Medicaid Waivers and Housing Supports for the Homeless: Implementation Challenges in Four States

Background. Among the social determinants of health, housing looms large in importance. Prior research has documented that homelessness harms health and drives up health care cost through higher rates of emergency department use and inpatient hospitalization. Aware of this problem, the Centers for Medicare and Medicaid Services invited states to apply for Medicaid Section 1115 waivers to pursue demonstrations designed to provide housing supports to the homeless. Our paper analyzes the implementation challenges of four states that obtained Medicaid housing-support waivers early on – California, Illinois, Maryland, and Washington. These states vary considerably in design and implementation challenges. California and Maryland feature an intergovernmental approach where state Medicaid agencies heavily rely on local governments to drive the initiative. In turn, Washington has turned to a third-party contractor in an effort to integrate Medicaid and housing supports. Finally, design and implementation in Illinois have been delayed and perhaps aborted due to leadership transitions, second thoughts about waivers as a policy tool, and other factors. As the social work profession works to end homelessness and close the health gap, policy solutions for addressing these Grand Challenges are much needed. This study seeks to understand implementation challenges related to one such policy, Medicaid Section 1115 waivers.

Methods. We relied on a qualitative, inductive methodology. An expert consultant in each state briefed us on the context and demonstrations while helping us identify highly informed interview subjects. In 2019, we conducted 28 semi-structured interviews by phone with 36 key stakeholders (e.g., government administrators, health care providers, nonprofit housing organization staff, consultants). The interviews, which averaged an hour in length, were transcribed and co-coded by two members of the research team. Our analysis also relies on an extensive review of public documents, media accounts, think tank analyses, and literature on health care, homelessness, and housing.

Results. Our research points to seven major implementation challenges which the four states have in varying degrees succeeded in addressing. (1) The housing supply challenge including issues of affordability and NIMBY/stigma. (2) Breaking down silos especially to facilitate integrated services by health care and housing providers. (3)Take-up to facilitate targeting the homeless in greatest need and assuring their uninterrupted enrollment in Medicaid. (4) Surmounting the administrative complexities of recruiting, contracting with, and paying housing support providers. (5) Staffing -- recruiting and retaining caseworkers who can effectively serve the homeless. (6) Durability -- assuring that the Medicaid-housing initiatives endures beyond the five-year waiver. (7) Sustaining implementation commitment to the housing initiative in the face of leadership transitions, second thoughts about waivers as a policy tool, and other developments.

Conclusions. Our research will distill lessons for states seeking to integrate Medicaid and housing support services, with a focus on the catalytic role that the social work profession might play. It will consider the potential and limits of Medicaid waivers as a tool to facilitate this integration. The broader question of how Medicaid policies and practices should be modified to better factor in housing as a social determinant of health will garner attention.