Very Low-Income Medicaid Enrollees With Complex Needs Require Integrated Health and Social Services

Published on: 

Enrollees in Minnesota's early Medicaid expansion had high rates of mental illness, substance use disorder, and housing instability, indicating they would benefit most from access to highly integrated health and social services.

An analysis of enrollees in Minnesota’s early Medicaid expansion found that these individuals would benefit most from access to highly integrated health and social services, according to an issue brief from The Commonwealth Fund.

Nathan D. Shippee, PhD, and Katherine D. Vickery, MD, MSc, both of University of Minnesota, analyzed data on the nondisabled, childless adults in the Minneapolis—St. Paul region who enrolled in Medicaid when it first expanded in Minnesota in order to better understand the needs of this population that has a very low income.

“Federal and state expansion of eligibility for Medicaid to formerly ineligible groups, including childless adults, has brought health coverage to a variety of historically uninsured individuals,” the authors wrote. “Many are homeless, have substance use disorders, mental illnesses, or have been in prison, and many have very complex medical and social needs as a result.”


Minnesota actually expanded its Medicaid program eligibility before the Affordable Care Act. These early enrollees in Minnesota were mainly male (60%) and 32% had less than a high school education. Early enrollees had very high rates of behavioral conditions with 37% diagnosed with anxiety, mood, or schizophrenic disorders, and more than one-fourth diagnosed with substance use disorders. In addition, 28% appeared to be homeless.

About 10% of enrollees faced all 3 issues: unstable housing, major mental illness, and substance use disorder. Approximately, 9% experienced substance use disorder and mental illness without homelessness being an issue.

Some proposed policy changes would scale back coverage or benefits for this population, which would make it difficult to meet their needs, Shippee and Vickery wrote. In order to best serve this population with complex needs, they recommended that healthcare payment and delivery models integrate physical health, behavioral health, and social services, which would have the added benefit of reducing confusion about which services are covered.

Insurance churn is not uncommon in this population, resulting in interruptions in medical care, reduced adherence, increased use of the emergency department, and worse self-reported quality of care and health. This churn removes the people considered the most at-risk from observable data.

“Linking data sources across different health and social sectors could thus help identify individuals eligible for Medicaid, help them retain continuous coverage, and provide policy makers with actionable evidence,” the authors concluded.


Shippee ND and Vickery KD. The complex needs of Medicaid expansion enrollees with very low incomes. The Commonwealth Fund website. Published May 31, 2018. Accessed July 6, 2018.