against state threshold standards. This dual eligibility criterion allows Medicaid to extend coverage to a broader range of individuals.
Medicaid has been particularly effective in improving access to care and supporting financial stability for low-income families. Research shows that after the expansion of Medicaid coverage under the Affordable Care Act (ACA), the number of uninsured individuals decreased significantly. The expansion also led to improved health outcomes, with increases in the number of low-income adults receiving preventive care, regular check-ups, and better management of chronic conditions. Additionally, Medicaid enrollees experienced a reduction in medical debt, improved access to credit, and lower rates of eviction.
The impact of Medicaid is also evident in the lives of those experiencing homelessness. Medicaid is an important avenue for homeless individuals to secure basic healthcare services, including primary care, mental health treatment, and management of chronic conditions. It helps address the specific health challenges faced by the homeless population, reducing the overall health disparities within this vulnerable group.
Furthermore, Medicaid's flexibility allows states to supplement mandatory benefits with optional services. This enables states to tailor their programs to meet the unique needs of their populations, including those experiencing homelessness. For example, states can offer access to full benefits for eligible individuals diagnosed with specific conditions, such as cancer or tuberculosis. This adaptability ensures that Medicaid remains a dynamic and responsive program, capable of addressing the evolving healthcare needs of low-income and underserved communities.
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Medicare and Medicaid revenues
Homeless people can access health care through community clinics and public city hospitals, which provide primary care and social workers who can help with Medicaid and Medicare applications. Medicaid and Medicare both play a role in providing health care for the homeless.
Medicare Revenues
Medicare spending grew 8.1% to $1,029.8 billion in 2023, or 21% of total NHE. Funding for Medicare, which totalled $888 billion in 2021, comes primarily from general revenues (46%), payroll tax revenues (34%), and premiums paid by beneficiaries (15%). The different parts of Medicare are funded in varying ways, and revenue sources dedicated to one part of the program cannot be used to pay for another part. Medicare expenditures per beneficiary were highest in Florida ($13,652) and lowest in Vermont ($8,726) in 2020. Part A, which covers inpatient hospital stays, skilled nursing facility stays, some home health visits, and hospice care, is financed primarily through a 2.9% tax on earnings paid by employers and employees (1.45% each). Higher-income taxpayers (more than $200,000 per individual and $250,000 per couple) pay a higher payroll tax on earnings (2.35%). Payroll taxes accounted for 90% of Part A revenue in 2021. Part B, which covers physician visits, outpatient services, preventive services, and some home health visits, is financed primarily through a combination of general revenues and beneficiary premiums. Part D, which covers outpatient prescription drugs, is financed primarily by general revenues (74%) and beneficiary premiums (15%), with an additional 11% of revenues coming from state payments for beneficiaries enrolled in both Medicare and Medicaid. The Medicare Advantage program (sometimes referred to as Part C) draws funds for Part A benefits from the Medicare HI trust fund, and funds for Part B and Part D benefits from the Supplementary Medical Insurance (SMI) trust fund.
Medicaid Revenues
Medicaid spending grew 7.9% to $871.7 billion in 2023, or 18% of total NHE. Medicaid is jointly financed by the federal government and the states, with the federal government paying close to 70% of total costs in fiscal year (FY) 2023. States are permitted to finance the non-federal share of Medicaid spending through multiple sources, including state general funds, health-care-related taxes, and local government funds. All states except Alaska finance some of the state costs with taxes on health care providers. States use provider tax revenues to fund Medicaid “base” rates and supplemental payments, to avoid Medicaid benefit cuts, and to expand Medicaid benefits. States may also receive waivers of certain requirements if they can prove the net effect of the tax is “generally redistributive” and not directly related to Medicaid payments. States that have adopted the ACA Medicaid expansion have realized budget savings, revenue gains, overall economic growth, and positive effects on the finances of hospitals and other health care providers. Medicaid enrollment and spending typically increase during recessions, and Congress has enacted legislation to temporarily increase the federal share of Medicaid spending to help states maintain their programs.
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Affordable Care Act (ACA) and Medicaid expansion
Homeless people are a medically vulnerable population with a high burden of disease and a lower average life expectancy of 41–47 years compared to the national average of 78 years. Before the Affordable Care Act (ACA), most adults experiencing homelessness did not qualify for Medicaid unless they could prove they qualified based on a disability, pregnancy, or age.
The ACA, enacted at the start of 2014, provides a framework for increasing healthcare access for vulnerable populations, including the 1.2 million people who experience homelessness each year in the US. The ACA expanded health insurance coverage by extending Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level (FPL) ($20,783 for a single individual in 2024). This expansion was originally mandatory for states, but a Supreme Court decision in 2012 made it effectively optional.
Medicaid expansion under the ACA has significantly increased health coverage for people experiencing homelessness. Adults in expansion states can now enroll regardless of disability, giving them access to both routine and urgent healthcare. This expansion has also increased access to primary care, mental health services, substance use treatment, supported employment, and transportation to medical appointments.
Medicaid expansion has also had positive economic impacts on healthcare providers. States that expanded Medicaid have seen a decrease in hospital uncompensated care costs, with federal Medicaid matching funds now available to help pay for mental health and substance use disorder treatments. Additionally, expansion has enabled states to lower corrections spending as more incarcerated individuals become eligible for and enroll in Medicaid.
However, there are still barriers for homeless individuals to acquire health insurance through the ACA. These include difficulty obtaining and providing required documentation, understanding the application, literacy barriers, lack of access to means of communication, and not receiving notifications to renew Medicaid access.
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Health care access for homeless people
Homeless people face many barriers when accessing healthcare. They are more likely to visit the emergency room, with use of ERs by the homeless increasing by 80% over the last decade. They also have higher rates of illness and die, on average, 12 years earlier than those with adequate housing.
The primary source of healthcare for homeless people is community clinics and public city hospitals, which provide primary care, including preventive care, for the homeless and others without insurance. Social workers at these facilities can help with Medicaid and Medicare applications. Medicaid is a state-run insurance program for low-income people, and it is an important avenue for the homeless to secure basic healthcare services. Eligibility for Medicaid is based on categorical criteria, such as age, and financial criteria, such as income. However, federal policy prevents the extension of Medicaid eligibility to childless, non-disabled, non-elderly adults.
Health Care for the Homeless centers are another vital source of healthcare for the homeless, providing clinical services, behavioral healthcare, and working closely with homelessness providers in their community. These centers are part of a larger network of clinics that include community health centers and migrant health centers, serving underserved communities. They are funded by the federal government and provide services to over 1 million people a year.
Some shelters have developed on-site clinics to bring services directly to the homeless. These are often staffed by volunteer doctors and nurses and rely on private donations. Rescue missions are another source of private, not-for-profit, non-tax-supported healthcare for the homeless. However, they face limitations such as limited hours, limited access to medications, and specialty services.
Overall, the healthcare landscape for the homeless is complex and varied, with a mix of public, private, and volunteer-based services. Successful programs offer a broad range of services, including convalescent care, prenatal care, and treatment for substance abuse. Coordination of patient treatment and social services is critical to breaking the cycle of homelessness and building trust with this vulnerable population.
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Frequently asked questions
Homeless people can have Medicaid, Medicare, or no insurance. Medicaid is the state-run insurance program for low-income people. Many homeless people qualify for Medicaid under various eligibility pathways, and it is an important avenue for them to secure basic health care services.
Medicare is typically for people over 65, so homeless people are less likely to have this insurance.
In the US, 28% of families with an annual income below $10,000 lack any form of health insurance.
Medicaid eligibility has two fundamental dimensions: whether a person meets specific categorical criteria (e.g., age) and whether a person's income and resources are within the state's threshold standards.
Homeless people may not be aware of whether they qualify for Medicaid, and this is the most common barrier to enrollment. If you are experiencing homelessness, you can visit a community clinic or public city hospital, where social workers can help you fill out a Medicaid application.
Medicaid covers a core package of 14 mandatory benefits, which may be supplemented by many optional benefits. Services typically include surgeries, skilled nursing, and some behavioral health treatments.
Medicaid can also fund health-related services for people experiencing chronic homelessness, and there are homelessness initiatives in place to provide permanent and affordable rental housing for people with disabilities who receive Medicaid services.
