States prepare to use Medicaid for rental assistance for the first time.
For more than a decade, researchers and advocates have argued that housing is a fundamental part of health care. Beginning this fall, for the first time, federal Medicaid dollars will start going toward paying some people’s rent.
It’s a significant policy development. Congressional regulations have long barred Medicaid funds from being used to pay for rent for people staying outside of nursing homes or medical facilities like hospitals. And while some states have used philanthropy or state-based Medicaid funding to pay for housing, those pots of money were extremely limited. Now, with rates of unsheltered homelessness reaching record highs in 2023, and rents growing to their most unaffordable levels ever, some states are preparing to use federal Medicaid dollars in the hopes that health will improve as housing stabilizes.
The Biden administration has made this possible through a longstanding Medicaid waiver program that allows states to test out new Medicaid ideas.
For nearly a decade, the federal agency that runs Medicare and Medicaid has been warming to the idea that housing could be health care. Since 2015, the Centers for Medicare and Medicaid Services has affirmed that Medicaid funds could go toward services that help people move into new housing, like moving costs or security deposits. In 2018, an influential federal commission told Congress that, while it’s long been known that poor housing conditions can worsen health outcomes, more recent data suggests that providing supportive housing to chronically homeless people also reduces ER visits in ways that case management or other outpatient services does not.
The “housing is health care” mantra got another major boost during the pandemic, when calls to stay at home to avoid catching and spreading disease grew louder and more urgent. Communities that halted evictions saw lower rates of Covid-19, a stark example of how access to housing is linked to health.
And in 2022, the Biden administration encouraged states to consider using Medicaid dollars for “health-related social needs” like housing, nutrition, and transportation — part of a broader White House effort to address social determinants of health.
“We think it’s incredibly exciting,” Dan Tsai, the deputy administrator and director of the Center for Medicaid and CHIP Services, told me. “This is a firm, clear stance, and we spent about a year of this administration working through how to define and create with guardrails the role of Medicaid in housing and nutrition.”
Tsai said their conclusion was based on both common sense and evidence-based practices, that for some groups of people, throwing “the same old against the wall” just would not drive better health.
Jeff Olivet, the executive director of the US Interagency Council on Homelessness, similarly told me he sees the ability to use Medicaid dollars for purposes like rent as “a real potentially game-changing set of supports” to help people exit homelessness and then stay stably housed.
Not everyone thinks this possibility is a good move for Medicaid, an already strained federal program with notoriously low reimbursement rates for doctors that disincentive treating patients. Just 3 percent of a state’s Medicaid spending can go toward “health-related social needs” like housing, but that could still easily amount to billions of dollars annually. Others doubt the claims that paying for housing will drive down overall government spending.
Sherry Glied, a dean and professor of public service at New York University, warned recently of “mission creep” in health systems, arguing that having hospitals and other medical institutions focus on the provision of social services could be a “dangerous distraction” from their core mission of serving patients, and one that policymakers should discourage.
The failure of Congress to dedicate more money to agencies like the Department of Housing and Urban Development is how we got to this point, said senior policy director for National Health Care for the Homeless Council Barbara DiPietro.
“More and more states are desperate to find any help, and that’s why they’re turning to Medicaid because they’re not getting real assistance from HUD,” she told Vox. “And Medicaid is an entitlement program while housing is not.”
The new pilot program authorizes Medicaid dollars for up to six months of rent and could herald much bigger shifts down the line if state results show improvements in health outcomes or cost-savings. It could also augur much larger shifts across state and federal governments to bring about more comprehensive visions of health care.
Arizona and Oregon will go first
The federal government has approved a handful of states to use waivers to finance rental assistance for up to six months. The first states to put this into practice are Arizona starting this October, and Oregon this November. The two are planning to target different subpopulations of Medicaid beneficiaries, and both are scrambling to figure out how to make this all possible given shortages of affordable housing.
Oregon’s Medicaid program currently provides coverage to roughly 1.5 million Oregonians, and the state estimates 125,000 of those people will soon be eligible to qualify for rental assistance under this new waiver. Oregon is opting to target beneficiaries at risk of becoming homeless, in effect using the funds as a preventive tool to help stave off the devastating economic, physical, and mental harms that come with losing one’s home. Individuals will literally get a “prescription” for housing.
To refer eligible people, the state will look to partner with community-based organizations. Housing nonprofits that get involved in this work will need to train their caseworkers as certified community health workers.
“It’s a little scary for them, because they don’t want to become medical providers in the same way a doctor doesn’t want to become a housing provider,” Dave Baden, the deputy director of Oregon’s Health Authority, told me. “We can’t medicalize the housing world.”
Over time, Baden hopes the state will be able to use this kind of funding to pay rent for people living on the streets, but he thinks Oregon needs to increase its housing supply first.
“This Medicaid waiver is not magically going to make housing exist, and I feel like we would have gummed our work to focus on those who were houseless to start with,” he said. “I don’t want to create a false benefit where we say, ‘Hey, Amy, here’s six months of rent, oh, I’m sorry I don’t have any housing for you.’”
Arizona, by contrast, is planning to target people designated as having a serious mental illness, building off a similar but much smaller state program that subsidizes rent for about 3,000 Medicaid beneficiaries each year.
That program, which is not time-limited, has been considered an extraordinary success: State data showed financing rent led to a 31 percent reduction in ER visits, a 44 percent reduction in inpatient hospital stays, and savings overall to Arizona’s Medicaid program of more than $5,500 per member per month.
“That’s one of the big reasons we felt so strongly about pursuing [the 1115 waiver] and being able to federalize some of that work,” said Alex Demyan, an assistant director with Arizona’s Health Care Cost Containment System. “We’re in a unique and advantageous position because we have a runway.”
With a significant affordable housing shortage, Arizona is looking to authorize a new kind of housing provider to help with supply issues, known as an “enhanced shelter.” These will be new organizations that contract with Medicaid to provide mostly congregate housing, and get reimbursed on a per-diem basis.
Demyan sees the opportunity to use Medicaid for rent as potentially transformative. “It’s a huge deal; this kind of cutting-edge work is really what makes working in Medicaid so rewarding in a lot of ways,” Demyan told me. “We get to play around in the sandbox of health policy and do things differently. I don’t think it’s any secret that there are better ways that we can do things.”
The fine print
As Oregon and Arizona — as well as other states that have applied to use federal Medicaid dollars for rent like New York, California, Hawaii, and Washington — prepare for the opportunity, they are hoping to build collaboration between government agencies, private companies, and community nonprofits that historically have rarely worked together.
“There has to be some system-level linkage between the housing and homelessness systems and the medical services; otherwise, we are very concerned about what will happen to people at the end of their six months,” said Marcella Maguire, the director of Health Systems Integration for the Corporation for Supportive Housing. “This funding will put more people into an already underresourced system. Long-term, I think it will reduce strain, but short-term it will increase strain.”
DiPietro, of the National Health Care for the Homeless Council, said she has some worries about how states might use this new Medicaid opportunity to jump people ahead of those waiting in the established line for subsidized housing, or even how receiving Medicaid funding could threaten their eligibility for other homeless services programs.
Olivet, of the US Interagency Council on Homelessness, said the eligibility issue is “certainly on our radar screen” and that his agency wants to serve as “connective tissue” to ensure federal policies are implemented in a strategic way. But state Medicaid departments have a “tremendous role” to play in shaping the specifics of each waiver, Olivet added, and coordination between health and housing providers “is where the real work will happen.”
Richard Cho, a senior housing and services adviser at HUD, told me there’s legal precedent for these kinds of eligibility concerns and that his agency is working closely to provide technical assistance to states.
When asked if he thinks Medicaid could one day fund rent for longer than six months, Tsai, of CMS, emphasized the importance of getting data first from these pilots. “It’s a huge first step,” he said. “No one believes Medicaid is here to supplant or replace the role of housing and nutritional agencies, but at the same time, clearly there’s a better way.”
The cost-effectiveness gamble
One undoubtedly appealing aspect of the policy proposal is that by paying for housing, Medicaid spending could ultimately go down over time, similar to how it worked with Arizona’s smaller program. It’s well-documented that people experiencing homelessness use significantly more health care resources on average than people with stable housing.
Proponents point to some encouraging research to back the idea, like a California permanent supportive housing program that reduced the use of expensive medical care and resulted in a roughly 20 percent net savings of total public cost. Another program in New York reduced inpatient hospital days by 40 percent, inpatient psychiatric admissions by 27 percent, and ER visits by 26 percent.
But other research evidence is less persuasive. One literature review published in 2022 found “mixed and mostly low-certainty evidence” that interventions to drive housing affordability and stability led to improved adult health outcomes. Another study published this month found participants had no difference in ER visits, inpatient use, or chronic disease control, but did report real mental health improvements, particularly from housing providers who showed them compassion.
“The success of health care–based housing interventions must not be judged solely by short-term chronic disease control and changes in health care use,” the study authors argued. “Given the complexity of US health care systems, innovations often struggle to demonstrate return on investment … [and] had our evaluation measured only health care use and chronic disease control, we would have overlooked the strong relational connection between patients and their advocates and missed the housing program’s possible effects on the social burden of disease in the current epidemic of social isolation in the US.”
Paula Lantz, a professor of health policy at the University of Michigan, told me she’s very supportive of Medicaid programs getting into housing interventions but has doubts about whether it will ultimately reduce costs, and notes there are moral challenges of really studying that question over time. “If you have a bunch of people in a control group who you know need services and help and you’re using them for research, the longer [they’re denied help], the larger the ethical issues there are,” she said.
Lantz says she worries that if the waivers don’t save Medicaid money, critics might seize on that to attack health care spending more broadly. Demyan, the assistant director with Arizona’s state Medicaid program, told me he would not be surprised if there’s “an initial bump in increase in cost of care” as states transition to this new model.
And what if it’s not, ultimately, cost-effective?
Tsai, the federal Medicaid official, said he’s confident there are “inefficiencies” in the system, and that governments can use funding in “wiser” ways to target certain groups of people. He also stressed the need to think about public savings over time, to remember some that many of the country’s biggest health disparities didn’t happen overnight.
Still, Tsai acknowledges, there is currently a lot of “unmet need” in health care, and saving money isn’t the only thing that matters. “That is why we want to evaluate very objectively,” he said, “and why we want to look at both health outcomes and cost.”
Congress should have approved Ukraine aid yesterday.
As the Senate considered approving $61 billion to Ukraine this weekend, Donald Trump published an all-caps rant making his opposition clear.
“FROM THIS POINT FORWARD, ARE YOU LISTENING U.S. SENATE(?), NO MONEY IN THE FORM OF FOREIGN AID SHOULD BE GIVEN TO ANY COUNTRY UNLESS IT IS DONE AS A LOAN,” he wrote on his Truth Social platform on Friday.
The Senate rejected Trump’s order, passing the bill Tuesday morning 70-29. But the bill still needs to clear the Republican-controlled House, where the former president’s influence has proven powerful in the past. Indeed, House Speaker Mike Johnson (R-LA) has already stated opposition to the Senate aid bill.
Which makes now a good time to remind ourselves that the objections to Ukraine aid are absurd.
Supporting Ukraine’s defense is one of the single easiest foreign policy calls of my lifetime, a policy that has both protected Ukrainians from Russian slaughter and advanced America’s geopolitical interests in Europe. It has done so at a relatively low cost in dollars and zero cost in American lives. There is nothing to gain by abandoning it, and everything to lose.
Let’s start with the most basic point: Russia’s invasion of Ukraine was an act of evil. Since the war’s beginning, the Russian government and its propaganda outlets have openly announced that their war aim is to seize Ukrainian territory and subjugate its government to the Kremlin.
This was evident not just in words, like President Vladimir Putin’s recent interview with Tucker Carlson, but also in deeds. The war began with a failed lightning thrust targeting the Ukrainian capital in Kyiv, during which Russian forces engaged in horrific atrocities: executing entire families and indiscriminately bombing populated areas.
There are many problems with the Ukrainian government it is an imperfect democracy whose battlefield performance has worsened as the war degenerated into a kind of stalemate. Its maximalist stated objective of winning all its territory back through force may very well be impossible.
But the justice of its basic cause is unimpeachable. Ukraine is fighting a classic war of self-defense, a country protecting its people and its sovereignty from a large neighboring dictatorship that wishes to crush it.
And the success of Ukraine’s war hinges crucially on American support.
Why American aid is so important
The United States, labeled “the arsenal of democracy” during World War II, is playing that role again today. America is providing Ukraine with advanced weapons systems, like HIMARS mobile artillery, and ammunition that neither the Ukrainians nor European allies can get to the field on their own in sufficient numbers.
Currently, American funding has been effectively suspended due to the holdup in Congress. We can already see the consequences: Ukrainian fighters, working with a third of the ammunition they need to fight, being forced to retreat.
What happens if the aid dries up indefinitely? Vox’s Josh Keating reported on this extensively, and his sources painted a grim picture:
“A failure to supply military aid to Ukraine isn’t going to cause an immediate Russian victory, but it is going to change the character of the war,” said Franz-Stefan Gady, a defense analyst with the Center for a New American Security who has made multiple research trips to the front lines in Ukraine. Gady said that while Ukraine’s military has traditionally been an “artillery dominant military force,” without shells for those guns, “they would likely start pursuing more asymmetric strategies. That is, withdrawing from certain sectors of the front lines into urban settlements, trying to draw Russian forces into urban combat.”
This scenario is … a grim prospect for Ukraine’s civilians. Urban combat always has an extremely high civilian death toll and given the heavy-handed tactics employed by the Russian military, the list of Ukrainian cities and towns entirely decimated by war — Mariupol, Bakhmut — would likely grow.
Even if you see the US government as human rights hypocrites or don’t believe protecting Ukrainian lives is America’s concern, the outcome of this war directly affects US interests.
Currently, the fighting is mostly in Ukraine’s more rural eastern half. If it moves west, into the heart of Ukraine’s largest cities, it moves closer to nearby NATO treaty allies. The odds of a scary spillover incident — of a miscalculation that could trigger a wider war between Russia and the American-led alliance — would rise accordingly.
At present, the best way to limit the risk of war between nuclear-armed powers is to help Ukraine keep Russia physically further away from NATO borders. Continuing aid, by contrast, is unlikely to trigger a direct escalation between Russia and the United States — as the past two years of fighting have shown.
Global security is worth a lot more than $61 billion
Again, it is unlikely that Ukraine will simply defeat Russia and win back all of its territories. The most likely scenario for the war’s end is — like most wars — negotiation.
But as in any negotiation, leverage matters. Political scientists often describe war as itself a process of bargaining, one in which it’s rational for states to continue fighting until the balance of power between the two sides is clear. To bring about a settlement in which Russia’s aggression is punished rather than rewarded, Ukraine needs to be strong on the battlefield.
And if Russia is rewarded, it has an incentive to engage in more provocations on NATO’s frontier. A world where Ukraine is forced to the table by American abandonment is a vastly more dangerous one.
Sixty-one billion dollars sure sounds like a lot of money. But the amount it purchases — sovereignty for an embattled democracy, civilian safety from Russian massacres, and decreasing the odds of a terrifying wider war — is easily worth the price. For Congress to do anything but rush it through would be an appalling betrayal not just of Ukraine, but of America.
This story appeared originally in Today, Explained, Vox’s flagship daily newsletter. Sign up here for future editions.
Is the situation really so dire for Democrats? Tuesday’s special election will give us a clue.
Even the race to replace George Santos in Congress is packed with drama.
The historic expulsion of Santos in December has prompted a rare special election in a swing congressional district that could prove a bellwether for November. A Democratic win in New York’s Third Congressional District, which Joe Biden won by 8 in 2020, would further shrink the already tenuous Republican majority and make it that much easier for Democrats to win back the House. A Republican hold, though, would be a huge boost for the GOP in the Long Island district located on the edge of New York City. After all, if they can survive George Santos’s scandals in the suburbs, perhaps they can survive Donald Trump’s too.
Who are the candidates?
Democrats are running perhaps their strongest possible candidate in the district: former Rep. Tom Suozzi. Suozzi represented the seat for three terms before giving it up in 2022 for a long-shot primary challenge to incumbent Gov. Kathy Hochul. Suozzi is a longtime local politician who is well-liked and has cultivated a moderate image. In contrast, the Republican candidate, Mazi Pilip, is a relative newcomer to politics, albeit one with a sterling biography. A first-term member of the county legislature and a mother of seven, Pilip is an Ethiopian Jew who served in the Israel Defense Forces before immigrating to the United States with her husband. She has run a cautious, sheltered campaign, dodging reporters and holding relatively few public events.
What are the polls saying?
The limited public polling available shows that the race will be very close. A recent Newsday/Siena College poll shows Suozzi with a narrow 48 percent to 44 percent lead, and one from Emerson College gives the Democrat an almost identical 50 percent to 47 percent margin. Both polls show Biden being deeply unpopular in the district with an approval rating under 40 percent, and the Siena poll shows Donald Trump winning a head-to-head matchup against Biden by a 47 percent to 42 percent margin in the district.
Why is this close?
First of all, it’s close because no one particularly cares about George Santos anymore. The disgraced former Congress member hasn’t been a major issue in the election, and local Republicans have done a good job of distancing themselves from him. Most called for Santos to be ousted from Congress over a year ago, and now Santos is simply viewed by voters as an aberration.
But there are also dynamics on the ground in the district that make it different from other suburban areas where Democrats have surged in the Trump era. Instead, it was a place where Republicans had made significant gains in local elections in recent years. Steve Israel, who represented a similar district in Congress for eight terms before retiring in 2016, told Vox that “it had strongly over-performed for Republicans and underperformed for Democrats, even while Democrats have been winning handily in suburbs across the rest of the country.”
In particular, Israel pointed to anxiety about crime and migrants in a district that borders New York City. “When progressives talked about defunding the police and cashless bail, that pushes a lot of moderate suburban voters to Republicans,” said the former Democratic representative. “A lot of suburban voters are either cops or know cops.” Further, he pointed out that “a lot of suburban voters [in the district] commute to New York City. So you’ve had this perfect storm of headlines on crime. And then add to that more recent headlines about migrants being bused into Manhattan. And that has triggered anxieties in a population that is generally moderate, that is generally progressive on social issues.”
These trends were clear in 2022 when Republicans overwhelmingly carried the district. Lee Zeldin, the GOP nominee for governor, won it by double digits as Republicans picked up a number of House seats in New York while having a disappointing night elsewhere.
The other key factor keeping things close is the strength of the Nassau County Republican Party. It’s one of the last political machines in the country and has a strong get-out-the-vote operation that has been credited with helping Republicans win an array of local races in recent years and creating a strong bench in the district. There’s the belief among Republicans that, if the race is close, it will carry Pilip to victory, despite the fact that Suozzi and his allies have outspent her on TV and radio ads.
What does this mean nationally?
At the most basic level, a Democratic win on Tuesday reduces the Republican majority on Capitol Hill to just three votes. With House Speaker Mike Johnson struggling to keep his conference united, this will make his task that much harder as Congress faces yet another government funding deadline in March — let alone as he deals with contentious issues like aid to Ukraine and immigration reform. A Republican win would give him just a little extra breathing room and provide a morale boost.
Further, Democrats see their path to taking back the House as winning the 18 GOP congressional districts that Joe Biden won in 2020. This is one of them, and if they can’t pick up this one, it bodes ill for their prospects in the other 17 districts — particularly the six other districts in New York and New Jersey.
At a broader level, it becomes a referendum on how much the migrant crisis will be an issue in 2024. As unprecedented numbers of undocumented immigrants enter the United States, straining social services in cities across the country, the issue has become increasingly front of mind for voters. Republicans have harped on it throughout the campaign, forcing Suozzi to go on the defensive about it. With the special election being the only one held in a competitive seat before November’s presidential election, the result will be a key data point moving forward on the topic.
It will also be a measuring stick for how much abortion will continue to be a live political issue now that more than a year has passed since the Supreme Court overturned Roe v. Wade. Suozzi has run as a stalwart pro-abortion-rights candidate, while Pilip has broadly labeled herself as “pro-life” while dodging more detailed questions about how she would vote on Capitol Hill.
And as Democrats respectively stay focused on abortion and Republicans on immigration, the result on Tuesday will be a clear indicator which of the two issues voters are more focused on ahead of November.