What does the Supreme Court decision on the Affordable Care Act mean for communities poised to use new Medicaid funding to bolster their homeless assistance? First and foremost, communities have to engage more intensively with the state policymaking process – this, actually, was true before the ACA ruling came down. And it will be true no matter what the results of elections in November.
Since the decision, we now know that Medicaid will not expand nationally to cover virtually all uninsured people who earn less than $15,000. Therefore, the presumption no longer holds that virtually all people experiencing chronic homelessness will be able to enroll in Medicaid beginning in 2014. But states do have the option to expand in 2014, taking advantage of substantial federal Medicaid subsidies to do so. The ACA cannot require states to expand their programs, but still offers to pay them 90-100% of the cost of covering all uninsured adult citizens who earn around $15,000 or less annually.
Access to health care services – including behavioral health and recovery support – can be a key part of successful housing outcomes for the 107,000 people who experience chronic homelessness on any given night. Without funding for health care, many communities struggle for sustainable solutions – specifically, adequate permanent supportive housing (PSH), which is proven effective to address chronic homelessness. Since Congress passed the ACA in 2010, homeless assistance systems have anticipated the Medicaid expansion – to help individuals and to enhance safety net capacity.
Full Medicaid coverage will not be a “given” in every state. The Supreme Court ruling means additional challenges for the national agenda to end chronic homelessness by 2015. According to the U.S. Interagency Council on Homelessness, 60 percent of the nation’s chronically homeless population is concentrated in six states – California, Florida, Georgia, Louisiana, New York and Texas. Four of these – California, Florida, Georgia and Texas – were projected to have the highest increases in Medicaid enrollment as a result of the ACA. Only two, New York and California, have indicated an intention to move forward with Medicaid expansion.
To see what might happen in your state, this map and this map from Think Progress are handy starting places. A note of caution: There are many unknowns about how this part of ACA implementation will actually unfold. To name a few:
- How many states will take up the expansion, despite what their governors said in the wake of the Supreme Court decision?
- In the states that do expand, what services and supports will be covered?
- Will ACA implementation really take place as soon as 2014?
- Can a state opt in after 2014?
While these and other questions are sorted out, it is more important than ever for homeless advocates to inform state leaders and community partners in the full debate about health care priorities. The necessary policy choices to support communities will be steps that integrate housing, health care, and behavior health/recovery resources at the community level.
- For chronically homeless populations, permanent housing is the first prescription, with person-centered services and supports to stabilize housing.
- Opting into the ACA Medicaid expansion will bring federal resources directly to these vulnerable individuals – who otherwise are among the highest users of state and local safety net resources.
- Failing to opt in means continued pressure on the capacity of state mental health programs and public safety operations.
Further, a number of promising Medicaid provisions remain in effect, including those meant to improve community supports for especially vulnerable enrollees, including those who are eligible because of a qualifying disability. These options were designed to be targeted to those most in need, and they tend to be less politicized. One example is the Medicaid health home. This optional benefit for people with severe mental illness (and other chronic conditions) pays for broadly-defined service coordination.
Several states, including New York, Missouri, Oregon and Rhode Island, have already opted to set up health homes. States can also offer home and community based services (HCBS) without applying for a federal waiver. In a recent proposed rule, Medicaid officials indicated that permanent support housing qualifies as a “community setting” for HCBS. Homeless advocates can join forces with advocates for older and disabled people, to press for their states to adopt these options in a way that adds to the capacity of homeless assistance.
Many states and communities have already embraced health care reform since the ACA passed in 2010. Often, homeless advocates have been at the table with Medicaid leaders, forging new strategies to integrate housing solutions with health care services to address chronic homelessness. The Alliance is paying close attention to successful new approaches and emerging best practices, especially in supportive housing. Speakers with hands-on experience and up-to-date policy knowledge will present on these topics at the July 16-18 National Conference on Ending Homelessness in Washington, DC.