As communities are becoming more advanced in their efforts to end chronic homelessness, they are taking steps to secure funding in systemic ways and from a variety of sources, including Medicaid.
Chronically homeless people make up just a small part of the overall homeless population (15 percent on a given night), but they are the hardest to help. All chronically homeless people struggle with serious physical or mental disabilities, including mental illnesses like schizophrenia and alcohol or drug addiction, that make obtaining and maintaining housing on their own extremely difficult.
For this population, the most effective intervention is permanent supportive housing—housing coupled with services that address the issues causing their housing instability. However, it is the most intensive of interventions and communities often find it often difficult to finance housing and services.
Several communities have found ways to use Medicaid to help finance the services component in permanent supportive housing for chronically homeless persons, even in states that opted not to expand Medicaid. While most people recognize housing as a key component of health, it is a complicated task to bring these services together enough to serve those in need.
Here are some examples of large scale efforts to use Medicaid to support or expand supportive housing.
- Louisiana (non-expansion state) – In order to sustain and increase the permanent supportive housing that Louisiana created while recovering from hurricanes Rita and Katrina, Louisiana sought multiple Medicaid Waivers and a State Plan Amendment (1915i) to allow Medicaid to cover services provided in permanent supportive housing for persons with severe mental illness who qualify. The Louisiana Behavioral Health Partnership (LBHP) manages these and other behavioral health programs for the State.
- Pennsylvania (expansion state) – Pennsylvania’s managed care organization is called HealthChoices, which has a behavioral health “carve-out” managed by counties across the state. Counties can then reinvest what they don’t spend from Medicaid monthly capitated payments to expand supportive housing programs.
- Massachusetts (long-term expansion state) – Massachusetts created a benefit covered by Medicaid called the Community Support Program for People Experiencing Chronic Homelessness (CSPECH). This started in Boston as a pilot and is now expanding across the state under a Medicaid 1115 waiver. This benefit allows for Massachusetts to target chronically homeless persons and provide services to meet their needs.
- Chicago/Cook County, IL (expansion state) – In this community, a group of providers created an Accountable Care Organization, called Together 4 Health, which allowed them to serve as the healthcare payer for services under Medicaid. This arrangement means Together 4 Health takes on the risk health care costs for their enrollees and the rewards of any savings they generate. Savings can then be reinvested in improving and expanding services.
- Los Angeles, CA (expansion state) – As the result of the Medicaid expansion waiver, dubbed Healthy Way LA, Los Angeles County spent less on uncompensated care. The county then used the funds it saved to invest in more permanent supportive housing.
- New York (expansion state) – In order to save the state money from increasing Medicaid costs, New York capped state Medicaid spending and used what it would have spent on Medicaid to reinvest in redesigning State Medicaid and health care to be more effective and save money. Supportive housing was included in the recommendations for redesign. New York has issued an RFP for supportive housing providers to partner with health homes to use supportive housing to improve health and reduce healthcare costs.
Many other places have developed coverage for supportive services or are on their way including Washington State, Oregon, Connecticut, Colorado, and Washington, DC. In addition, many communities are receiving technical assistance on integrating supportive housing and Medicaid from the Department of Housing and Urban Development (HUD) and national technical assistance providers. Finally, collaborative grant opportunities offered by HUD and the Department of Health and Human Services offer opportunities for communities to plan around Medicaid financing and grant funding for outreach and housing services.
You may be saying to yourself: That’s great, but what can I do in my community?
These implementations are not without problems and unfortunately these strategies will not work everywhere as Medicaid operates differently in every state. The good news is that we already know that supportive housing is effective and that, even in states that have not adopted the Medicaid expansion, communities are finding opportunities for better integration of housing and health care.
For health care providers who are looking for effective solutions to improve health and reduce costs, selling supportive housing should not be too difficult. The struggle will be how to arrange programs and partnerships within States and smaller communities around Medicaid and housing.
Our upcoming conference in July will offer several workshops on Medicaid that will cover several important topics around Medicaid and housing. In addition, there will be a pre-conference meeting offering attendees working on Medicaid with an opportunity to talk with experts about what options may be available and how best to move forward in their state.
Do you know of a community that is using Medicaid to provide homeless assistance? We want to hear about it. Email program and policy analyst Jayme Day at email@example.com.