Medicaid and Permanent Supportive Housing
Housing is one of the social and economic factors that play a critical role in determining an individual's health.
What's the issue?
The Affordable Care Act (ACA) gave states the option of expanding Medicaid coverage to include childless adults with incomes at or below 138 percent of the federal poverty level beginning in 2014. The ACA also gave states additional tools to use in serving this newly insured population, which would include virtually all of a state's homeless adults. Housing is one of the social and economic factors that play a critical role in determining an individual's health. Improving access to housing and the services needed to maintain housing can be a key component of improving health status for Medicaid beneficiaries. States can also use the new opportunities and tools provided by the ACA and other policy options to support individuals with disabilities living in community settings, including those who had formerly been homeless and other newly eligible members of the expansion population.
What are states doing?
To use Medicaid to support the broadest population that might be eligible for supportive housing, states need to have expanded Medicaid to include low-income, childless adults. Individuals in states that have expanded Medicaid eligibility are more likely to be able to use Medicaid to access supportive services. Thirty-one states and the District of Columbia have expanded their Medicaid programs since 2014, but nineteen states have not. Chronically homeless individuals in states that have not expanded access can likely only qualify for Medicaid if they can demonstrate that they have a disability that would qualify them for Supplemental Security Income (SSI). Qualifying for SSI can be particularly difficult for individuals without access to their medical records or other needed documents and with no address to which such documents could be delivered.
In 2012 almost all states had 1915(c) waivers to provide home and community-based services as an alternative to institutional care. (The four states that do not have 1915(c) waivers--Arizona, Hawaii, Rhode Island, and Vermont--cover home and community-based services under waiver authority for managed care.) However, in most states that were covering services under 1915(c) waivers, those services were available only to certain populations. The most commonly covered populations are the elderly, people with intellectual or developmental disabilities, and people who are physically disabled. The population least likely to be eligible for 1915(c) waivers are those with mental illness, which could limit the availability of services to some residents of supportive housing.
A recent report from the U.S. Department of Health and Human Services (HHS) describes how six states and localities have used Medicaid to provide services needed by residents living in supportive housing. The authors of the HHS report recognize the complexities of using Medicaid for this purpose but emphasize the value of Medicaid as a funding source for meeting the needs of supportive housing residents.
Some states are also tackling health care delivery system reforms that might incorporate nonmedical support services. Under Medicaid accountable care organizations (ACOs), provider organizations bear financial risk for the care furnished and are held accountable for the health outcomes of their assigned patient population. ACOs might receive capitated payments or a share of savings from reductions in Medicaid spending, creating a financial incentive to ensure that the patient's care is well coordinated and effective. ACOs in Washington, Oregon, and other states have social service provisions including supportive housing in their models.