Medicaid Waivers to Address Homelessness: Political Development and Policy Trajectories

This article reviews the role of Medicaid waivers in homeless policy and their emerging role as a mechanism to address homelessness. The authors evaluate the political development of waivers in housing and homeless policy over the past thirty years, and they investigate the status of current and approved waivers targeting homelessness. They then consider how waivers may shape homeless policy governance going forward (including the success of existing systems), and they address implementation and efficacy questions related to the role of health care payers in solutions to homelessness. The authors find that the scope of Medicaid waivers for addressing homelessness has always been present, but it significantly expanded after enactment of the Affordable Care Act and more notably following the COVID-19 pandemic. These expansions brought new opportunities for states to fund responses to homelessness through Medicaid social determinants of health provisions providing wraparound medical services for populations at risk of or experiencing homelessness and through time-limited coverage of direct housing costs paired with payment for essential medical services. More than one third of states have an 1115 waiver specifically targeting homelessness, with nearly one in five states including provisions that cover direct housing costs (e.g., rent). Going forward, Medicaid's involvement in homeless policy has the potential to reshape state and local responses to homelessness.