CHICAGO — In a back room at the Franciscan House of Mary and Joseph, one of the largest homeless shelters in Chicago, a social worker named Sheena Ward guided Terry Cannon through a Medicaid application.
A wet cough punctuated Mr. Cannon's often wry answers to Ms. Ward's questions about his disability status, military service and marital history. "I have glaucoma, I'm going blind. I have lung disease, I'm dying," he said. "How can they deny me? If they do, give me a couple years and I'll be gone."
Today, most state Medicaid programs cover only disabled adults or those with dependents, so Mr. Cannon and millions of other deeply impoverished Americans are left without access to the program. But starting Jan. 1, President Obama's health care law will expand Medicaid coverage to adults with incomes under 138 percent of the federal poverty line, and enrollment is expected to increase by about nine million next year. Thousands of homeless people will be among the newly covered.
Housing advocates say they believe that the Medicaid expansion has the potential to reduce rates of homelessness significantly, both by preventing low-income Americans from becoming homeless as a result of illness or medical debt and by helping homeless people become eligible for and remain in housing.
"We really feel like this is the last piece of the puzzle that we need to end chronic homelessness," said Steve Berg, the vice president for programs and policy at the National Alliance to End Homelessness.
But signing up homeless people for Medicaid is a huge logistical challenge, as housing advocates acknowledge. Homeless individuals often do not have an email address, phone number or permanent address. Many are unaware of the health care law or are skeptical of public programs.
Housing advocates and social workers across the country are now on a major push to inform impoverished and homeless people that they are eligible for Medicaid in the 25 states that are expanding the program and in the District of Columbia, and to enroll them.
For homeless people, experts said, the Medicaid expansion will mean more consistent treatment for medical conditions, including alcoholism, drug addiction, chronic pain and depression. For states and cities, they said, it will mean a more effective safety net, and perhaps even a cheaper one.
"You cannot successfully treat someone for diabetes if they're living under a bridge," said Ed Blackburn, the executive director of Central City Concern, a nonprofit agency in Portland, Ore. "And serious mental illness and chronic health conditions are barriers to getting housing."
To help spread the word, Heartland Alliance, the nonprofit organization where Ms. Ward works, has stationed employees in soup kitchens, shelters and medical clinics to increase awareness and encourage enrollment. "They're accustomed to a no," Ms. Ward said of her homeless clients. "You really have to encourage them and let them know it's their right to be covered."
The conditions of homeless life can also make it difficult to enroll. At the House of Mary and Joseph, Julie Nelson, associate director of outreach, benefits and entitlements at Heartland Alliance, huddled with 48-year-old Marvin Cosper. "I heard about Obamacare," he said, nodding, as Ms. Nelson walked him through the basics of the available plans.
But when she explained that it might take 60 days for him to be enrolled, he bristled. "I'm just passing through," he said.
Mr. Cosper is a former drug addict and onetime crack cocaine dealer who has spent much of the past 20 years homeless, moving from state to state. "I was under the impression it was federal," he said. "I thought it was federal, so whatever state you were in, you could use that card."
"That's a really good question," Ms. Nelson said. "It goes state by state." About half of states have opted out of the Medicaid expansion, a decision made possible by the Supreme Court's 2012 ruling on the law.
Mr. Cosper decided to sign up for Medicaid anyway.
Another client, Donna Terrell, who is 54 and has been homeless for a decade, worked with Ms. Nelson to sort out whether she was enrolled already.
"I'm in limbo," Ms. Terrell said, settling onto a cot with a plastic mattress in a room that would hold about 40 women that night. She said she had filled out the paperwork but had never received an enrollment card, ending up with $6,000 in medical bills instead. She and Ms. Nelson determined that Ms. Terrell did have coverage, but her card had been sent to a shelter that had shut down months before.
If the logistical challenges of signing up homeless people for Medicaid can be mitigated, housing advocates and social workers say, the Medicaid expansion could provide profound benefits for them, even though some experts caution that finding doctors who accept Medicaid will continue to be a challenge in many states.
Studies suggest that most chronically homeless Americans are uninsured. It can be logistically difficult for people with very low or nonexistent incomes to gain access even to charity care and free clinics, because getting there costs money and because clinics' hours and ability to provide care are limited.
The Medicaid expansion is expected to greatly improve access to care for hundreds of thousands of homeless Americans, who would be able to see physicians and specialists, often at no cost.
It might also shift the burden of care from emergency rooms to doctors' offices, with benefits for state budgets. Homeless people tend to use health care services in the most expensive ways, said Jennifer Ho, a senior adviser at the Department of Housing and Urban Development. "They show up when they're sicker," she said. "They stay longer. And it's harder to discharge them because they don't have a place to go."
Housing advocates emphasized that the Medicaid expansion would not directly help homeless people find housing. But officials at federal agencies, national housing organizations and local nonprofit organizations pointed to several ways it could reduce rates of homelessness.
In addition to helping prevent homelessness due to medical debt or untreated illness, the expansion could free up money for nonprofit groups to spend on housing, rather than on health care, officials at the National Alliance to End Homelessness said.
The expanded coverage might also make it easier for homeless people to find and stay in housing. For instance, some housing units require prospective tenants to have Medicaid, Ms. Nelson said. Moreover, the expanded Medicaid program would "pay for services that help people become stable so that they can remain in housing," said Karen Batia, the executive director of Heartland Alliance's health outreach operations.
"It's a means to an end," said Ms. Ward, the social worker, adding that it would help organizations like Heartland "treat the person holistically."
Some states might try to bring down medical costs by asking the federal government for waivers to spend Medicaid dollars on supportive housing, experts said.
But first, the challenge is expanding Medicaid to a fragile and hard-to-reach population.
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