Harnessing Medicaid to Help Solve Homelessness

Five years since the passage of the Affordable Care Act, many of the major objectives of the law are being met; 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. With so many people now able to access health care coverage, the results are in: the Affordable Care Act is working. 

Of course, increasing access to health coverage is only one objective of the law. The other major objective is to shift the focus of health care away from procedures and treatments and towards the overall quality of care and people’s health outcomes. For people who experience homelessness, we know that having stable housing is essential to health. Stable housing not only has direct benefits on health—reducing exposure to high-risk behaviors and the negative effects of life on the streets—but it also creates a platform for better care. Thus, for people experiencing homelessness, the ultimate measure of whether or not the Affordable Care Act is working may be the degree to which it can incentivize the health care system to address housing needs as a foundation for better health.

It is important to note that attending to housing needs does not mean the health care system should pay for housing costs—things like rent subsidies or capital for construction costs. We already have a set of housing programs (like Housing Choice Vouchers, public housing, low-income housing tax credits, and the Continuum of Care) that can cover these costs, though we need to increase investments in these programs. The role of the health care system is to finance and provide the health and social services that not only address people’s physical and behavioral health conditions, but that also help people find housing, obtain housing, and remain in housing. 

The most immediate place where this support of housing needs can happen is through the coverage of services for people in supportive housing under Medicaid. As guidance released last year by the U.S. Department of Health and Human Services made clear, Federal rules allow states to cover the broad set of services for people in supportive housing under Medicaid. This includes things like pre-tenancy supports, tenancy supports, and move-in supports. States have a variety of options for covering these services, from 1115 Demonstration Waivers to Home and Community Based Services to Health Homes. Many of these services can be provided by community health centers, including Health Care for the Homeless programs. 

Increasing the role of Medicaid in financing services in supportive housing also has the ability to increase the number of supportive housing units, albeit indirectly. For example, HUD’s Continuum of Care (CoC) Program currently funds over $195 million in services costs in supportive housing, including about $170 million for services that theoretically could be covered by Medicaid. If Medicaid were to cover even half of these supportive services, it would free up enough CoC funding to create over 8,500 new units of supportive housing.

Medicaid is a joint Federal and state program, and so while the Federal government allows for the coverage of these services, it is ultimately up to states, communities, and providers to choose to do so. In most instances, this requires states seeking changes to their Medicaid plans. It also requires increasing the capacity of supportive housing services providers to learn how to deliver services under a health care and Medicaid context. It may mean bringing in a new set of providers and partners to the table, namely, hospitals, managed care organizations, and Accountable Care Organizations. And most importantly, it means deciding that investing in case management and supportive services—coordinated with housing—is a wiser and more cost-effective use of Medicaid than allowing people to cycle in and out of emergency rooms and inpatient stays in hospitals.

The Affordable Care Act offers a wide range of exciting opportunities to improve health care and housing situations for people experiencing homelessness, but we cannot sit back and wait for the health care system to reform on its own. Health reform is up to all of us. It is up to all of us to ensure that the health care system recognizes its role and obligation to address housing needs for people whose primary barrier to better health is the lack of housing. It is up to us to help states redesign their Medicaid plans to increase the coverage of supportive housing services. It is up to us all to harness health reform to help solve homelessness.