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New Cross-State Analysis Examines Health Services Disparities Among Medicaid Enrollees and Permanent Supportive Housing Programs

With the recent expiration of the federal eviction moratorium and the heightened focus on social determinants of health during the COVID-19 pandemic, this new cross-state analysis of permanent supportive housing programs is timelier than ever.

“In New Jersey, about 90 percent of Medicaid-enrolled adults with long-term homelessness had one or more mental illness or substance use disorder diagnoses,” said Joel Cantor of Rutgers University, the principal investigator of a new project examining health disparities among Medicaid enrollees experiencing homelessness. Recent years have shown an alarming increase in rates of homelessness, disproportionately burdening Black, Indigenous, and People of Color (BIPOC). The COVID-19 pandemic magnified the links between homelessness, health disparities, and inadequate access to health services, particularly with the recent expiration of the federal eviction moratorium in August. The sharpened focus among health policy makers and health services researchers on connections between housing and other social determinants of health (SDOH) and health outcomes underscores the need for research on housing support for those experiencing homelessness.

After the implementation of the Affordable Care Act in 2016, many states expanded Medicaid coverage to include a larger proportion of their state’s low-income population, including many individuals experiencing homelessness. Before the COVID-19 pandemic, the majority of Medicaid enrollees (57 percent) lived in inadequate or unaffordable housing, nearly double the rate of the overall U.S. population (31 percent). Since state Medicaid programs have served as the incubators for many innovations in state health policy, Medicaid is uniquely positioned to address the sharpening focus on SDOH, including homelessness. Cantor and the research team acknowledge this timely opportunity: “While Medicaid is not the agency with primary responsibility for addressing homelessness, the effects of chronic homelessness deeply affect Medicaid beneficiaries and thus have motivated these agencies to provide support services to serve this population.” One way state Medicaid programs have been tackling homelessness is through permanent supportive housing (PSH) programs.

Permanent Supportive Housing Programs: What We Know and Don’t Know

Unlike traditional models where temporary housing support is tied to treatment success, PSH programs provide long-term rental assistance while addressing other medical and behavioral health issues. While Cantor states current research has linked PSH programs to “improvements in housing stability and reductions in avoidable hospital use,” he acknowledges that, except for people with HIV/AIDS, research has not yet demonstrated the impact of PSH programs on health outcomes. Furthermore, most studies on PSH programs were conducted over a decade ago, lacked long-term follow-up, and were limited to specific populations and programs, thus minimizing generalizability. To address these holes in the PSH literature, in collaboration with AcademyHealth, Rutgers University Center for State Health Policy and the University of Pittsburgh School of Public Health launched a new research project examining the impacts of PSH programs.

New PSH Cross-State Analysis to Address Gaps in Literature

Funded by the National Institute on Minority Health and Health Disparities and with dissemination support from AcademyHealth, Rutgers University and the University of Pittsburgh will examine health services disparities among Medicaid enrollees who have experienced homelessness and evaluate the impact of PSH programs on those disparities. The study will fill gaps in the PSH literature in several important ways:

  1. The study is population-based. By studying all persons receiving PSH in New Jersey and Pennsylvania, the findings are generalizable.
  2. The research will examine a broad range of health services outcomes beyond hospital use to include the use of community-based primary care, behavioral health services, preventive care, continuity of care, dental services, and more.
  3. The research design will incorporate a qualitative component. This mixed methods approach will “shed new light not just on how health services metrics changes following PSH placement, but also how and why they improve or fail to improve,” says Cantor.
  4. The study will examine longer-term outcomes because the data spans ten years (2011-2020).

How SUPLN and MODRN’s Infrastructure Facilitate Cross-State Analyses

The study’s cross-state design also allows for examination of larger and more diverse groups, enabling the exploration of health equity among rural and BIPOC populations in particular. The infrastructure of AcademyHealth’s State-University Partnership Learning Network (SUPLN) and Medicaid Outcomes Distributed Research Network (MODRN) made this type of cross-state analysis possible. Cantor, referring to the project as a “SUPLN success story,” described the current study as a direct outgrowth of previous work within the Pennsylvania and New Jersey SUPLN partnerships: after learning of Rutgers’ previous study conducted for their Medicaid agency partner, the PA Department of Health Services partnered with the University of Pittsburgh Medicaid Research Center to assess changes in Medicaid expenditures and utilization associated with receiving PSH. SUPLN’s facilitation of cross-state and inter-agency collaboration spurred this demonstration of effective knowledge-building in state health policy research. MODRN enabled further cross-state collaboration by establishing the Medicaid common data model and analytic methods. New Jersey and Pennsylvania’s current collaboration allows the researchers to explore differences in their previous findings, which may be related to methodological, study population, or programmatic differences.

Cantor and the research team emphasize how multi-state networks like SUPLN and MODRN are “vitally important for understanding how programs work in practice among diverse populations ꟷ not just idealized trial conditions.” As states develop Medicaid-funded housing support programs for enrollees who have experienced homelessness, this current PSH study can establish a model for how other states can examine PSH programs by informing the design of these initiatives, as well as establishing measures and methods that will be useful for evaluation. Cantor and team also expect to identify how housing programs can collaborate more effectively with health care organizations to “optimize care for people experiencing homelessness and, ultimately, to improve their health and well-being.”

Find more information about the project here.

Learn more about the Evidence-Informed State Health Policy Institute and its networks here.

Caitlin Otter

Former Research Assistant - AcademyHealth

Caitlin Otter is former a Research Assistant at AcademyHealth, where she supported the Evidence-Informed State... Read Bio

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Rachel Campbell-Baier

Research Associate - Mathematica

Rachel is currently a Health Research Associate based out of Mathematica’s DC office. Prior to starting at Mat... Read Bio

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