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Pulling it Together: How the ACA Can Help The Homeless

Estimates are that there are approximately 630,000 people who are homeless on any given night in the U.S. — about two-thirds in shelters and one-third on the street or without real shelter. Several million people are estimated to experience homelessness over the course of a year. About two-thirds are individuals and the balance are in families.

These numbers are virtually identical to national estimates we used when I worked intensively on the issue of homelessness in the 1980s in state government in New Jersey and at the Robert Wood Johnson Foundation.

Back in the 1980s homeless families were the face of the homeless problem. Today, after two wars, it is the homeless vet.

Then, homelessness was often featured on the front covers of major national news magazines and on national TV news shows. Today it has largely slipped from the national consciousness and remains a prominent but local issue mainly in some urban areas where the homeless are on the streets in significant numbers.

There may be many reasons for this. The problems of the homeless may seem less urgent to the country when the middle class are struggling in a weak economy, and there may be less national emotional space to think about deep poverty, chronic mental illness, substance abuse, and the challenging combination of all three of these we often see in chronic homeless populations. The problems of urban America and low-income housing have also become less prominent, even as there seems to be more discussion of income inequality. At the same time, with cutbacks in state and federal funding, the budgets of cities and counties and community organizations who deliver services to the homeless could not be tighter.

When I worked on this problem previously, I focused mostly on establishing health and other outreach services for the homeless across the country through a national program operating in 19 cities I developed at the Robert Wood Johnson Foundation in partnership with the Pew Charitable Trusts and the U.S. Conference of Mayors. Later I worked on developing affordable housing options for homeless families as Commissioner of Human Services in New Jersey, trying to get homeless families out of “welfare hotels” and off of emergency homeless assistance and into more permanent arrangements. The overriding lesson I learned in all of this work was the importance of effective outreach to connect homeless people to services (and the difference housing, income support, and health care services could make if the connection was effectively made and sustained). Much of the debate about the homeless focuses on the chronically homeless population so visible in big cities and there is no doubt that this population can be very challenging. But several cities have shown good results with programs that aim to get even the hard core homeless off the streets and into better life situations, as chronicled in Malcolm Gladwell’s nice 2006 New Yorker piece, “Million Dollar Murray.” The fact that several million people move in and out of homelessness each year also suggests that for most who experience homelessness, it is not a long term situation; more can be done to address the larger problem of people living on the margin in our country – the sometimes homeless.

Another lesson I learned working on these programs was the effectiveness of peer outreach, especially in programs for homeless and runaway youth. This was a lesson we adopted at Kaiser in working on the loveLife HIV prevention program in South Africa, which deploys about 1,500 young people each year called Groundbreakers, who work in villages and urban neighborhoods across the country as the vanguard of the HIV prevention effort for youth and young adults. The Groundbreakers, all well trained young leaders, do absolutely stunning work in their distinctive purple and black loveLife t-shirts operating out of a network of youth-friendly clinics and youth centers established by the program. This kind of outreach, whether here or in South Africa, is work that can only be done at the grassroots level by exactly the front line service workers who are endangered by today’s tough budgetary environment at the state and local level. I remember talking with a homeless teenager in South Jersey, probing about whether this service or that would be more useful in health clinics we wanted to set up. His response: “Commissioner you don’t understand. What I need is not this or that service. What I need is someone I can trust.” His remark and many others like it caused us to develop intervention models that heavily emphasized social and mental health services in our “health care” clinics.

8355_cover_PITI go through this background now because there is a new opportunity to connect homeless people to services through the Affordable Care Act (ACA), which many people may not be aware of. That is because many homeless people are both poor and uninsured and will qualify for Medicaid coverage under the ACA in states that opt to expand Medicaid with mostly federal money. The ACA will provide coverage, in most states for the first time, for low-income, childless adults, which is who the majority of the homeless are. The vast majority of people who are homeless will be eligible for Medicaid under the ACA expansion since they generally have little income (except undocumented immigrants who are ineligible). We have just published a new report co-authored by Samantha Artiga and Rachel Arguello of our staff and Barbara DiPietro and Sarah Knopf of the National Health Care for the Homeless Council, which discusses in very practical terms what it will take to connect homeless people to an expanded Medicaid program under the ACA and get them the broad range of health care services they need. Many homeless families may also already be eligible for Medicaid under their state’s current rules, and other homeless adults qualify for Supplemental Security Income (SSI) but are not enrolled. Better outreach facilitated by the ACA could assist them as well.

Providing better health coverage can help connect the homeless to needed health services. That is important not only to relieve suffering, but because untreated medical and mental health problems are significant contributing factors to unemployment and homelessness. Increased Medicaid coverage can also relieve burdens on safety net clinics and hospitals who serve the uninsured homeless now. But the biggest payoff will come if the availability of health coverage under the ACA also provides a new outreach opportunity that serves as a gateway to housing, employment, and other services state and local agencies and community organizations use to help the homeless get back on their feet. Just as importantly, this new effort could bring renewed attention at the state and local level to the problem of homelessness itself.