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Publication Briefs

Study Suggests Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users

The Patient Protection and Affordable Care Act (ACA) represents one of the most significant overhauls of the U.S. healthcare system, and includes the option for states to expand Medicaid to cover all adults under the age of 65 with household income equal to or less than 138% of the poverty level. This will affect many low-income Veterans, especially homeless Veterans. This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Using VA data, investigators identified all Veterans under the age of 65 who used VA healthcare in FY10 (n=3,841,225), who were then categorized as homeless (n=134,234) or non-homeless (n=3,706,991). Analyses were limited to Veterans under the age of 65 because Medicare-enrolled elderly Veterans are not eligible for the Medicaid expansion. In addition, all Veterans with a service-connected disability were categorized as not LEME, as their disability payments exceed the Medicaid expansion income threshold. Measures included sociodemographic characteristics and medical and psychiatric diagnoses.


  • Among all VA healthcare users under the age of 65, homeless Veterans are two times more likely to be LEME than non-homeless Veterans (64% vs. 30%).
  • Regardless of housing status, Veterans who are LEME were physically healthier than those not LEME, but were more likely to have liver disease and HIV/AIDS. In addition, Veterans who are LEME were more likely to have substance use disorders and PTSD.
  • Among homeless VA healthcare users, those who are LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who are not LEME. Among non-homeless VA healthcare users, those who are LEME were younger and more likely to be OEF/OIF/OND Veterans.


  • Data only addressed the likely eligibility of Veterans for the Medicaid expansion. It could not be determined from VA data who is currently eligible for Medicaid but not enrolled.
  • Findings only include VA service users, so do not include the large number of uninsured Veterans who may benefit from the Medicaid expansion.


  • Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the ACA may be important.

Dr. Tsai was supported by an HSR&D Career Development Award. Drs. Tsai and Rosenheck are part of HSR&D's Pain Research, Informatics, Multi-morbidities, and Education Center in West Haven, CT.

Tsai J and Rosenheck R. Homeless and Non-Homeless Veterans Affairs Service Users Likely Eligible for the Medicaid Expansion. Journal of Rehabilitation Research and Development 2014;51(5):675-84.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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