The Challenge

Increasing Medicaid and other health care expenditures are a significant driver of budgetary pressure on states. Care for about 5 percent of Medicaid enrollees nationwide accounts for more than 50 percent of all Medicaid spending. Those high-need, high-cost enrollees also have a range of challenges in the social determinants of health.

The Role of Housing

Among the most important interventions for this group is addressing homelessness and housing instability. Housing First is an evidence-based, permanent, supportive housing intervention for chronically homeless individuals that has the potential to improve health outcomes and reduce costs to health care and other public safety net programs.

The Roap Map

This road map provides states with a step-by-step guide to creating greater access to housing solutions for high-need, high-cost Medicaid enrollees in order to improve health care outcomes and reduce overall spending on health care and public safety net programs.

State teams work with key stakeholders to develop their housing strategy, including:
  • Scanning the environment;
  • Developing a housing and health care strategy for the complex care population;
  • Incorporating key elements of behavioral health services integral to a housing intervention;
  • Assessing bridge solutions for individuals with complex care needs;
  • Defining the services in supportive housing; and
  • Building capacity for capital and operating resources
State teams and stakeholder partners iteratively plan and obtain buy-in for an overarching health and housing strategy, including:
  • Developing Medicaid waiver and state plan amendment options for services; and
  • Communicating the plan and engaging leadership
State teams and stakeholder partners implement housing solutions, evaluate and communicate outcomes and reinvest a portion of savings.
This includes:
  • Implementing permanent supportive housing (PSH) and bridge housing solutions;
  • Evaluating short- and long-term programmatic outcomes, including health outcomes and cost savings; and
  • Deciding on a savings versus reinvestment strategy to support additional housing solutions that will deliver return on investment

What Can Governors Do?

Act as a convener of key groups that may be partnering for the first time, such as: federal field offices, local agencies, state cabinet officials, state budget officers, local government officials, Continuae of Care, clinical and social services providers, the housing developer community, housing finance agencies (HFAs), public housing authorities, the Medicaid director, behavioral health officials, managed care organizations (MCOs), administrative service organizations (ASOs) and other stakeholders.
Direct Medicaid leadership to pursue authorities to cover supportive services, including tenancy support, and ensure that the most vulnerable populations have access to this resource. Prioritize high-need, high-cost populations and reinvest savings into the broader plan.
Direct Medicaid leadership to work with MCOs or through their fee-for-service program to leverage contracts for provision and payment of supportive housing services.
Consider a "no wrong door" policy for streamlined eligibility determination for public programs, including permanent supportive housing.
Leverage state-funded subsidy programs that can support "no wrong door" supportive housing policies.
Create a universal waiting list for affordable housing units to help prioritize the neediest populations.
Encourage public-private partnerships with the state's HFA or cabinet-level housing agency to create financial incentives for the development of supportive housing units and use tax credit set-asides to dedicate affordable rental units for vulnerable populations.
Encourage state programs to incentivize and implement best practices such as Housing First.
To most effectively centralize resources and discussions, create an interagency council on homelessness (ICH). Ensure that ICH governance structure is modeled after best practices.
Support capacity-building opportunities for supportive housing programs, including improving services and administrative capacity to bill Medicaid or partner with Medicaid providers.