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By Jack Tsai, Robert A. Rosenheck, Dennis P. Culhane, and Samantha Artiga

Medicaid Expansion: ChronicallyHomeless Adults Will Need

Targeted Enrollment And AccessTo A Broad Range Of Services

ABSTRACT Homeless adults may gain access to health services under the

Affordable Care Acts Medicaid expansion, which takes effect in 2014.

This study analyzed the health coverage, health status, and health

services use of 725 chronically homeless adults with disabilities in eleven

cities in the United States. Nearly three-quarters of the chronically

homeless adults in this study with incomes below the threshold for the

Medicaid expansion were not enrolled in Medicaid. Fifty-three percent

were uninsured or relied solely on state or local assistance, and

21 percent had other coverage that included Department of Veterans

Affairs health care. The findings on differences in health status and

service use across groups suggest that the Medicaid expansion offers

important opportunities to increase coverage and access to care for

chronically homeless adults. There may be potential savings for states

that expand Medicaid, as people transition from state and local assistance

to more comprehensive services under Medicaid. Targeted outreach and

assistance to enroll eligible homeless people will be necessary. A broadrange of physical and mental health services will be required, including

case management to coordinate services.

The Affordable Care Act created aframework for one of the most im-portant changes to the US healthcare system in history. One of theacts main components is the ex-

pansion of Medicaid coverage to include people

under age sixty-five with incomes of up to138 percent of the federal poverty level (in2013, $15,856 for an individual), beginningin 2014.

Prior to health reform, eligibility for Medicaidwas limited to low-income people in certain cat-egories, including children, pregnant women,parents with dependent children, people whoqualified as disabled, and elderly adults. TheMedicaid expansion in 2014 extends eligibilityto low-income, nonelderly, nondisabled adultswithout dependent childrenoften called

childless adultswho were historically exclud-ed from the program.

Although the Affordable Care Act originallyexpanded Medicaid in all states, the 2012Supreme Court decision on the act effectivelymade implementation of the expansion a state

option.1 As of the end of July 2013, twenty-sixstates had decided to participate in the expan-sion, thirteen had decided to opt out, and elevenremained undecided or were pursuing alterna-tive models.2 Coverage for adults who are newlyeligible under the Medicaid expansion will becompletely federally funded until 2016.

States are considering a wide array of factorsas they decide whether or not to implement theexpansion, including its impacts on coverageand costs.2 States may have to ramp up resourcesto enroll people in Medicaid and will have to pay

doi: 10.1377/hlthaff.2013.0228HEALTH AFFAIRS 32,NO. 9 (2013): 155215592013 Project HOPEThe People-to-People HealthFoundation, Inc.

Jack Tsai (Ja [email protected])is a core investigator for theVeterans Affairs New EnglandMental Illness, Research,Education, and Clinical Centerand an assistant professor ofpsychiatry at the YaleUniversity School of Medicine,

in West Haven, Connecticut.

Robert A. Rosenheck is asenior investigator for theVeterans Affairs New EnglandMental Illness, Research,Education, and Clinical Centerand a professor of psychiatryand public health at the YaleUniversity School of Medicine.

Dennis P. Culhane holds theDana and Andrew Stone Chairin Social Policy at theUniversity of Pennsylvania, inPhiladelphia.

Samantha Artiga is associatedirector of the KaiserCommission on Medicaid andthe Uninsured, in Washington,D.C.

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a small portion of theexpenses for newly eligibleadults after 2016.3,4 At the same time, there arepotential advantages for the states to expandingMedicaid. For example, the expansion wouldprovide offsetting savings in spending for ser-

vices the states would otherwise provide to un-insured people, and building on state-fundedefforts with federal dollars would save states

and localities billions of dollars.5

Among other people who could gain coverageunder the Affordable Care Acts Medicaid expan-sion are the estimated 1.2 million people acrossthe country who are homeless in a given year,including roughly 110,000 chronically homelessadults.6 Given their low incomes, manycurrentlyuninsured or underinsured homeless adults willgain from the Medicaid expansion a new path-way to coverage and new health care opportuni-ties.7,8 Despite these impending changes andthe often complex health conditions and needsof chronically homeless adults,9,10 there has been

no recent comparison between the chronicallyhomeless adults currently enrolled in Medicaidand those newly eligible for Medicaid underhealth reform in the states that will implementthe expansion.

This study was intended to provide insightsinto the characteristics and health needs ofchronically homeless adults with disabilitieswho are likely to be eligible for Medicaid follow-ing the programs expansion in 2014. Specifi-cally, the study examined the health coverage,sociodemographic characteristics, health status,and health service use of chronically homeless

adults with incomes below the threshold in theMedicaid expansion. It also compared thosecurrently enrolled in Medicaid to those whoare uninsured, rely solely on state or local assis-tance, or are covered by other insurance such as

Veterans Affairs (VA) health care. The resultsmay inform planning efforts among states thatdecide to participate in the Medicaid expansion.

Study Data And MethodsProgram Description Data were obtained on725 chronically homeless adults with incomes

below the threshold for the Medicaid expansionwho participated in the Collaborative Initiativeto Help End Chronic Homelessnessan eleven-sitefederallysupportedhousing initiativefrom2004 to 2009.11 The initiative provided adultswho were chronically homeless with permanenthousing and supportive primary health careand mental health services. A person who waschronically homeless was defined as an unaccom-panied homeless individual with a disablingcondition who has either been continuouslyhomeless for 1 year or more or has had at least

four episodes of homelessness in the past 3years.11(p2)

Sample The program originally enrolled 756participants, but the analyses in this study werelimited to the 725 participants who were underage sixty-five and had a monthly income of lessthan$1,246which equates to anannual incomeof $14,945 for an individual (or 138 percent of

the federal poverty level, the eligibility thresholdfor theMedicaid expansion, in 2009). Thisstudyfocused on the assessments of the participantsat baseline, when they enrolled in the program.

Measures Assessments of participants socio-demographic chracteristics, health insurancecoverage, health status, and health care usewere conducted by local clinical staff designatedas program evaluation assistants at each of theprograms sites. These staff were knowledgeableabout Medicaid eligibility rules as well as avail-able state and local assistance programs. Theyconducted face-to-face interviews with partici-

pants using various self-report measures.Health insurance coverage was assessed by

asking participants, During the past threemonths, were you covered by any of the follow-ing health insurance programs?and then ask-ing them to respond yes or no to each of thefollowing forms of coverage: Medicaid, Medi-care, VA, state or local medical assistance, pri-

vate insurance, some other health insurance, orno health insurance.

Histories of homelessness were based on par-ticipants reports of the age at which they firstbecame homeless, the total number of years they

had been homeless, and the total number ofyears they had been incarcerated. Participantswere also asked how many days in the previousthree months they had stayed in their own apart-ment, room, or house; stayed in an institution(a halfway house, residential program, hospital,or jail or prison); and been homeless (stayedoutdoors or in shelters, vehicles, or abandonedbuildings).

Health status was assessed with the twelve-item Short-Form Health Survey;12 a ten-itemrating scale for observed psychotic behavior;13

the mean score of the psychoticism, depression,

and anxiety subscales of the Brief SymptomInventory;14 and the alcohol and drug subscalesof the Addiction Severity Index.15 Psychiatric di-agnoses were based on participants reports.Medical conditions reported by participantswere drawn from a list of twenty-three con-ditions.16

To assess health care use, participants wereasked detailed questions about the numberand type of medical, mental health, and sub-stance abuse treatment visits they had madeduring the previous three months. Visits were

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separated into emergency department, in-patient, outpatient medical, outpatient mentalhealth, and outpatient substance abuse visits.Inpatient medical, mental health, and substanceabuse visits were combined into a single in-patient category because of the low counts ineach individual category.

The number of medical conditions for which

participants were treated in the previous threemonths, out of the conditions on the list16 thatthey reported having, was their number of medi-cal conditions treated. Participants reportedwhether or not they had had one or more pre-

ventive procedures from a list of fourteen, haddiscussed with a physician one or more of fourhealth behaviors (smoking, alcohol consump-tion, diet, and exercise), and had had one ormore of three health tests (HIV/AIDS, hepatitisC, and tuberculosis) in the previous year.

Last, participants were asked to respond yesor no when asked if they had had any trouble

paying for health care in the previous threemonths.

Data Analysis Participants were divided intothe following four mutually exclusive groupsbased on their reported health insurance cover-age: those with Medicaid; those with no healthinsurance; those receiving state or local assis-tance only; and those with other health insur-ance, including VA health care. Participants whoreported multiple types of coverage were cate-gorized as covered by Medicaid, if they had thatcoverage; by state or local assistance, if they hadthat but not Medicaid; and by other health in-

surance, if they hadneitherMedicaid nor state orlocal assistance. The rationale for this categori-zation was that Medicaid generally offers morecomprehensive coverage than state or local as-sistance, and people with otherhealth insurancemay be less likely than others to enroll inMedicaid after the expansion.

Participants in each of the four groups werecompared on sociodemographic characteristics,histories of homelessness, health status, andhealth care use with chi-square tests, analysisof variance, and multinomial logistic regressionand analysis of covariance (differences in pro-

gram site and sociodemographic characteristicswere controlled for). Before tests of difference,we conducted a log transformation on depen-dent variables with non-normal distributions.Post hoc group comparisons were conductedwith Fishers least significant difference testand pairwise chi-square tests. Given the numberof comparisons and the inflated probability oftype 1 errors (the incorrect rejection of a truenull hypothesis), significance was 0.01 for allanalyses. The online Appendix provides addi-tional details about the study methods.17

Limitations The study sample came fromeleven cities participating in a federally sup-ported housing initiative for chronically home-less adults with disabilities. Thus, it may not berepresentative of chronically homeless adultswithout disabilities or of other cities acrossthe country. The data came from the period200409, and conditions and characteristics of

homeless populations may have changed sincethat time.

In interpreting our results, it is important toconsider the variation by state in eligibility forMedicaid before the passage of the AffordableCare Act. In all but one of the study states, eligi-bility for adults was generally very limited. Theexception was New York, which expanded cover-age to adults with incomes up to the federalpoverty level during the study period. All ofthe states covered adults with disabilitiesthrough Medicaid. However, experience sug-gests that homeless people face serious chal-

lenges in qualifying through this pathway be-cause of the difficulty they have in acquiringmedical documentation of their disability so thatthey can qualify for Supplementary SecurityIncome and then Medicaid.7

The study presents a cross-sectional compari-son, so causality and stability of these findingsare not conclusive. Nearly all of the measures,including insurance coverage, were based onself-report, and their validity cannot be con-firmed. However, there is some evidence thatadults with severe mental illnesses are able toaccurately and reliably report their health ser-

vice use,18 illness history,19 and health status.20

Study ResultsOf the sample of 725 chronically homelessadults with incomes below the threshold forthe Medicaid expansion, more than three-quar-ters had some form of insurance. Of those withinsurance, 226 (31.17 percent) were covered bystate or local assistance, 185 (25.52 percent)were covered by Medicaid, and 153 (21.10 per-cent) were covered by some other health insur-ance (Exhibit 1). Among those who reported

other forms of health insurance, 79.74 percenthad VA health care, 12.50 percent had Medicare,5.92percenthad private insurance, and9.80 per-cent had some other health insurance. Of thoseenrolled in Medicaid, 11.35percent alsoreportedreceiving state or local assistance.

Characteristics And Histories Of Home-lessness The sample was racially diverse andconsisted mostly of single males in their fortieswho had less than a high school education and amonthly income of less than $400 (Exhibit 1).On average, these adults first became homeless

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in their early thirties, had been homeless formore than eight years in their lifetime, andhad been homeless for more than fifty days inthe previous three-month period.

There were a few significant differences be-tween the chronically homeless adults withMedicaid and those who were uninsured or re-ceiving state or local assistance. Those receivingstate or local assistance wereyounger,were more

likely to be white, and had lower incomes thanMedicaid enrollees(Exhibit 1). In addition, com-pared to Medicaid enrollees, those with no in-surance were younger, were less likely to be vet-erans, and had lower incomes. There were nosignificant differences in homeless histories be-tween those with Medicaid and those who wereuninsured or receiving state or local assistance.

Reflecting the fact that most of the people inthe otherinsurance group reported having ac-cess to VA health care, members of the othergroup were significantly more likely than thosein other groups to be veterans (Exhibit 1). They

also were generally older, were more likely to bemale and white, and had more years of educa-tion. With respect to recent homeless history,those with other health insurance hadalso spentfewer days in their own place in the previousthree months than those without health insur-ance and those on Medicaid.

Health Status And Health Care Use Therewas a high prevalence of both physical and men-tal health conditions among the people in thesample (Exhibit 2). Most of the participantsreported multiple medical conditions and high

rates of psychiatric disorders, particularly sub-stance use disorders. Compared to the nationalaverage scores of 50 for both physical andmental health on the twelve-item Short-FormHealth Survey12scores that have a standard de-

viation of 10the total sample reported worsehealth. The samples average score for mentalhealth was 39, which is more than one standarddeviation below the national average.

After we controlled for characteristics of theprogram site and sociodemographic charac-teristics of the study participants, we foundfew differences in health status across coveragegroups. However, chronically homeless adultswith no health insurance were 1116 percentless likely than those with any coverage to reporthaving schizophrenia. Those with other healthinsurancethe groupcontaining the largest pro-portion of veteranswere more likely than themembers of any other group to report havingpost-traumatic stress disorder. There were noother significant differences on health status

across groups, including the number of medicalconditions. There were differences on some in-dividual medical conditions, as shown in theonline Appendix.17

To examine suppression effects, we repeatedthese analyses without controlling for differenc-es in site and sociodemographic characteristics.

We found nearly no differences in health statusacross groups, except that people with no healthinsurance had higher physical scores on theShort-Form Health Survey12 than those withMedicaid and reported fewer medical problems

Exhibit 1

Sociodemographic Characteristics And Homeless Histories Of Chronically Homeless Adults, By Health Insurance Status

(1) Medicaid(n= 185)

(2) Noinsurance(n= 161)

(3) State orlocal assistanceonly (n= 226)

(4) Otherhealth insurancea

(n= 153) Column comparison

Characteristic

Mean age (years) 46.91 42.54 44.65 48.27 1;4 > 2;3****

Male (%) 74 78 68 89 4 > 1; 3****White (%) 26 36 44 44 3;4 > 1***Education (years) 11.82 11.33 11.74 12.36 4 > 2***Married (%) 1 1 1 1 b

Veteran (%) 23 7 15 81 4 > 1 > 2; 4 > 3****Monthly income ($)c 546.53 227.88 272.48 474.83 1 > 4 > 2; 1 > 3****

History of homelessness

Age when first homeless (years) 33.50 30.54 30.59 35.91 4 > 2; 3****Lifetime years homeless 8.72 7.41 8.63 7.64 b

Lifetime years incarcerated 3.14 2.89 3.22 2.04 b

Days in own place, past 3 months 8.19 6.57 5.29 3.22 1;2 > 4***Days in institution, past 3 months 13.88 14.68 17.48 15.73 b

Days homeless, past 3 months 53.14 53.96 55.71 59.17 b

SOURCE Authorsanalysis.NOTEColumn comparisons are among numbered columns. a Includes Veterans Affairs health care. b No significant differences among numberedcolumns. cA log transformation was conducted on these variables before group differences were tested. ***p < 0:01 ****p < 0:001

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than those with any coverage. Participants re-ceiving state or local assistance had higher

Brief Symptom Inventory scores14 than membersof all other groups, reflecting greater subjectivedistress.

The total sample reported using a wide rangeof health services during the previous month,with the highest use reported for outpatientmental health and substance abuse services(Exhibit 3). On average, study participants indi-cated that 53 percent of their total number ofreported medical conditions had been treated.In addition, these chronically homeless adultsreported receiving an average of seven out offourteen specified preventive procedures and

discussing three out of four identified healthbehaviors with a physician in the previous year.Lastly, 29 percent of the total sample reportedproblems paying for care during the previousthree months.

After we controlled for differences in site andsociodemographic characteristics, we found nosignificant differences in reported health careuse between Medicaid enrollees and those withany other form of coverage. However,thereweresignificant differences in reported health careuse between those who did not have insurance

and those who did (Exhibit 3). The group with-out insurance reported less use of outpatient

medical services and preventive procedures thanall of the other groups. In examining the four-teen preventive procedures individually, thosewithout insurance were significantly less likelyto have had each procedure, except the hearingscreening and colonoscopy.

Chronically homeless adults without healthinsurance also reported less use of inpatientservices than those with Medicaid coverage orstate or local assistance (Exhibit 3). And theyreported less use of emergency department ser-

vices than those with Medicaid,as well as less useof outpatient substance abuse services and dis-

cussing fewer health behaviors with a physician,compared to those with other health insurance.Moreover, participants without health insur-ance were more likely to report having troublepaying for their health services than those withcoverage. In fact, they were more than threetimes as likely as Medicaid enrollees to reportthis problem (63 percent versus 20 percent).

Nearly all of these results remained the samewhen we did not control for differences in siteand sociodemographic characteristics. The ex-ceptions were that people without health insur-

Exhibit 2

Health Status Of Chronically Homeless Adults, By Health Insurance Status

(1) Medicaid(n = 185)

(2) Noinsurance(n = 161)

(3) State orlocal assistanceonly (n = 226)

4) Otherhealth insurancea

(n= 153)Columncomparison

Psychiatric diagnoses (%)

Alcohol use disorder 46 55 58 50 b

Drug use disorder 56 55 49 50 b

Schizophrenia 23 8 19 24 1;3; 4 > 2***Bipolar disorder 15 19 24 17 b

Post-traumatic stress disorder 3 7 7 14 4 > 1; 2;3***Major depression 29 30 29 22 b

Development disability 13 11 9 7 b

Scores on:

Brief Symptom Inventoryc 1.44 1.43 1.73 1.46 b

Observed psychosis scaled 0.27 0.17 0.22 0.19 b

SF-12e physical 43.37 47.24 44.58 44.49 b

SF-12e mental 40.43 38.22 38.24 38.73 b

ASIf alcohol scale 0.11 0.14 0.13 0.11 b

ASIf drug scale 0.06 0.05 0.05 0.05 b

Medical conditions

Numberg

4.23 3.01 4.10 4.09

b

SOURCE Authors analysis. NOTES Column comparisons are among numbered columns. Column comparison tests of difference controlled for site of the CollaborativeInitiative to Help End Chronic Homelessness (see Note 11 in text) and participants age, sex, race or ethnicity, education, veteran status, and monthly income.aIncludes Veterans Affairs health care. bNo significant differences among numbered columns. cMean score of the psychoticism, depression, and anxiety subscales ofthe Brief Symptom Inventory. Scores range from 0 to 4, with higher scores indicating more subjective distress. See Note 14 in text. dScores range from 0 to 3,with higher scores indicating more exhibited psychotic behaviors. See Note 13 in text. eScores on the twelve-item Short-Form Health Survey (SF-12) range from 0to 100, with a score of 50 representing the normal level of functioning in the general population and higher scores indicating better health. See Note 12 in text.fScores on the Addiction Severity Index (ASI) range from 0 to 1, with higher scores indicating more serious substance use. See Note 15 in text. gFrom a list oftwenty-three medical conditions. See Note 16 in text. ***p < 0:01

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decreased useof state and locally fundedservicesif thesepeople transitioned to Medicaid. Savingswill be particularlysubstantialfor adultswho aremade newly eligible by the expansion, sincecoverage for newly eligible individuals will be100 percent federally funded until 2016, afterwhich federal funding decreases to 90 percentover time.7

Chronically homeless adults who were un-insured reported fewer health problems thanMedicaid enrollees, but they still reported abroad range of physical and mental health con-ditions. Compared to Medicaid enrollees, theyreported significantly less use of care, includingpreventive services, and markedly greater prob-lems in affording care. These findings could re-flect better health status among this group, butthey may also reflect undiagnosed anduntreatedconditions, given the participants limited use ofhealth care services and reported difficulties inaffording care.

An important randomized controlled studyof Medicaid expansion in Oregon showed thatMedicaid coverage increased health care use,including various screening procedures; im-proved self-reported health; and reduced finan-cial strain.22 These findings, taken together withthe results of our study, suggest that enrollinguninsured chronically homeless adults in Med-icaid could improve their access to treatmentand preventive services andthat these adults willrequire a broad range of services.

It may be particularly important to providecase management or care coordination services

for chronically homeless adults, given theirrange of health care needs and problems.6

Moreover, access to preventive and primary carewill be one key to identifying conditions inhomeless adults early, preventing them fromworsening over time, and controlling the adultshealth care costs. Basic preventive proceduressuch as measuring blood pressure, cholesterol,and glucose levelswere often found to be lack-ing in this population.

Conclusion

The Medicaid expansion under the AffordableCare Act will likely increase coverage optionsand provide broader access to care for manychronically homeless adults who are uninsuredor rely solely on state or local assistance pro-grams. Moreover, states that expand Medicaidmay experience offsetting cost savings, as chron-ically homeless adults who previously reliedon state and local assistance transition to Medic-aid. Conversely, in states that do not expandMedicaid coverage, poor uninsured adults willnot gain a new coverage option, and many willlikely remain uninsured and continue to face

barriers to accessing needed care.The findings of this study illustrate the broad

and varied health care needs of chronicallyhomeless adults. Ensuring access to preventiveand mental health services is particularly im-portant for addressing the needs of this popula-tion, and the services available to this groupshould include case management and othersupportive services,such as help with housing.

The Collaborative Initiative to Help EndChronic Homelessness Funders Group

representing the Department of Housingand Urban Development, the Departmentof Health and Human Services, and the

Department of Veterans Affairsprovided essential support and guidance

to the authorsevaluation of theinitiative. The evaluation has beencompleted, and the federal government

is no longer involved. The viewspresented here are solely those of the

authors and do not represent theposition of any federal agency or of theUS government.

Enrolling uninsuredchronically homelessadults in Medicaidcould improve their

access to treatmentand preventiveservices.

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NOTES

1 National Federation of IndependentBusiness v. Sebelius, 567 U.S., 2012

WL 2427810 (2012 Jun 28).2 Advisory Board Company. Beyond

the pledges: where the states standon Medicaid [Internet]. Washington(DC): The Company; 2013 Jul 26[cited 2013 Aug 8]. Available from:

http://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMap

3 Holahan J, Buettgens M, Carroll C,Dorn S (Urban Institute,

Washington, DC). The cost andcoverage implications of the ACAMedicaid expansion: national andstate-by-state analysis. Washington(DC): Kaiser Commission onMedicaid and the Uninsured; 2012.

4 Sommers BD, Epstein AM. Medicaidexpansionthe soft underbelly ofhealth care reform? N Engl J Med.2010;363(22):20857.

5 Dorn S, Buettgens M. Net effects ofthe Affordable Care Act on statebudgets. Washington (DC): UrbanInstitute; 2010.

6 Nardone M, Cho R, Moses K.Medicaid-financed services in sup-portive housing for high-needhomeless beneficiaries: the businesscase. Hamilton (NJ): Center forHealth Care Strategies; 2012.

7 DiPietro B, Knopf S, Artiga S,Arguello R. Medicaid coverage andcare for the homeless population:key lessons to consider for the 2014Medicaid expansion. Washington(DC): Kaiser Commission onMedicaid and the Uninsured; 2012.

8 Montgomery AE, Metraux S,

Culhane D. Rethinking homeless-ness prevention among persons withserious mental illness. Soc IssuesPolicy Rev. 2013;7(1):5882.

9 Mechanic D. Seizing opportunitiesunder the Affordable Care Act fortransforming the mental and be-havioral health system. Health Aff

(Millwood). 2012;31(2):37682.10 Ku L. Ready, set, plan, implement:

executing the expansion ofMedicaid. Health Aff (Millwood).2010;29(6):11737.

11 Mares AS, Rosenheck RA. HUD/HHS/VA Collaborative Initiative toHelp End Chronic Homelessness.

West Haven (CT): NortheastProgram Evaluation Center; 2009.

12 Ware J Jr., Kosinski M, Keller SD. A12-Item Short-Form Health Survey:construction of scales and prelimi-nary tests of reliability and validity.Med Care. 1996;34(3):22033.

13 Dohrenwend B. PsychiatricEpidemiology Research Interview(PERI). New York (NY): ColumbiaUniversity Social PsychiatryUnit; 1982.

14 Derogatis LR, Spencer MS. The BriefSymptom Inventory: administration,scoring, and procedures manual1.Baltimore (MD): Johns HopkinsUniversity School of Medicine,Clinical Psychometrics ResearchUnit; 1982.

15 McLellan AT, Luborsky L,Woody GE,OBrien CP. An improved diagnosticevaluation instrument for substanceabuse patients. The AddictionSeverity Index. J Nerv Ment Dis.1980;168(1):2633.

16 Brook RH, Ware JE, Davies AR,Stewart AL, Conald CA, Rogers WH,et al. Conceptualization and mea-surement of health for adults in thehealth insurance study. SantaMonica (CA): RAND Corporation;1979.

17 To access the Appendix, click on the

Appendix link i n the box to the rightof the article online.

18 Goldberg RW, Seybolt DC, LehmanA. Reliable self-report of health ser-vice use by individuals with seriousmental illness. Psychiatr Serv.2002;53(7):87981.

19 Goodman LA, Thompson KM,Weinfurt K, Corl S, Acker P, MueserKT, et al. Reliability of reports of

violent victimization and posttrau-matic stress disorder among menand women with serious mental ill-ness. J Trauma Stress. 1999;12(4):58799.

20 Salyers MP, Bosworth HB, SwansonJW, Lamb-Pagone J, Osher FC.Reliability and validity of the SF-12health survey among people withsevere mental illness. Med Care.2000;38(11):114150.

21 Pennucci A, Nunlist C, Mayfield J.General assistance programs forunemployable adults. Olympia(WA): Washington State Institute forPublic Policy; 2009 (ContractNo. 09-12-4101).

22 Baicker K, Taubman SL, Allen HL,Bernstein M, Gruber JH, NewhouseJP, et al. The Oregon experimenteffects of Medicaid on clinical out-comes. N Engl J Med. 2013;368(18):171322.

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