Last month, I dedicated a column on Medicaid expansion and homelessness. It is a complex issue and one that I am not very familiar with. But I decided I wanted to take you along as I continue to learn more about how other states have utilized Medicaid waivers to assist people experiencing homelessness or at-risk of homelessness. My goal is to offer additional food for thought as I take a closer look at two main tools that states have used to leverage Medicaid dollars in their quest to improve housing services for people experiencing homelessness or at risk of homelessness.
Let’s start with support services, which can be enhanced through Medicaid waivers, and how they are essential in addressing homelessness. Fundamentally, homelessness is a description of a housing status. However, housing alone does not resolve homelessness for everyone, especially when people struggle with severe and persistent mental illness, physical disabilities, substance use and other issues that prevent them from accessing housing quickly. In addition, the disconnection of different systems, such as housing, healthcare, criminal justice and foster care systems, further complicates the path to housing for many people. Without housing we cannot end homelessness, but we also need support services that are available to some extremely vulnerable people to help them access and retain housing.
The federal Department of Housing and Urban Development (HUD) has encouraged providers to increasingly leverage mainstream funding for support services. As outlined in our Nov. 8 column, many states developed Medicaid waivers. Tennessee, however, is among the 10 states that have not expanded Medicaid. The federal government wants to see more cross-systems collaboration and recognizes access to affordable housing as an important social determinant of health. Most recently, HUD together with the U.S. Department of Health and Human Services (HHS) announced a Housing and Services Partnership Accelerator, which provides technical assistance to states that have Medicaid expansion under an approved section 1115 demonstration project or an approved section 1915(i) state plan.
The latter allows states to enter a Medicaid amendment to design a service package that is targeted to people with specific needs. Such an amendment package could include special services for people with developmental disabilities, physical disabilities, mental illness, or substance use disorders. In any case, Tennessee has neither a 1115 demonstration project waiver nor an amendment under 1915(i) and will miss out on this particular opportunity for federal assistance.
The reason I mention this new federal initiative even though Tennessee is ineligible for it is to highlight how complicated Medicaid expansion is. The federal government realizes that Medicaid-covered services to assist with housing and support are still new, they are complex, and many states have expressed assistance with the implementation of their efforts.
CSH, a national advocacy nonprofit that works to advance supportive housing, published a policy brief in spring of 2023 and recently hosted a series of Webinars outlining strategies that leverage Medicaid for Housing Related Services, which are defined as “the services that support individuals to obtain and maintain housing in a community-integrated manner.”
Fundamentally, Housing Related Services, as described by CSH, include a pre-tenancy and a tenancy focus. Pre-tenancy supports focus on outreach and engagement to people experiencing homelessness. Eligible services include helping people get their documents together; assist them in identifying and applying for rental subsidies they qualify for; help them fill out needed paperwork; support with the housing navigation process to identify housing units; identify resources to help with the actual move-in, etc.
Post-tenancy supports usually include care coordination and referral processes to community-based providers for health care, budgeting, understanding tenancy rights and lease obligations, redetermination to ensure housing subsidies continue, employment and education assistance, and other specialty needs. When appropriate services will be provided in-home, especially for people with disabilities.
Medicaid waivers can help with both pre- and post-tenancy support depending on the negotiated state waivers. Let’s look at a few state examples.
Arizona’s Medicaid expansion was approved in October 2022. Arizona used the section 1115 demonstration for individuals who are homeless or at risk of homelessness or are transitioning out of emergency shelters, for individuals transitioning out of institutional care of congregate settings, and individuals transitioning out of child welfare. Services covered include pre-tenancy and tenancy sustaining services such as education on tenant rights and eviction prevention, assistance with housing navigation, moving expenses, move-in costs including housing deposits and home remediation services when necessary for the household’s health as well as accessibility for people with disabilities.
North Carolina’s section 1115 demonstration project is focused heavily on medical respite care and offers post-hospitalization housing for up to six months. The project is called Healthy Opportunities Pilots and focused on three regions of the state.
The section 1115 waiver is a demonstration project, which allows for states to negotiate the following housing supports:
- Rent or temporary housing up to six months;
- Traditional respite services;
- Day habilitation programs and sobering centers;
- Pre-tenancy and tenancy sustaining services;
- Housing transition navigation services;
- One-time transition and moving costs;
- Medically necessary home accessibility modifications and remediation services; and
- Medically necessary home environment modifications.
Other eligible services include nutrition and case management. But again, states generally negotiate what the actual demonstration project will look like under section 1115.
In 2021, the federal government issued a 51-page letter to states that details opportunities states can apply for to better address social determinants of health. CSH provides a chart of all state Medicaid expansion programs that are currently in place in its 2022 policy brief.
One of the issues that’s always on top of the minds of policy makers is the cost savings these programs can achieve. But the housing crisis we are facing in our communities today that continue to increase homelessness should focus on quality of life for everyone. Building healthy communities will pay for itself. The reality is that the United States has the know-how and the dollars to truly prevent and end homelessness. It would require a shift from subsidizing wealthy people and corporations to investing in poverty reduction measures such as low-income affordable housing subsidies, accessible transportation, health care, and quality education. And maybe we could actually save dollars by improving health policies, reform criminal justice systems, and slightly realign military investment strategies. But all that is worth a separate column. For now, let’s just say, it is political will that we need to create programs that provide safety nets for the poor, the sick, the elderly, people with disabilities, and for our children. If we want people to work and lift themselves up by their bootstraps, then we need to ensure that they have access to those boots — with bootstraps.
We just need to remember; advocacy starts at the local level.
Every state and every locality is in a different place when it comes to housing supply, systems coordination, and support services. In a 2021 study published in The Milbank Quarterly* the authors identified the following challenges when it comes to the implementation of Medicaid demonstration projects. Those challenges listed were (and I quote):
- Resolving the housing supply and NIMBY (Not In My Back Yard);
- Removing silos between health care and homeless services providers;
- Enrolling and retaining the target populations in Medicaid;
- Contracting with and paying tenancy support providers;
- Recruiting and retaining key workers;
- Ensuring Medicaid’s waiver durability; and
- Reducing administrative crowd-out and waiver burden.
I’ll add another challenge: implementing and constantly improving a Housing Crisis Resolution System at the local level that clearly outlines roles and responsibilities across the homelessness, housing, health, and other sectors. Such a Housing Crisis Resolution System should improve access to affordable housing and needed support services.
We also need to stop merely talking about homelessness prevention and start figuring out how to actually stem the inflow of people into the homelessness system. We have a big gap when it comes to assisting people while they are still in housing (prevention) or after they obtained housing as they transition out of homelessness. Funding mechanisms like Medicaid can provide some sustainable dollars to help fill that gap. Of course, it helps to be located in a state that is open to discussing and adopting Medicaid expansion to improve services for some of its most vulnerable citizens.
What can you do? For starters, call your local representative, the TennCare Bureau, and the Governor’s Office and tell them that we need Medicaid expansion in Tennessee.
*Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States by Frank J. Thompson, Jennifer Farnham, Emmy Tiderington, Michael K. Gusmano, and Joel C. Cantor.