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If Housing Is a Health Care Issue, Should Medicaid Pay the Rent?

(NY TIMES) Lucy Tompkins, June 26, 2022

With federal housing money in short supply, state and local authorities are looking to health dollars to help tackle homelessness.

Living on the streets, Hanif Hightower learned which Philadelphia shelters were likely to have an open bed during the cold months or where he could get a meal or a hot shower. But his resourcefulness had limits. Addicted to crack cocaine and struggling with clinical depression, he cycled in and out of jail and temporary rehab programs, returning to the streets each time he was released. Years passed this way. Then one day, in May 2019, an outreach worker for a local nonprofit offered him a way out: an apartment of his own, no strings attached.

Hightower, who is now 39, was on a list he didn’t know existed: the homeless people in Philadelphia most frequently found in the city’s shelters or jail cells. Being on this list made Hightower eligible for something called supportive housing, which combines services like counseling and job training with keys to a home.

For decades, research has shown that this combination of housing and services is the most effective way to provide for people experiencing chronic homelessness, who make up about a quarter of the nation’s homeless population and have the most acute needs. People are considered chronically homeless if they have a documented disability — including mental illness or addiction — and have been without housing for at least a year. Both Presidents George W. Bush and Barack Obama put money into creating more supportive-housing beds, and since 2007, when the government started keeping track, the number nationwide has more than doubled. Between 2007 and 2016, chronic homelessness declined by a third.

But money for this kind of housing flatlined during the Trump administration, and the number of people enduring chronic homelessness has been rising — up by 42 percent between 2016 and 2020, the last time there was a full national count. While the Department of Housing and Urban Development has modestly increased spending on homelessness programs that fund supportive housing from year to year, about 90 percent of the money goes just to keep existing programs up and running.

Faced with this HUD funding gap, some local officials are eyeing an unlikely source: Medicaid. The government-funded health insurance for people with low incomes and disabilities was not intended to provide housing. But some argue that it has a role to play because the health issues of the chronically homeless can’t be treated without stable housing.

In the last decade Medicaid has inched toward acknowledging the interconnectedness of housing and health. It has encouraged more state Medicaid programs to cover housing-related costs like furniture or security deposits — basically everything except paying the rent. Some states, like Arizona, have shown remarkable success by using state Medicaid funds for supportive housing, and they are now asking permission to use federal Medicaid money, too. It’s an appealing option for states because unlike rental assistance from HUD, Medicaid is an entitlement, and its budget expands to accommodate everyone who qualifies. No one has to ask Congress for funds.

Philadelphia undertook one of the earliest experiments in transforming Medicaid funds into support for housing. Hightower is one of its beneficiaries.

Source: NY Times