What the Supreme Court’s Health Reform Decision Means for Tenants of Supportive Housing

The Supreme Court’s ruling to uphold the Affordable Care Act was an historic win for uninsured Americans. While most media coverage has focused on the individual insurance mandate, which requires all Americans who can afford it to have health insurance, maintaining the constitutionality of Medicaid expansion was also a major victory. So what’s next and what does this mean for tenants of supportive housing?

Looking ahead, Medicaid will be a vital part of financing the services for tenants of supportive housing.  In the past, a significant subset of people in supportive housing were not eligible for Medicaid, including people with a substance use disorder as a primary diagnosis, people with chronic but not serious physical illnesses, and people with a mental illness or cognitive impairment that does not qualify as a serious mental illness or disability. The Affordable Care Act made most of these men and women eligible by expanding Medicaid to people with incomes below 138% (with 5% income disregard) of the federal poverty level (FPL), regardless of illness or disability.

The Court’s ruling last week declared that this expansion of Medicaid is constitutional, including the federal government’s incentives for states to participate in the expansion.  However, the Court said the federal government may not penalize states that do not participate—making the expansion optional for states.  CSH and supportive housing advocates must work aggressively to encourage participation among states to expand Medicaid to people below 138% of the poverty line.

Fortunately, there is a strong case to make for states to expand Medicaid to these populations. Federal incentives to expand Medicaid eligibility are strong: the federal government covers 90-100% of Medicaid costs for the several years for newly enrolled beneficiaries as opposed to about 50% for currently enrolled Medicaid beneficiaries.  This enhanced federal match represents a huge financial “carrot” to states and counties, where the cost of providing uncompensated care to uninsured people drives up costs for state and local governments, hospital systems, and taxpayers alike.  Adopting Medicaid expansion and taking advantage of the enhanced federal match can help states and communities address their budgetary woes, while giving health care access to many low-income and vulnerable individuals.

As we move forward, advocates of supportive housing must also work to ensure that the services people access in supportive housing are included in the insurance benefit package and reimbursable through Medicaid.  Currently, newly eligible people will only have basic Medicaid coverage, which means care coordination, specialty care, case management, long-term mental health treatment and intensive substance use treatment most likely will not be included in their basic benefit package. We must work together  to encourage states not only to expand Medicaid coverage, but also to create benefit packages that allow tenants of  supportive housing to have their service needs reimbursed by Medicaid.  There are a number  options available for securing these benefits, including but not limited to the following:

  • Home and Community Based Services (HCBS) are available through either Medicaid waivers or state plan amendments and can target those leaving institutions or at-risk of institutional care. Using a range of supportive housing approaches, people can be integrated in their community and avoid expensive hospital or nursing home care.

  • The Health Home state plan amendment option temporarily provides additional funds to states that establish a mechanism for providers to create coordinated networks that comprehensively meet the complex needs of patients with chronic health conditions. Given what we know about the affect permanent housing can have on a person’s health and the inability to maintain good health outcomes without housing, supportive housing services should be a key component of any health home network.

  • Additional Medicaid waiver opportunities, including  the 1115 waiver, Targeted Case Management benefit, and the Medicaid rehabilitation state plan option, provide states flexibility to pilot initiatives that target the most vulnerable and often most expensive Medicaid beneficiaries, many of whom require supportive housing and the services that come with it. 

As we continue to sort through the Supreme Court’s rule and understand its implications, we’ll provide additional guidance and identify next steps as we push to expand access to care for supportive housing tenants.  Meanwhile, advocates should be organizing, reaching out and building coalitions with other partners working to expand Medicaid coverage for those with incomes below 138% FPL.

CSH looks forward to working with all of you to capitalize on the tremendous opportunity the Court’s ruling avails us all to expand coverage and ensure that everyone, including our most vulnerable people, have access to quality and affordable health care.



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