Medicaid Expansion
Medicaid Expansion
Achieving Public Health Goals Through Medicaid Expansion: Opportunities in Criminal Justice, Homelessness, and Behavioral Health With the Patient Protection and Affordable Care Act
false DiPietro, Barbara, PhD ; Klingenmaier, Lisa, MPH, MSW . American Journal of Public Health, suppl. Supplement 103.2 (Dec 2013): E25-E29.
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States are currently discussing how (or whether) to implement the Medicaid expansion to nondisabled adults earning less than 133% of the federal poverty level, a key aspect of the Patient Protection and Affordable Care Act. Those experiencing homelessness and those involved with the criminal justice
system-particularly when they struggle with behavioral health diagnoses-are subpopulations that are currently uninsured at high rates and have significant health care needs but will become Medicaid eligible starting in 2014. We outline the connection between these groups, assert outcomes possible from greater collaboration between multiple systems, provide a summary of Medicaid eligibility and its ramifications for individuals in the criminal justice system, and explore opportunities to improve overall public health through Medicaid outreach, enrollment , and engagement in needed health care. [PUBLICATION ABSTRACT]
States are currently discussing how (or whether) to implement the Medicaid expansion to nondisabled adults earning less than 133% of the federal poverty level, a key aspect of the Patient Protection and Affordable Care Act. Those experiencing homelessness and those involved with the criminal justice system-particularly when they struggle with behavioral health diagnoses-are subpopulations that are currently uninsured at high rates and have significant health care needs but will become Medicaid eligible starting in 2014. We outline the connection between these groups, assert outcomes possible from greater collaboration between multiple systems, provide a summary of Medicaid eligibility and its ramifications for individuals in the criminal justice system, and explore opportunities to improve overall public health through Medicaid outreach, enrollment, and engagement in needed health care. [PUBLICATION ABSTRACT]
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States are currently discussing how (or whether) to implement the Medicaid expansion to nondisabled adults earning less than 133% of the federal poverty level, a key aspect of the Patient Protection and Affordable Care Act.
Those experiencing homelessness and those involved with the criminal justice system-particularly when they struggle with behavioral health diagnoses-are subpopulations that are currently uninsured at high rates and have significant health care needs but will become Medicaid eligible starting in 2014.
We outline the connection between these groups, assert outcomes possible from greater collaboration between multiple systems, provide a summary of Medicaid eligibility and its ramifications for individuals in the criminal justice system, and explore opportunities to improve overall public health through Medicaid outreach, enrollment , and engagement in needed health care. (Am J Public Health. 2013; 103:e25-e29. doi:10.2105/ AJPH.2013.3
STARTING IN 2014 (OR EARLIER should states choose), the Patient Protection and Affordable Care Act (ACA)1 will give states the option to expand Medicaid to most people earning at or below 133% of the federal poverty level (FPL). Those experiencing homelessness will greatly benefit from this policy change because most nondisabled adults were previously ineligible for Medicaid. Of the 836 980 patients seen in 2012 at federally funded Health Care for the Homeless clinics, 61.1% were uninsured (even though the vast majority of these individuals lived below the poverty level).2 (Health Care for the Homeless grantees are part of the Health Center Program as authorized under section 330 of the Public Health Service Act, as amended, and administered by the Health Resources and Services Administration. They are also sometimes referred to as “federally funded health centers” or “Health Resources and Services Administration-funded health centers.”) Although the health of all those living in poverty is a concern to the public health community, those who are both homeless and involved with the criminal justice system are even more vulnerable. In particular, when individuals experiencing homelessness with a behavioral health diagnosis are unable to access broad-basedmental health treatment, untreated symptoms can lead to incarceration.3 Focusing attention on these subgroups could yield wider individual and system benefits from the Medicaid expansion, because these groups tend to have even lower income, lack health insurance at a higher rate, and need a wider range of health care services than their stably housed but still impoverished counterparts.
Providers and administrators in both the criminal justice system and the community not only share a common set of patients, they also share important public health goals. Such goals include increasing community safety, reducing incarceration and recidivism rates and health care costs, improving patients’ health status, and increasing the community’s capacity to deliver needed medical and behavioral health services to improve overall individual and public health.
Decisions that directly influence these goals are happening now. It is critical for health care providers who serve homeless populations and persons within the criminal justice system to inform and influence the outcomes of a changing environment in health care access and delivery. Because of eligibility and enrollment changes, the ACA creates new possibilities for stronger partnerships between service providers and policymakers, and public health advocates can initiate and guide this process.
HOMELESSNESS, INCARCERATION, AND BEHAVIORAL HEALTH
Among adults in jail in the United States, 15.3% were homeless at some point in the year before their incarceration. This is 7.5 to 11.3 times the estimate of homelessness among the entire US adult population (1%-2%).4 In the state and federal prison population, this rate drops to 9%, with those who are homeless more likely to be incarcerated for a property crime, have had previous criminal justice system involvement for property and violent crimes, and have mental health problems, substance abuse problems, or both.5 Individuals experiencing homelessness who are incarcerated for such offenses can spend significant time “behind the wall”-more than 40% of respondents in a recent study in Baltimore, Maryland, spent a combined total of five or more years incarcerated over their lifetime.6 These two public health issues have a direct relationship: homelessness can lead to incarceration, and incarceration can lead to homelessness.7
Community health care providers who treat homeless populations often experience patients suddenly dropping out of care without notice only to reappear weeks or months later to report having been in jail. During such transitions, medication regimens and treatment plans are disrupted, possibly with adverse health implications.
