A Closer Look: Opening Doors, as Amended in 2015 - Spotlight on Medicaid

To accompany the release of Opening Doors, as amended in 2015, we will be taking a closer look at each of the four key updates to the document this week. We’ll be sharing comments from partners, community members, and the USICH staff on how the updates are impacting their daily work, helping to prevent and end homelessness across America, as well as highlight the key changes around the updated topic.

Spotlight on Medicaid

“When launched in 2010, Opening Doors was more than a blueprint for effective Federal, state and local partnerships to end homelessness, it motivated all of us - inside and outside of government - to work harder, together, to address the needs of our most vulnerable people. Five years later, it is just as impactful; a platform on which proven solutions such as supportive housing can expand, and an affirmation that services through Medicaid, coordinated assessment and access, and cooperation among systems must grow too if we are to succeed and tackle homelessness once and for all.”

Deb DeSantis, President/CEO, Corporation for Supportive Housing

The Affordable Care Act creates new opportunities to leverage Medicaid to end homelessness, specifically by financing services that can help people obtain and maintain housing as well as achieve health and well-being. All states now have the opportunity to expand Medicaid eligibility to nearly all individuals under the age of 65 with incomes up to 133 percent of the Federal poverty level. As of May 2015, 30 states including the District of Columbia have acted to expand Medicaid programs, and provide health coverage to millions of adults without dependent children for the first time.  More than 16 million Americans have gained health coverage, bringing the number of people without insurance down to historic lows. Included in the newly insured are approximately six million of the lowest income Americans, who have gained access to public health insurance through Medicaid and the Children’s Health Insurance Program (CHIP). And while the data is limited on the specific number of people experiencing homelessness who have gained coverage, we have numerous reports that enrollment in Medicaid and other types of health insurance among people experiencing homelessness has grown significantly.

In addition, the Affordable Care Act is shifting the focus of health care on “value” not “volume” and on addressing “whole person” health needs, which will increase the coverage of care management services and services that address social needs, namely, housing.

The evidence is clear that housing integrated with health care is an effective and cost-saving intervention for people experiencing homelessness, including people experiencing chronic homelessness, as well as children and youth with behavioral health needs. The integration of housing with services is increas­ingly identified as a way to address complex health care needs that overlap with vulnerabilities associated with race and gender, extreme poverty, HIV/AIDS, mental illness, chronic substance use, incarceration, and histories of exposure to trauma and violence, as well as homelessness.  In addition, supportive housing can be part of strategies to reduce avoidable emergency department visits and inpatient hospitalizations among individuals who are frequent users of such crisis health services.

The newly amended Opening Doors provide more specific information regarding the role of Medicaid in covering health and supportive services to end homelessness, including services that support housing stability, such as in permanent supportive housing.

Specifically, the plan was revised and expanded to include several new strategies:

  • [Under Objective 4] Increasing the use of mainstream resources to cover and finance services in permanent supportive housing. As more individuals experiencing chronic homelessness are eligible for Medicaid through the Affordable Care Act, there are greater opportunities for Medicaid to finance services for people in supportive housing.

-HHS will provide information, tools, and resources to describe how certain services provided through supportive housing can be considered Medicaid covered services.

-HUD and HHS will increase the capacity of supportive housing providers to provide Medicaid services directly or to partner with Medicaid providers such as those participating in Health Care for the Homeless programs or other health centers.

-HHS will provide updated information to States on how to use behavioral health resources to assist people exiting homelessness.

  • [Under Objective 7] Promotion of integration of evidence-based Medicaid behavioral health services for children and youth, including intensive care coordination, peer services, intensive in-home services, mobile crisis and stabilization services, and other home and community based services.
  • [Under Objective 9] Encourage states to link housing assistance with care management approaches for people experiencing homelessness identified as Medicaid high utilizers. States pursuing initiatives focused on high need, high cost Medicaid beneficiaries can identify homeless subpopulations through data matching with HMIS, as well as link care management services with housing.

View all the of updated strategies in Opening Doors, as amended in 2015

Many resources have been developed on leveraging Medicaid to cover supportive housing services. Below we have gathered just some of the tools related to the topic:


Having spent years working to achieve the goals of Opening Doors, and countless hours working on the 2015 Amendment, we asked the staff of USICH to share their thoughts on what the Plan and its recent updates mean to them:

I began my career working to connect people living with HIV/AIDS in rural West Virginia to safe, stable housing. I quickly learned that housing alone was not enough. A huge part of my role was also to make sure that these individuals and families had access to critical health care and other supports needed to stay in stable housing, improve health, and achieve overall well-being. There is growing consensus that housing interventions paired with health care and services are among the most promising practices for preventing new HIV infections. Evidence also suggests that, for people experiencing or at-risk of experiencing homelessness who have chronic health conditions, integrating housing with health care is a cost-effective intervention.

Opening Doors Objective 7 points to the need for increased partnership between housing and health care in order to improve health and stability. Five years ago, I relied on the plan to help me understand the importance of these partnerships and how to improve them in my community to make sure that people had access to housing and comprehensive care. Today, with the expansion of Medicaid, I also look to the Plan to help me understand new opportunities for innovation in care and service delivery. We still have a lot of work to do, but I believe that Opening Doors continues to help us move closer to lasting solutions through innovations in practice and in partnership in communities across the country.

Lindsay Knotts, Policy Advisor


In the fifteen years in which I have worked to end homelessness—starting with work to provide housing to people living with HIV/AIDS—I have seen first-hand how homelessness is not only a human tragedy, but a public health crisis and a health policy failure.  On the other hand, I have seen how supportive housing has saved lives and helped people achieve remarkable improvements in health—while also lowering public costs.  Few things make as much moral and fiscal sense as ending chronic homelessness through supportive housing.  But there has never been a way to systematically bring supportive housing to scale…until recently.

As the 2015 amendment to Opening Doors makes clear, the Affordable Care Act is a game changer for bringing permanent supportive housing to scale.  It creates the possibility of being able to more systematically solve half of the supportive housing funding puzzle (supportive services) through Medicaid.  It provides more specific strategies on ways that we can take advantage of the tools in the Affordable Care Act to fully leverage Medicaid to finance the services in supportive housing.  If and when we implement these strategies, and if the investments are made on the housing side, I have no doubt that we will achieve an end to chronic homelessness and save the lives and restore hope for thousands of Americans.

Richard Cho, Senior Policy Director