Medicaid and health systems are playing a growing role in providing housing and other services to people experiencing homelessness, investments that could bolster - or eventually overtake - existing governance structures, new Cornell research finds.
As of August 2023, nearly one-third of states had Medicaid waivers targeting homelessness, and more than half of the 100 largest health systems had homeless mitigation programs, according to the research - the first to document the scope of their involvement in solutions to homelessness.
Most states with Medicaid waivers have partnered with longstanding nonprofit networks known as Continuums of Care - funded by the U.S. Department of Housing and Urban Development (HUD) - to provide services. But many health systems say they are taking action due to the failure of local governments and the chronically underfunded Continuums of Care to address rising homelessness, which affects millions of Americans annually and worsened during the pandemic.
"Health care actors are making significant investments that could help prop up the existing homeless policy system, which has an enormous amount of expertise," said Charley Willison, assistant professor in the Department of Public Ecosystem Health, in the College of Veterinary Medicine. "On the flip side, if this trend continues, it could lead to more spending cuts by HUD for housing and homelessness, which would not be helpful."
Willison is the lead author of "Entrenched Opportunity: Medicaid, Health Systems, and Solutions to Homelessness," published Sept. 27 in the Journal of Health Politics, Policy and Law, in a special issue focused on Medicaid's 60th anniversary in 2025. Co-authors are Naquia Unwala, a research associate in the Department of Public and Ecosystem Health (CVM) and a member of Willison's Public Health Governance Lab; and Kasia Klasa, a doctoral student at the University of Michigan.
Since the Affordable Care Act's passage in 2010, some health care policymakers have viewed expansions of Medicaid - the primary insurer for low-income Americans and those experiencing homelessness - as a potential "silver bullet" for ending homelessness. But a lack of coordination between local governments, the Continuum of Care program and state governments has limited progress, Willison reported in her 2021 book, "Ungoverned and Out of Sight: Public Health and the Political Crisis of Homelessness in the United States."
More recently, the Centers for Medicare and Medicaid Services for the first time allowed states to use up to 3% of their Medicaid budgets for direct housing costs, further recognizing housing as a key social determinant of health. The extent to which states have implemented related programs was unknown, as was the level of interventions led by health systems whose bed capacity, staffing and costs are challenged by homelessness.
To investigate those questions, the research team conducted a national survey of more than 200 Continuums of Care. Nearly half said Medicaid expansion had helped people experiencing homelessness, but more than half also reported administrative burdens and challenges accessing housing resources.
The scholars also collected approved Medicaid waivers (called 1115 and 1915 waivers) with at least one provision targeting homelessness. They found 14 states have adopted them, including 11 with among the highest rates of homelessness and two - Florida and North Carolina - that had not expanded Medicaid at the time the study was conducted in 2023 (but North Carolina since has). Most of the waivers assigned Continuums of Care as implementing entities, with the rest engaging health systems.
Reviewing the websites of the 100 largest health systems, the team identified 54 with formal programs to address high-risk homeless populations - citing as drivers, like Medicaid, health equity and costs. But surprisingly, Willison said, they also directly blamed the existing governance system's failure to address the problem.
"American cities have been struggling with chronic homelessness for decades," one health system's housing director wrote. "I share others' frustration when I constantly see city leaders pledge to eliminate homelessness, but the problem continues to get worse."
Given those sentiments, Willison said, it is notable that a majority of states with waivers are looking to Continuums of Care to implement Medicaid waiver programs. Despite their expertise, Willison said, Continuums of Care lack governing authority, except in some big cities that have partnered with them, and resources. Health care institutions including Medicaid and health systems, by comparison, are longstanding, entrenched actors that wield considerable political power in shaping U.S. health and social policy.
Growing involvement by Medicaid and health systems could help Continuums of Care fill gaps, Willison said, or ultimately reshape the entire governance system, potentially causing HUD to continue pulling back.
"Because U.S. policy is structured around health care institutions, they're the ones that have political power to make big changes in social policy, and while not ideal, it's at least a way to get something done," Willison said. "In the best case, their involvement would help raise awareness that boosts HUD funding, but there is potential for retrenchment."
The research was funded in part by Poverty Solutions at the University of Michigan and the National Institute of Mental Health.
