Entrenched Opportunity: Medicaid, Health Systems, and Solutions to Homelessness.

Context: As inequality grows, politically powerful healthcare institutions - namely Medicaid and health systems - are increasingly assuming social policy roles, particularly solutions to housing and homelessness. Medicaid and health systems regularly interact with persons experiencing homelessness who are high utilizers of emergency health-services, and experience frequent loss of/inability to access Medicaid services, resulting from homelessness. This research examines Medicaid and health system responses to homelessness, why they may work to address homelessness, and the mechanisms by which this occurs.

Methods: Primary data were collected from Medicaid policies and the 100 largest health systems and national survey data from local homeless policy systems to assess scope, and measure mechanisms and factors influencing decision-making.

Findings: Nearly one-third of states have Medicaid Waivers targeting homelessness and over half of the 100 largest health systems have homeless mitigation programs. Most Medicaid Waivers use local homeless policy structures as implementing entities. A plurality of health systems rationalize program existence based on the failure of existing structures.

Conclusions: Entrenched healthcare institutions may bolster local homeless policy governance mechanisms and policy efficacy. Reliance on health systems as alternative structures, and implementing entities in Medicaid Waivers, may risk shifting homeless policy governance and retrenchment of existing systems.