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Waiver proposal would help R.I. pay for housing for those with complex medical needs

The Rhode Island General Assembly is now considering legislation that would allow the state to request flexibility to direct Medicaid funds toward housing

A group of unhoused people make their way to the temporary shelter inside the Cranston Street Armory in Providence, Rhode Island on May 4, 2023.Matthew Healey for The Boston Globe

People who experience chronic homelessness have a life expectancy that is 26 years lower than the rest of the population.

Their homelessness robs them of a generation of life.

But what if we could provide the care and support necessary to address those health outcomes? If we collectively came together to view housing as an integral part of health care, we could.

According to the National Health Care for the Homeless Council, poor health is a leading cause of homelessness. Injury or illness can quickly impact employment and create housing instability. The health disparities are only compounded amongst those who do experience homelessness. The country’s homeless population is twice as likely as the housed population to suffer from diabetes, twice as likely to experience a heart attack, 20 times as likely to have HIV, and 36 times more likely to have hepatitis C — one of the costliest chronic diseases to treat.

In 2021, Crossroads Rhode Island launched an innovative partnership with a health insurance provider that provided rent and supportive services to house individuals experiencing homelessness and who also had high health care costs. The pilot reduced inpatient hospitalizations, improved client health, and saved the lowered claims for the insurer. Even more, over 40 percent of the clients have successfully been stabilized in permanent supportive housing.


Building on this success, the Rhode Island General Assembly is now considering legislation — which was drafted in collaboration with the Rhode Island Office of Medicaid — that would allow the state to request flexibility to direct Medicaid funds toward housing for people with complex medical needs. Our waiver proposal is modeled on waivers like Arizona’s, which was recently approved by the Centers for Medicare and Medicaid Services.

These waivers save money. A lack of access to stable housing costs taxpayers — on average — $35,000 per year per individual, according to the National Alliance to End Homelessness.


Rhode Island’s housing and homelessness crisis has the potential to create a public health crisis if we don’t act quickly to address critical needs. While this legislation aims to address one component of that crisis by providing flexibility to pay for housing, we can’t expect to move the needle if there isn’t also adequate housing stock available for people who need it most. Crossroads Rhode Island is taking several steps to accelerate development of new housing, including one new project in the heart of Providence that is focused specifically on meeting the needs of the state’s most medically vulnerable individuals.

Earlier this month, the Providence City Plan Commission gave its full and unanimous support for the Pine Street apartments, a development that will create 35 new permanent supportive apartments and provide residents with 24-7 case management support and access to on-site health services. This innovative project is moving forward with financial support from Rhode Island Housing, the federal government and the city of Providence (from funds designated for affordable housing development). Crossroads has also raised funds from private donors and funders. The development is scheduled to break ground this fall.

The public cost of homelessness is daunting and — bluntly — avoidable. Modest investments to provide extremely low-income individuals and families with a safe, permanent apartment to call home are far more cost-effective than calls to expand shelter. In fact, we know that it costs far more to support an individual in emergency shelter than it does to provide permanent housing and prevent homelessness in the first place. One study by RAND Corporation found that Los Angeles County cut costs by 20 percent by putting people with complex mental health issues in supportive housing instead of relying on law enforcement and emergency departments.


As a state, we should view the housing crisis as a looming public health crisis and we should take proactive measures — like allowing Medicaid to support housing — to address those looming challenges before they metastasize.

Karen Santilli is the chief executive officer of Crossroads Rhode Island. Josh Miller, a Democrat, represents Providence and Cranston in the Rhode Island Senate.