October 18, 2025
Introduction
We cannot address public health without talking about housing. Housing instability is considered a health-related social need (HRSN), an adverse social condition that contributes to poor health. Other HRSNs include food insecurity, a lack of transportation, and financial instability. HRSNs are a result of underlying social determinants of health (SDOH), which are the conditions and systems that shape their daily lives, such as poverty, education, and pollution. For example, providing an inhaler to a child with respiratory issues will not fully resolve their complaints if they live in an area with poor air quality, and no amount of medicine will cure a homeless person who lacks a shelter to protect them from the elements. An unequal distribution of SDOH causes individual HRSNs.[1] One 2015 study finds that SDOH and associated HRSNs can account for as much as 50% of health outcomes—just as much impact as an individual’s health behaviors and clinical care.[2] If public health programs do not address HRSNs, they neglect major root causes of health, increasing costs while missing ways to improve patient well-being.
While it is common practice to screen patients for social needs and connect them to social services, only 30 percent of hospitals and health systems have formal partnerships with community-based HRSNs providers, a gap that leaves many under-resourced patients’ needs unaddressed.[3] The HRSN/SDOH framework reflects a holistic understanding of health care and enables governments to implement a prevention-focused approach that can be both lifesaving and cost-effective, particularly for populations with complex care needs.
In particular, the United States’ housing crisis is a salient public health concern, as housing insecurity is associated with worse access to preventive and primary care.[4] One study found that housing-insecure respondents had three times higher odds of delaying care due to cost.[5] Because individuals who are low-income, women, Black or Hispanic, unmarried, and middle-aged are more likely to experience housing insecurity, addressing this issue will promote equity by reducing stark socioeconomic health disparities.[6]
Medicaid—a federally funded, state-administered health insurance for low-income families, disabled individuals, and other vulnerable populations—offers an opportunity to implement the HRSN/SDOH framework at a large scale to address housing insecurity. Medicaid enrollees are more likely to experience housing insecurity, with 57 percent of Medicaid enrollees living in a home that was inadequate or unaffordable in 2019.[7] As of June 2025, 70 million people were enrolled in Medicaid.[8] Because of the population they serve, state Medicaid administrators are uniquely positioned to create initiatives to treat HRSNs.
Medicaid is fundamentally a joint state-federal venture. Medicaid dollars represent the largest source of federal revenues for state budgets, and Medicaid represents nearly $1 out of every $5 spent on health care in the U.S.[9] Ultimately, including housing support and other services that address HRSNs into Medicaid requires cooperation between federal, state, and local governments, as well as contracted nonprofits and managed care organizations (MCO) that directly deliver health services. For example, guidance and rule-changes from the Biden administration encouraged states to incorporate housing support into Medicaid benefits.[10] Flexibility from the federal government combined with creativity and proactivity from state Medicaid administrators, driven by the belief that housing is a major factor in health outcomes that the public sector has a role in addressing, has the potential to impact millions of Americans.
Medicaid and 1115 waivers
Medicaid is a federally funded social safety net program established by the Social Security Amendments of 1965. While originally established to provide care for those receiving cash assistance, Medicaid coverage has since expanded to cover pregnant women, disabled individuals, and those who need long-term care.[11] Most notably, the Obama administration’s Affordable Care Act allowed states to expand Medicaid coverage to adults with incomes up to 138 percent of the poverty level.[12]
Medicaid is jointly funded by state and federal governments, and states have broad discretion to administer their own Medicaid programs. Congressional regulations broadly bar federal Medicaid funds from being used to directly pay room and board costs outside of stays at certain facilities like nursing homes, but in the last few years the federal government has carved out exceptions, enabling states to implement programs that provide tenancy supports and even direct rental assistance for some enrollees.[13] This positive step was led by the Biden administration, though the first Trump administration experimented with a program in North Carolina that provided housing and nutrition supports to certain Medicaid enrollees.[14] In 2021, the Centers for Medicare and Medicaid Services (CMS) under Biden released guidance for states to utilize 1115 waivers, a particular type of program exempt from certain federal mandates, to experiment with housing and nutrition assistance programs.[15] This newfound focus on HRSNs broke from the longstanding prohibition on Medicaid payments for room and board.
The CMS guidance included strict requirements concerning spending limits, the delivery of health care services, and program monitoring and evaluation. The Biden administration approved 18 new 1115 waivers that address HRSNs.[16] Oregon, Arizona, and California are among the handful of states that have implemented waivers, providing for up to six months of rent for certain Medicaid populations or short-term room and board costs during transitions from an inpatient setting.[17]
The Biden administration also made an adjustment in 2023 to exempt HRSN initiatives from an existing budget neutrality requirement, making it easier for states to launch 1115 programs.[18] CMS still limits the amount of funding a state can use for HRSN initiatives to no more than 3 percent of annual Medicaid spending, though this amounts to hundreds of millions in large states; CMS also implements spending caps above which states no longer have access to federal funds, which limits state participation.[19] While existing HRSN 1115 waivers remain untouched and valid for five years each, CMS under the Trump administration rescinded broad support for programs that address HRSNs and SDOH and is now considering them on a case-by-case basis.[20]
Evidence-based housing interventions
Medicaid-covered housing supports could include tenant rights education, one-time transition costs, and home accessibility modifications, all of which have always been permitted under federal regulations because they do not count as “room and board” costs.[21] Oregon and Arizona have begun to cover rent for up to 6 months for individuals experiencing homelessness or those transitioning from institutional care facilities to a community setting, which was newly allowed under the 2021 CMS guidance.[22] Oregon has nearly $1 billion available for housing support programs during its five-year 1115 waiver, which includes money for air conditioners, air filters, and food benefits in addition to rental assistance. Notably, $904 million is federal funding and only $71 million is state funding, demonstrating that states so far have relied on a disproportionate federal match to support these programs.[23]
Research on housing assistance programs for low-income, homeless, or frequently hospitalized adults is promising, pointing to improvements in health and reductions in hospitalizations. Individuals who receive rental assistance have threefold lower odds of reporting poor or fair self-rated health than those waiting on rental assistance.[24] One study in Chicago found that for homeless adults offered a housing intervention (transitional housing after inpatient discharge with a move to long-term housing afterwards) there were reductions of 29 percent in hospitalizations, 29 percent in hospital days, and 24 percent in emergency room visits.[25]
While studies showing correlation between housing insecurity and poor health do not prove that one causes the other, as both issues could have an underlying root cause such as financial instability, analyses of these interventions support the reasoning that stable housing is a prerequisite to good health, offering a way out of an endless cycle of homelessness and poor health.[26] However, though the chronically homeless population could greatly benefit from Medicaid-supported housing interventions, particularly because of their elevated health care costs, obstacles such as paperwork requirements, inadequate service coverage, and a lack of linkages between Medicaid and homelessness providers persist in limiting coverage.[27]
Housing interventions are also cost effective. A KPMG analysis of a pilot program in San Mateo, California estimated a return-on-investment of $1.57 in savings for every $1 spent on housing supports.[28] This cost-savings component of housing assistance is highly salient to a U.S. health care system that has some of the highest per capita costs among developed countries, yet some of the poorest patient results.[29] As some lawmakers aim to save money by rooting out alleged “fraud, waste, and abuse,” they might turn their attention towards interventions that definitively lower costs.[30] By approaching the housing crisis from multiple angles, states might reinvest health care savings in funds to expand affordable housing.[31]
Studies analyzing the effectiveness of Medicaid-specific housing initiatives are limited but show promising results. Arizona, whose Medicaid rental assistance program targets people with a serious mental illness, has seen a 31 percent reduction in emergency room visits, a 44 percent reduction in hospital stays, and an average of $5,563 in Medicaid savings per member per month since launched in 2023.[32] These findings and a broader body of research studying other housing assistance interventions, including vouchers, suggest that investing in a “housing first” approach to tackle HRSNs could yield both better health outcomes and Medicaid savings. However, state Medicaid rental assistance remains limited; for instance, individuals that drop off assistance that only lasts six months could continue to struggle without long-term support. Further, the One Big Beautiful Bill Act’s Medicaid changes are likely to reduce coverage, including work requirements, more stringent eligibility paperwork requirements, and cuts to food stamps.[33]
State-level program administration
To secure the longevity and expansion of Medicaid rental assistance programs, state and federal officials must work together. Even under a more favorable federal administration that encourages states to address HRSNs in Medicaid, state administrators face challenges in ensuring that rental assistance yields intended results.
For instance, health care and homeless services providers exist in their own siloes, each with their own policies, standard practices, and professional norms. One world is made up of the Department for Housing and Urban Development, local housing authorities, nonprofit tenancy support providers, and developers; the other is composed of CMS, state Medicaid agencies, managed care organizations, and hospitals.[34] Data-sharing and patient coordination between the two worlds is different because the individual entities in each were not designed to interact with each other.[35] Eligibility is also difficult to verify, particularly because in some states, individuals must meet certain health criteria and housing instability standards in addition to financial thresholds for Medicaid to qualify for Medicaid rental assistance.[36] This interacts with the data-sharing difficulties between the housing and health care sectors and is further impacted by new federal eligibility documentation requirements. Homeless services worker shortages and layers of contracts among homeless services providers also slow down service delivery.[37] And the current 1115 tenancy support waivers only last for five years, making them vulnerable to elimination if they are not renewed—which has become more precarious under the second Trump administration.[38]
Finally, a lack of affordable housing itself is a major obstacle to supporting Medicaid beneficiaries in maintaining housing. Nationally, there are only 24 available and affordable units for every 100 individuals earning less than 30 percent of the area median income; without subsidies, it is practically impossible for low-income individuals to find a place to live.[39] Rental assistance programs do not have the overall capacity to serve all eligible individuals, most of whom are stuck on years-long waitlists.[40] Because Medicaid rental assistance is short-term, it will likely not solve this root cause of a lack of affordable housing supply, though it can support individuals in getting back on their feet after experiencing poor health. An analysis of Oregon’s rental assistance program found that services like short-term hotel and motel stays were used more frequently than anticipated, reflecting a lack of affordable housing that could serve as a long-term placement for patients.[41] State Medicaid administrators might consider this obstacle and their limited role in addressing the housing crisis by positioning Medicaid rental assistance programs in a more transitory role.
Conclusion
California Governor Gavin Newsom said in his 2020 State of the State address, “Doctors should be able to write prescriptions for housing the same way that they do for insulin and antibiotics.”[42] The interest in Medicaid rental assistance emerged from the understanding that an individual’s environment and stability in a non-medical sense greatly affect their health outcomes. Housing encourages greater autonomy for vulnerable enrollees and better health overall while decreasing costs.
However, the pilot programs that exist are few and far between, and the Trump administration’s broad Medicaid changes will decrease coverage, threatening the gains that these initiatives are making. Real progress at the intersection of public health and housing can only be accomplished at scale through federal, state, and local cooperation. Federal guidance and funding can create flexibility for state governments to experiment with new programs, leaning on services operated by local partners.
Medicaid, despite its broad reach, has a limited ability to effect change when a major root issue is the unavailability of affordable housing itself. CMS guidance from 2022 stated that “Medicaid-covered affordable housing supports should supplement, but not substitute existing housing funds”; Medicaid may be better situated to address the short-term housing needs of those transitioning out of institutional care facilities, for instance.[43] A commitment to improving health nationwide through addressing HRSNs and SDOH must recognize that poor health is a reflection of multi-dimensional poverty and disenfranchisement that can only be improved by cross-cutting policy.
Photo Credits: https://www.pexels.com/photo/close-up-photo-of-a-stethoscope-40568/
Works Cited
[1] Whitman, Amelia, Nancy De Lew, Andre Chappel, Victoria Aysola, Rachael Zuckerman, and Benjamin Sommers. 2022. “Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts.” https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf, 2.
[2] Hood, Carlyn, Keith Gennuso, Geoffrey Swain, and Bridget Catlin. 2016. “County Health Rankings Relationships between Determinant Factors and Health Outcomes.” American Journal of Preventive Medicine 50 (2). https://doi.org/10.1016/j.amepre.2015.08.024, 132.
[3] Artiga, Samantha, and Elizabeth Hinton. 2018. “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity.” The Henry J. Kaiser Family Foundation. The Henry J. Kaiser Family Foundation. May 11, 2018. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/.
[4] Martin, Patricia, Winston Liaw, Andrew Bazemore, Anuradha Jetty, Stephen Petterson, and Margot Kushel. 2019. “Adults with Housing Insecurity Have Worse Access to Primary and Preventive Care.” The Journal of the American Board of Family Medicine 32 (4): 521–30. https://doi.org/10.3122/jabfm.2019.04.180374, 523–524.
[5] Ibid. 524.
[6] Ibid. 523.
[7] Corallo, Bradley. 2021. “Housing Affordability, Adequacy, and Access to the Internet in Homes of Medicaid Enrollees | KFF.” KFF. September 22, 2021. https://www.kff.org/medicaid/housing-affordability-adequacy-and-access-to-the-internet-in-homes-of-medicaid-enrollees/.
[8] Medicaid. 2024. “October 2024 Medicaid & CHIP Enrollment Data Highlights | Medicaid.” Medicaid.gov. 2024. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights.
[9] Elizabeth Williams, Anna Mudumala, Robin Rudowitz, and Alice Burns. 2025. “Medicaid Financing: The Basics | KFF.” KFF. January 29, 2025. https://www.kff.org/medicaid/medicaid-financing-the-basics/.
[10] Hinton, Elizabeth and Amaya Diana. 2024. “Section 1115 Medicaid Waiver Watch: A Closer Look at Recent Approvals to Address Health-Related Social Needs (HRSN) | KFF.” KFF. March 4, 2024. https://www.kff.org/medicaid/section-1115-medicaid-waiver-watch-a-closer-look-at-recent-approvals-to-address-health-related-social-needs-hrsn/.
[11] Centers for Medicare & Medicaid Services. 2023. “History.” http://www.cms.gov. Centers for Medicare & Medicaid Services. 2023. https://www.cms.gov/about-cms/who-we-are/history.
[12] Harker, Laura, and Breanna Sharer. 2024. “Medicaid Expansion: Frequently Asked Questions.” Center on Budget and Policy Priorities. June 14, 2024. https://www.cbpp.org/research/health/medicaid-expansion-frequently-asked-questions-0.
[13] Reyneri, Dori Glanz. 2023. “How States Can Use Medicaid to Address Housing Costs.” Shelterforce. June 5, 2023. https://shelterforce.org/2023/06/05/how-states-can-use-medicaid-to-address-housing-costs/.
[14] “All-State Medicaid and CHIP Call.” 2022. https://www.medicaid.gov/sites/default/files/2022-12/covid19allstatecall12062022.pdf, 8–12.
Diana, Amaya, Elizabeth Hinton, and Robin Rudowitz. 2025. “Section 1115 Waiver Watch: Early Signs Point to New Directions under Trump Administration | KFF.” KFF. May 2, 2025. https://www.kff.org/medicaid/section-1115-waiver-watch-early-signs-point-to-new-directions-under-trump-administration/.
[15] Costello, Anne Marie. 2021. “RE: Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH).” Centers for Medicare & Medicaid Services. January 7, 2021. https://www.medicaid.gov/sites/default/files/2022-01/sho21001_0.pdf.
[16] Diana et al. “Section 1115 Waiver Watch.”
[17] Hinton and Diana. “Section 1115 Medicaid Waiver Watch.”
[18] Diana et al. “Section 1115 Waiver Watch.”
[19] Centers for Medicare & Medicaid Services. 2022. “Addressing Health-Related Social Needs
in Section 1115 Demonstrations.” December 6, 2022. https://www.medicaid.gov/sites/default/files/2023-01/addrss-hlth-soc-needs-1115-demo-all-st-call-12062022.pdf, 18.
[20] Snyder, Drew. 2025. “CMCS Informational Bulletin: Rescission of Guidance of Health-Related Social Needs.” Centers for Medicare & Medicaid Services. March 4, 2025. https://www.medicaid.gov/federal-policy-guidance/downloads/cib03042025.pdf.
[21] Costello. “RE: Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH).”
[22] Reyneri. “How States Can Use Medicaid to Address Housing Costs.”
[23] Botkin, Ben. 2024. “Oregon Health Authority to Launch New Rental Assistance Program in November.” OPB. October 28, 2024. https://www.opb.org/article/2024/10/28/oregon-health-authority-rental-assistance-program-medicaid-housing/.
[24] Keene, Danya E., Linda Niccolai, Alana Rosenberg, Penelope Schlesinger, and Kim M. Blankenship. 2020. “Rental Assistance and Adult Self-Rated Health.” Journal of Health Care for the Poor and Underserved 31 (1): 325–39. https://doi.org/10.1353/hpu.2020.0025, 331.
[25] Tsega, Mekdes, Corinne Lewis, Douglas Mccarthy, Tanya Shah, and Kayla Coutts. n.d. “ROI Calculator for Partnerships to Address the Social Determinants of Health Review of Evidence for Health-Related Social Needs Interventions.” https://www.commonwealthfund.org/sites/default/files/2019-07/ROI-EVIDENCE-REVIEW-FINAL-VERSION.pdf, 1.
[26] Keene et al. “Rental Assistance and Adult Self-Rated Health.”
[27] Thompson, Frank J, Jennifer Farnham, Emmy Tiderington, Michael K. Gusmano, and Joel C. Cantor. 2021. “Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States.” The Milbank Quarterly 99 (3): 648–92. https://doi.org/10.1111/1468-0009.12514.
Willison, Charley E., Denise Lillvis, Amanda Mauri, and Phillip M. Singer. 2021. “Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness.” Journal of Health Politics, Policy and Law 46 (6). https://doi.org/10.1215/03616878-9349142.
[28] Tsega et al. “ROI Calculator for Partnerships to Address the Social Determinants of Health,” 3.
[29] Wager, Emma, Matthew McGough, Shameek Rakshit, Krutika Amin, and Cynthia Cox. 2024. “How Does Health Spending in the U.S. Compare to Other Countries? – Peterson-Kaiser Health System Tracker.” Peterson-Kaiser Health System Tracker. January 23, 2024. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/.
[30] Krawczeniuk, Borys. 2025. “Bresnahan, Region’s Other GOP Congressmen Back ‘One Big Beautiful Bill’ in House.” WVIA Public Media. WVIA. May 22, 2025. https://www.wvia.org/news/local/2025-05-22/bresnahan-regions-other-gop-congressmen-back-one-big-beautiful-bill-in-house.
[31] Dohler, Ehren, Peggy Bailey, Douglas Rice, and Hannah Katch. 2016. “Supportive Housing Helps Vulnerable People Live and Thrive in the Community | Center on Budget and Policy Priorities.” Center on Budget and Policy Priorities. May 31, 2016. https://www.cbpp.org/research/supportive-housing-helps-vulnerable-people-live-and-thrive-in-the-community.
[32] Snyder, Jami. 2021. “RE: AHCCCS Housing and Health Opportunities (H2O) 1115 Waiver Amendment Request.” Arizona Health Care Cost Containment System. May 26, 2021. https://www.azahcccs.gov/Resources/Downloads/HousingWaiverRequest/AHCCCSHousingHealthOpportunitiesH2OWaiverAmendment.pdf, 9.
[33] Krawczeniuk. “Bresnahan, Region’s Other GOP Congressmen Back ‘One Big Beautiful Bill’ in House.”
[34] Thompson et al. “Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness,” 664.
[35] Ibid. 664.
[36] Ibid. 666–668
[37] Ibid. 669–670
[38] Ibid.
[39] Keene et al. “Rental Assistance and Adult Self-Rated Health,” 332–333.
[40] Keene et al. “Rental Assistance and Adult Self-Rated Health,” 331.
[41] Gill, Monique, Alyssa Craigie, Megan Holtorf, Ben Gronowski, and Catherine J Livingston. 2025. “Participant Needs, Service Utilization, and Costs in a Medicaid Housing Pilot Program.” JAMA Network Open 8 (5): e2512405–5. https://doi.org/10.1001/jamanetworkopen.2025.12405, 7–8.
[42] “Governor Newsom Delivers State of the State Address on Homelessness.” 2020. California Governor. February 19, 2020. https://www.gov.ca.gov/2020/02/19/governor-newsom-delivers-state-of-the-state-address-on-homelessness/.
[43] “All-State Medicaid and CHIP Call,” 13.
Policy & Political Review 