Abstract There is ample evidence that homelessness is associated with inadequate access to essential health services and that African American, Hispanic/Latinx and rural populations are at high risk for homelessness and/or its consequences. However, there is insufficient knowledge about gaps in use of specific types of healthcare among homeless adults, whether such gaps are greater among minority and rural populations, and the potential of permanent supportive housing (PSH) programs to mitigate the gaps. This study aims to: 1) quantify the contribution of homelessness to gaps in essential health services use among Medicaid beneficiaries by race/ethnicity and rural residential status; 2) evaluate the extent to which the gaps are mitigated by placement in PSH programs; and 3) identify Medicaid and PSH policy and programmatic strategies for improving access to essential health services and reducing associated racial/ethnic and rural disparities. This study will overcome shortcomings in prior research by using novel large scale, population- based, long-term data, combined with integrated quantitative-qualitative research methods. The study will address the first two aims using 10 years (2011-2020) of linked homeless services and Medicaid administrative data for New Jersey and Pennsylvania. The contribution of homelessness to healthcare gaps and disparities will be measured by comparing utilization and spending for a broad spectrum of community-based and hospital health services among adults experiencing homelessness to matched Medicaid beneficiaries who have not been homeless. PSH will be evaluated by comparing trends in healthcare use and disparities by race/ethnic and rural residential status among those receiving housing placements to adults in similar circumstances who did not receive such placements. Specific actionable strategies for improving policy and practice will be identified in focus groups with front-line PSH professionals during which quantitative findings will be shared and discussed.

Narrative In spite of clear evidence that homeless adults have poor access to essential health services and that supportive housing can mitigate some consequences of homelessness, not enough is known about ways Medicaid and supportive housing policies can help reduce homelessness-related healthcare gaps. This project will analyze 10 years of linked homeless services and Medicaid data in NJ and PA to quantify the contribution of homelessness to gaps in healthcare access and evaluate how permanent supportive housing can help remedy those gaps. Project findings will inform Medicaid and supportive housing policies and programmatic strategies for improving healthcare access among homeless adults and reducing associated racial/ethnic and rural access disparities.