Painting a picture
At a crowded weekly meal distribution in Fort Lauderdale, a battered wheelchair sits idle beside a cardboard sign reading “Anything Helps.” As volunteers pass out plates of pasta, a van pulls up and two men in crisp polo shirts step out. With slick smiles they offer some cash and a cold soda to anyone ready to sign up for health insurance.
Brian, a 61-year-old former violinist, thought only of that free soda. He had been relying on Broward Health’s Homeless Clinic for psychiatric care under the federal W72 grant, which covers all treatment for uninsured, homeless patients. The afternoon he accepted the soda, an agent guided Brian’s finger across a dotted line, signing him up for health insurance. Weeks later, Brian had returned to the homeless clinic for his medicine, only to be confronted with a $1,000 bill. His W72 coverage had vanished. Enrollment in a subsidized marketplace plan—a policy Brian never intended to use—automatically disqualified him from grant care. Unable to pay the surprise copays and meet the insurmountable deductible, he now faces thousands in medical debt with no reliable path back to treatment.
Not far away, another individual, who we’ll call E, was persuaded by the promise of a ten-dollar bill to sign up for marketplace insurance. Already stabilized on vital heart medication, E discovered too late that his new plan carried a deductible of $1,800. As he talked with me about the ten-dollar ordeal, after three days without medication, his leg was notably swollen.
Florida’s Three Safety Nets—And Where They Clash
On paper, the United States offers a layered safety net for people with nowhere else to turn.
Medicaid, the nation’s primary safety-net insurance, jointly funded by federal and state governments, provides comprehensive coverage with minimal cost. In theory, it is the strongest option for homeless adults. But in Florida—a state that chose not to expand Medicaid under the Affordable Care Act—childless adults under 65 are almost entirely ineligible for Medicaid coverage, no matter how low their income. And those who do qualify still must navigate an enrollment process requiring internet access, proof of income, and periodic renewals that are nearly impossible for people living without stable housing to complete.
Health Care for the Homeless (HCH) programs, authorized under Section 330(h) of the Public Health Service Act, provide federal grant funding to clinics to treat uninsured homeless patients at no cost. In Broward County, the W72 grant reimburses providers for everything from prescriptions to dental work, as long as the patient is homeless and has no insurance. Clinics like Broward Health carefully check property and insurance databases to ensure care goes only to those who are unhoused and uninsured.
Private marketplace insurance, sold by private companies through ACA exchanges, appears to be free for the poorest enrollees thanks to federal subsidies that cover premiums. ACA plans are discounted through tax-credits, and an individual is only eligible if their income is at least 100% above the Federal Poverty Level. So, since homeless individuals have no income, not only are they being signed up illegitimately, but then these plans are riddled with deductibles and copays, sometimes running into thousands of dollars. As Becker’s Payer Issues reports, agents can earn upfront commissions of around $150 per enrollment, plus monthly residuals of $20-30 for up to a year—a powerful incentive for aggressive marketing in shelters and meal lines.
The irony is that all three programs are federally funded, yet rather than complementing each other, they often cancel one another out. Signing up for a marketplace plan—even unknowingly—automatically disqualifies someone from HCH coverage and can block Medicaid approval. By accepting the free soda, a homeless individual may trade unlimited free care for a plan they can never afford to use. On top of this, there is essentially no vetting process required to sign up individuals, and there is little to no regulation for agents.
A Growing Crisis in Numbers
The scale of the problem is staggering. A 2024 study in The American Journal of Accountable Care found that while 61% of homeless adults nationwide are insured, only 39% rely on Medicaid or Medicare. The remainder either remain uninsured (39%) or are covered by private plans (22%)—the very plans least suited for people with no stable income.
Florida’s gaps only worsen the picture. Thousands of childless adults fall into the “coverage gap,” earning too little to qualify for marketplace subsidies yet unable to access Medicaid. Those who do manage to enroll often experience recurring paperwork requirements, leading to lapses in coverage.
Emergency rooms remain the fallback. Homeless adults use hospital ERs at a rate of 141 visits per 100 people annually—more than triple the rate for housed adults, which hovers around 40. Chronic illnesses such as hypertension, diabetes, and mental health disorders—all disproportionately prevalent in homeless populations—drive much of this demand.
The intent behind federal grants like W72 is clear: bridge gaps by creating spaces where uninsured individuals can access care without forms, premiums, or copays. Yet once a person is enrolled in marketplace insurance, clinics label them “insured,” effectively closing the doors.
The Hidden Mechanics of the Safety Net
Federal programs create a complex web of incentives and rules. Medicaid, W72 grants, and ACA marketplace insurance are funded by taxpayer dollars, yet their interactions often strand homeless individuals in bureaucratic limbo.
Medicaid provides comprehensive coverage: hospital care, mental health services, and prescriptions at minimal cost. But enrollment in Florida demands strict documentation and income verification, often unattainable for those without a permanent address or reliable mail. Missed paperwork or a single forgotten notice can leave someone uninsured for weeks, forcing reliance on emergency rooms as the only option.
W72 grants, locally administered but federally funded, aim to bridge these gaps. Clinics like Broward Health can treat homeless patients entirely free of charge, reimbursed directly by the grant. However, these grants are only available to individuals who are both homeless and uninsured. Enrollment in a private insurance plan—even if fully subsidized—immediately disqualifies someone from that grant care specified for unhoused, uninsured patients. A single signature on a marketplace form can erase access to essential care.
In layman’s terms, when a homeless individual is uninsured, they qualify for completely free coverage under federal grants for individuals that are both homeless and uninsured. The second this individual signs up for health insurance, they are still homeless, but no longer uninsured, disqualifying them for care for both homeless and uninsured individuals.
The Marketplace Trap
ACA marketplace plans seem benevolent, offering zero-premium options to low-income consumers. But the hidden cost, for those that were signed up illegitimately, can run into the thousands. Field Marketing Organizations (FMOs) funnel federal subsidies to insurance agents, who are incentivized to sign up as many people as possible. The agents get their $150 commission, and the insurance company gets their multi-thousand-dollar federal subsidies—and this is for every additional enrollee. At meal distributions or shelters, agents often offer cash, gift cards, or small perks like a soda, creating the illusion of charity.
The consequences are immediate: enrolling in a marketplace plan removes eligibility for W72 grants and other homeless-specific programs. Clinics that previously offered free care can no longer treat these patients without risking financial loss. Individuals who unknowingly sign up are left with medical bills they cannot afford, prescriptions they cannot access, and no fallback beyond costly emergency care.
This incongruous system creates a cycle in which the federal government simultaneously funds free care and pays commissions to enroll people out of it. The safety net, instead of catching the vulnerable, lets them fall through and then acts as a barrier.
Financial Incentives and Systemic Gaps
The system heavily favors agents and insurers over patients. Unscrupulous agents earn hundreds upfront and monthly residuals of $20-30 for up to a year per enrollee. Insurance companies profit through the federal subsidies mentioned prior while clients, often with no income or savings, struggle to cover copays and deductibles.
Clinics operating on W72 grants face financial uncertainty when patients are unknowingly enrolled in marketplace plans. Retroactive eligibility changes prevent clinics from overriding insurance requirements, forcing them to turn patients away even when medically necessary. This drives overuse of emergency departments, burdening hospitals and taxpayers. Homeless patients end up in ERs at rates three times higher than housed adults—a preventable cost both financially and medically.
Regulatory Blind Spots
A major problem lies in fragmented oversight. The Centers for Medicare & Medicaid Services (CMS) monitors Medicaid and traditional Medicare, but W72 grants and marketplace insurance enrollments largely fall outside their direct supervision. State oversight is minimal, and no regulation mandates agents to disclose that signing up for marketplace insurance cancels access to free care programs.
This regulatory gap leaves room for ethically questionable and illegal practices to continue unchecked. Field Marketing Organizations (FMOs), intermediaries between insurers and agents, distribute payments without ensuring that enrollees fully understand the consequences of signing up. The system relies on trust—trust that vulnerable populations are ill-equipped to provide, creating a structural imbalance that traps the homeless in financial and medical vulnerability.
The Broader Implications
The interaction between federal programs, private insurers, and local clinics highlights systemic tension. Policies designed to help often clash, creating obstacles for the homeless. Federal dollars intended for direct patient care are diverted to commissions, premiums, and administrative overhead.
From a public health perspective, these gaps exacerbate chronic disease prevalence, emergency department overuse, and preventable hospitalizations. Homeless populations bear both financial and emotional costs that are rarely visible. What should function as a safety net becomes a complex web of conflicting incentives, leaving individuals exposed to medical and financial risk.
Unraveling the Safety Net
Florida’s homeless population faces a cruel paradox: programs meant to protect them often end up creating new barriers. Medicaid, W72 grants, and ACA marketplace insurance each serve vital purposes, but their interactions reveal systemic gaps and misaligned incentives. A safety net on paper can become a trap in practice, with federal dollars flowing to agents and insurers while patients experience interrupted care, mounting medical debt, and preventable health crises.
At the heart of this problem lies bureaucracy. Eligibility requirements, documentation demands, and retroactive cancellations assume a level of stability most homeless individuals cannot achieve. Minor lapses—misplaced paperwork, missed notices, or accidental enrollment in a marketplace plan—can trigger cascading consequences: untreated chronic conditions, psychiatric destabilization, amputations, strokes, and preventable hospitalizations that could have been avoided with timely, grant-supported care.
Financial incentives make matters worse. Commissions, residuals, and federal subsidies favor agents and insurance carriers over patients, diverting funds away from the programs meant to provide care. Clinics operating on W72 grants navigate razor-thin margins, forced to turn patients away or risk financial collapse. Preventive care is undermined, and expensive emergency interventions become inevitable.
The human toll extends beyond individual stories of missed prescriptions or canceled coverage. It reflects structural flaws at the intersection of public policy, private profit, and social services. Homelessness itself is worsened by these health inequities, perpetuating a cycle of vulnerability and medical neglect. Addressing the problem requires more than piecemeal solutions—it demands alignment of federal programs, transparent oversight of insurance practices, and a commitment to ensure care reaches those it is intended to help.
Florida’s experience is a cautionary tale. Generosity on paper is not enough. Without intentional design, coordination, and accountability, even well-funded programs can fail the people they were meant to protect. The ultimate challenge is simple but profound: to create a system where access to care—not bureaucracy or profit—determines who receives help and how it is delivered.
