Why Medicaid matters for people experiencing homelessness

In his April 23, 2025, State of the City address, Mayor Justin Bibb cautioned that proposed federal and state budget cuts could reduce Ohio’s Medicaid funding by up to 50 percent, jeopardizing health care for many of Cleveland’s most vulnerable residents. He also discussed the encampments that had been cleared out around the city and the rehousing of residents through the “A Home for Every Neighbor” initiative.

Those two topics are not as unrelated as they may seem.

In July 2023, the General Assembly passed House Bill 33, which required the Ohio Department of Medicaid to submit a Section 1115 work requirement waiver for the Medicaid expansion population, often referred to as Group VIII.  To qualify for enrollment in Group VIII, if the pending waiver is approved, an individual would need to satisfy at least one of the following criteria:

• Be at least fifty-five years of age
• Be employed
• Be enrolled in school or an occupational training program
• Be participating in an alcohol and drug addiction treatment program
• Have intensive physical health care needs or serious mental illness

Although homelessness itself does not automatically qualify someone for an exemption under Ohio’s pending Group VIII (Medicaid expansion) 1115 work requirement waiver, many people would be exempt from the work requirements due to other exemption criteria laid out in the proposal, but homelessness in and of itself is not an exemption from the requirement. Maintaining robust Medicaid coverage is critical not only for treating chronic and acute health conditions common among unhoused Clevelanders, but also for funding supportive services like case management, housing stabilization, and rental assistance that underpin housing-first strategies and reduce reliance on emergency care.

In his address, Mayor Bibb cautioned that if Congress finalizes the current budget plan, Ohio could face a 50 percent reduction in Medicaid matching funds, imperiling hospitals and health centers that serve low-income Clevelanders. These “choppy headwinds” threaten to reverse gains made since Ohio expanded Medicaid in 2014, which now covers nearly 100,000 residents of Cuyahoga County.

Encampment closures and rehousing efforts

Under “A Home for Every Neighbor,” the city has closed almost 50 encampments and secured permanent housing for 154 formerly unsheltered individuals, with ongoing wraparound services funded by the city council’s recent $2 million allocation. These efforts reflect a housing-first approach, recognizing that stable shelter is a prerequisite for effective healthcare delivery.

Homelessness is explicitly not a standalone exemption.

Ohio’s Group VIII Waiver and homelessness

Ohio’s pending Group VIII 1115 Demonstration waiver will require able-bodied adults covered by the Medicaid expansion (ages 19–64) to meet at least one of five engagement criteria which includes being over age 55; employed; enrolled in school or vocational training; participating in substance-use or alcohol treatment; or living with serious mental illness or intensive physical healthcare needs. Homelessness is explicitly not a standalone exemption; however, individuals experiencing homelessness often qualify under other categories, such as mental illness or treatment program participation.

For those whose records cannot be electronically verified, county case workers will allow applicants to submit documentation such as shelter letters or provider attestations to establish eligibility. The waiver also contemplates “good-cause” exceptions for life circumstances—including unstable housing—that impede work or community engagement.

Medicaid matters for Clevelanders experiencing homelessness

People experiencing homelessness face disproportionately high rates of diabetes, hypertension, Chronic Obstructive Pulmonary Disease (COPD), mental illness, and substance misuse disorders. Medicaid coverage ensures access to primary care, mental health counseling, and medications reducing costly emergency department visits and hospital readmissions.

Ohio’s Medicaid Home Choice program covers transition costs and offers case management, tenancy supports, and tenant-based rental assistance for those exiting institutional care or homelessness. These services are crucial for supporting housing stability and preventing returns to encampments.

Barriers to Medicaid enrollment and retention

A national study found that 70 percent of uninsured homeless individuals lacked awareness of Medicaid eligibility or could not produce required documents. In Cleveland, outreach teams report similar challenges in gathering proof of income, residency, or identity.

Newly housed individuals often move to neighborhoods far from their usual clinics, impeding appointment attendance and medication adherence.

Unreliable transportation is a major obstacle: newly housed individuals often move to neighborhoods far from their usual clinics, impeding appointment attendance and medication adherence.

Experiences of discrimination in healthcare settings deter many unhoused patients until crises force emergency care. Additionally, some providers limit Medicaid panels due to low reimbursement rates and administrative burdens.

To combat the impact of potential burdens, there are a few steps to take. One of the steps is to explore housing status as a criterion for exemption within the Section 1115 work requirement waiver. This exemption would reinforce the idea that there truly is a home for every neighbor, and health care and supports as well.