The Policy Stack: How SAMHSA, the White House, and Louisiana Are Rewriting Drug and Homelessness Response

On April 24, 2026, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a Dear Colleague letter that withdraws federal funding eligibility from fentanyl test strips, sterile water, saline, ascorbic acid, sterile syringes, safer smoking supplies, and overdose hotlines. Signed by Principal Deputy Assistant Secretary Christopher Carroll, the letter operationalizes the July 2025 Executive Order directing the agency to defund what the order termed "so-called harm reduction" programs. This action arrives as Louisiana's House Bill 211 advances toward the state Senate, threatening fines and imprisonment for unauthorized public camping. Together, these federal and state moves construct a coordinated policy framework that abandons decades of evidence on what prevents HIV and HCV transmission, reduces overdose mortality, and connects people who use drugs to treatment.

For people living with HIV and HCV, people who inject drugs, and people experiencing homelessness, these are not parallel debates. They are the same policy question, asked at different levels of government.

What the Updated Guidance Actually Removes

The April 2026 letter preserves SAMHSA funding for naloxone and nalmefene, medication lock boxes, sharps disposal, wound care, FDA-approved home testing kits for HIV and viral hepatitis, navigation to PrEP and PEP, and condom distribution. It eliminates funding for fentanyl, xylazine, and medetomidine test strips intended for use by people who use drugs, alongside syringes, safer smoking supplies, sterile water, saline, ascorbic acid, and overdose hotlines that provide a remote companion to people while using.

This represents a significant retreat from the July 2025 SAMHSA guidance, which had preserved test strips even as it shifted the agency's overall framing. STAT News notes that the test strip policy reverses a position the federal government held since 2021. The carve-out permitting test strip purchases for law enforcement, emergency medical services, and healthcare professionals captures the structural problem: test strips work because they reach people before an overdose, not after. Each strip costs roughly one dollar. Rachel Winograd, who oversees Missouri's central warehouse for overdose prevention supplies, confirmed her usual order for 80,000 test strips on the afternoon the SAMHSA letter arrived in her inbox.

A second letter issued the same day warns grantees against medication-only treatment for opioid use disorder, encouraging clinicians to review continued use of methadone or buprenorphine "at least annually." As STAT observed, current standards of care do not support withholding medication from patients who decline psychosocial services, and the ASAM guideline the letter cites contradicts that framing.

The Evidence the Policy Discards

Syringe services programs (SSPs) are among the most studied public health interventions of the past three decades. A meta-analysis of more than 6,000 patients found a 58% HIV transmission risk reduction among SSP participants. High-coverage programs reduced HCV transmission by 52% in one UK meta-analysis and by 76% in a Cochrane review of nearly 2,500 patients. New York City saw a 29% reduction in HCV prevalence among people who inject drugs after SSP introduction. The economic case is equally clear: full harm reduction averts approximately 70 HCV treatments per 1,000 people who inject drugs, translating to roughly $2 million to $6.7 million in annual savings per 1,000 people based on direct-acting antiviral pricing.

The connection to current epidemiology is direct. HCV infections in the United States increased 124% between 2013 and 2020, largely driven by injection opioid use, and over 75% of overdose deaths in 2023 involved fentanyl. A meta-analysis published in Viruses demonstrated that combined harm reduction with medications for opioid use disorder reduced HCV transmission nearly fourfold compared to limited or absent access. The Department of Veterans Affairs, in its December 2025 analysis referenced in CANN's previous coverage, described SSPs as one of the most effective public health interventions ever devised, with reductions in new HIV and HCV cases of up to 67% and a five-fold increase in the likelihood of achieving abstinence among participants.

The evidence base is not contested in the medical literature. It is contested in federal policy.

The Executive Order's Architecture of Enforcement

The April 2026 SAMHSA letter does not stand alone. Section 4(a)(i) of Executive Order 14321, signed July 24, 2025, directed HHS to ensure SAMHSA grants "do not fund" harm reduction or safe consumption efforts. Section 3 instructs the Attorney General, HHS, HUD, and the Department of Transportation to prioritize discretionary grants for jurisdictions that enforce prohibitions on urban camping, loitering, and squatting, and that move people with mental health conditions or substance use disorder into treatment through civil commitment.

The order's foundational claims warrant examination. It asserts that the "overwhelming majority" of unhoused people are addicted to drugs or have a mental health condition. The data tell a different story: roughly one-third of people experiencing homelessness have a substance use disorder, and roughly one-third have a mental health condition. Penn LDI's Dennis Culhane has observed that housing affordability is the primary explanatory variable in modeling homelessness rates by city or county, and that 84% of households in shelters do not receive Housing First or rental assistance to exit homelessness. The Department of Veterans Affairs implementation of Housing First reduced veteran homelessness by 55%, and the administration has not modified that program.

A federal appeals court ruled on March 31, 2026 that HUD's attempt to cap permanent housing spending at 30% of grants was unlawful, describing the policy as a slapdash imposition of political whims. The administration must now go to Congress to alter that framework.

Louisiana HB 211: The Cascade in Practice

Louisiana's House Bill 211, authored by Representative Debbie Villio, criminalizes unauthorized public camping with fines up to $500 and six months imprisonment for a first conviction, escalating to $1,000 and one to two years with hard labor for subsequent convictions. The bill passed the Louisiana House in April 2026 and awaits action in the Senate Judiciary C Committee.

State officials have acknowledged that supporting the bill could improve Louisiana's standing with the Trump administration when discretionary federal grants are awarded. This is the EO's incentive structure functioning as designed. The downstream context matters: Louisiana has the nation's highest poverty rate and the highest incarceration rate in the Western world. About 60% of Louisiana's unhoused population is Black despite the state being 30% Black. Roughly one in three Louisiana households are extremely low income, and the National Low Income Housing Coalition estimates a shortage of more than 100,000 affordable homes for those families. New Orleans Councilmember Lesli Harris compared the bill to internment camps and warned it would produce no lasting housing or services.

The Homelessness Court program created by HB 211 allows participants to have charges dismissed upon successful completion, but defendants may be required to pay for treatment costs, with courts authorized to mandate unpaid labor when payment is impossible. Pastor Jeremy Babineaux, quoted in KPLC's coverage, asked the question that the bill's text does not answer: how do unhoused people pay fines and program fees when they cannot afford housing in the first place?

Where the Syndemics Compound

Harm reduction defunding does not happen in a vacuum. Encampment sweeps, civil commitment mandates, and treatment-first housing conditions interact with the loss of test strips, sterile supplies, and overdose hotlines to produce harms that exceed the sum of their parts. For people who inject drugs and live with or are at risk for HIV or HCV, the result is a policy environment that systematically severs the connections that public health depends on.

Sweeps and criminalization disrupt continuity of care in concrete, documented ways. Research compiled by the National Alliance to End Homelessness finds that enforcement actions cause loss or destruction of legal documents, medical equipment, prescriptions, and personal effects, while displacing people from the locations where outreach workers and providers know to find them. People moved from one public area to another lose contact with street medicine teams, syringe services, and the case managers who help them apply for Medicaid or get on antiretroviral therapy. Those connections are how the Ending the HIV Epidemic and HCV Elimination plans actually reach the populations that drive ongoing transmission.

The economics are not subtle. Chronic homelessness costs taxpayers approximately $31,000 per person per year under enforcement-driven approaches, while permanent supportive housing with case management costs roughly $10,000 per year. The U.S. Interagency Council on Homelessness has documented that anti-homeless enforcement can cost three times more than housing the same people. Housing First programs, when compared to treatment-first models, reduce homelessness by 88% and, among people living with HIV, decrease emergency department visits by 41%, hospitalizations by 36%, and mortality by 37% within two years, according to research summarized in the AMA Journal of Ethics.

The convergence is what makes the compounding harm difficult to undo. A person who loses access to sterile syringes is more likely to acquire HCV. A person whose encampment is swept loses the ID required to enroll in Medicaid coverage for direct-acting antivirals. A person facing civil commitment or a camping conviction acquires a record that disqualifies them from future housing applications. Each link in the chain, individually defensible to its proponents, produces a population less reachable by the public health system than it was a year ago.

Specific Actions for Advocates

The federal policy framework can be challenged at multiple points. The April 2026 SAMHSA guidance is administrative, not statutory, and Congress retains appropriations authority. The FY2026 Labor-HHS package, as we previously reported, already includes structural protections requiring advance notice before HHS reorganizations and grant terminations. The FY2027 cycle is the next opportunity to direct SAMHSA on allowable harm reduction expenses and to push back on the medication-only treatment framing in the second April 24 letter.

For people working in HIV and HCV care, the most immediate action is documentation. State health departments and Ryan White grantees should be tracking, in real time, the gaps that emerge as SAMHSA-funded programs lose access to test strips and sterile supplies. Quantifying lost services and projected transmission impacts gives appropriators and oversight committees the data they need to act. Sharing that documentation with state public health officials, congressional staff, and the press converts administrative changes into a public record.

For Louisiana readers, HB 211 sits before the Senate Judiciary C Committee. The cost-effectiveness data is unambiguous, and the bill's own structure invites scrutiny: a program that requires payment from people who cannot afford housing, with unpaid labor as the alternative, will not produce the rehabilitative outcomes its sponsors claim. Constituent contact with committee members, paired with testimony from clinicians and people with lived experience, is the most direct lever. The state's existing crisis with HIV transmission and HCV in rural and Delta communities makes the public health case immediate.

At the federal level, Representative Rashida Tlaib's Unhoused Persons Bill of Rights, reintroduced April 30, 2026, calls on HHS to declare the unhoused crisis a public health emergency and proposes universal housing vouchers, expanded rental assistance, and non-carceral approaches to unsheltered homelessness. The resolution will not pass the current Congress, but its cosponsors are the policymakers most likely to move incremental protections through appropriations and oversight.

The Pridgen et al. review published in Harm Reduction Journal in June 2025 outlines additional federal and state actions worth pursuing: amending 21 U.S.C. 863 to decriminalize syringes and drug-checking equipment; protecting Medicaid coverage of PrEP in light of the Braidwood litigation; expanding scope of practice for nurse practitioners and physician assistants to prescribe PrEP; and opposing Medicaid lockouts based on substance use. None of these require the current administration's cooperation. All of them require sustained engagement from the advocacy community.

The Cost of Choosing Ideology Over Evidence

The federal government has, simultaneously, committed to ending the HIV epidemic, eliminating hepatitis C as a public health threat, and reducing overdose mortality. Yet, achieving any of those goals requires reaching the populations whose injection drug use, housing instability, and disconnection from systems of care drive ongoing transmission and death. The April 24, 2026 SAMHSA guidance, the July 2025 Executive Order, and state bills like Louisiana HB 211 move in the opposite direction. They withdraw the tools that connect public health systems to the people they are meant to serve, and they create incentives for jurisdictions to use enforcement against the populations the federal government has committed to helping.

The evidence on syringe services programs, fentanyl test strips, Housing First, and medications for opioid use disorder is not preliminary. It spans decades, multiple meta-analyses, and the operational experience of the Department of Veterans Affairs, which the current administration has chosen to leave intact. The contradiction is the policy.

For us, the path forward is to keep the evidence in front of the people making decisions: appropriators, state legislators, Medicaid directors, hospital systems, and the press. Public health goals like ending the HIV epidemic and HCV elimination are not abstract aspirations. They depend on specific tools, specific funding streams, and specific connections to the populations most at risk. Each test strip removed, each encampment swept, each treatment-first mandate imposed represents a measurable cost to those goals.

Patients deserve policy grounded in what works. The administrative and legislative actions of the past nine months have moved in a different direction. We have the data, the clinical experience, and the cost analyses to make the case for course correction. The work now is to make that case loudly enough, often enough, and to the people with the authority to act.

The Great American Recovery Needs More Than a Slogan

On February 2, 2026, Health and Human Services Secretary Robert F. Kennedy Jr. took the stage at SAMHSA's Prevention Day to announce a $100 million pilot program addressing homelessness and addiction, alongside a meaningful expansion of medication access for families affected by opioid use disorder. In the same speech, Kennedy characterized harm reduction as a "non-effective intervention" that "enabled future drug use." The contradiction captures the current state of American addiction policy: genuine progress on biomedical treatment access undermined by ideological rejection of the evidence-based strategies needed to keep people alive long enough to access that treatment.

The scope of the crisis is not in dispute. According to the White House fact sheet accompanying the Great American Recovery Initiative, 48.4 million Americans, or 16.8% of the population, live with substance use disorder. Nearly eight in ten did not receive treatment in 2024. These numbers should focus policymakers on removing every barrier between people and care. Instead, the administration is simultaneously expanding some pathways while actively dismantling others.

The Biomedical Frontier

One area of genuine scientific promise involves glucagon-like peptide-1 (GLP-1) receptor agonists, medications originally developed for diabetes and obesity that are showing unexpected potential for treating addiction. These drugs target the brain's mesolimbic reward pathways, and emerging research indicates they may modulate the dopamine neurotransmission involved in addictive behaviors.

The implications are significant. As the British Journal of Pharmacology notes, no FDA or EMA-approved medications currently exist for cocaine or stimulant use disorders. This treatment gap disproportionately affects marginalized communities, including LGBTQ populations where methamphetamine use remains a significant concern intersecting with HIV and HCV transmission.

Early evidence is encouraging. A large observational study using the VA database found that people with alcohol use disorder who used GLP-1 medications had a 50% lower rate of alcohol bingeing compared to those not on the medications. People with opioid use disorder on these medications had a 40% lower rate of overdose. Clinical trials are now underway for multiple substance use disorders, including a trial specifically enrolling people with both cocaine use disorder and HIV.

"This research is very important because alcohol and drug addiction are major causes of illness and death, yet there are still only a few effective treatment options," Dr. Lorenzo Leggio of the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism noted in October 2025.

The critical question is access. As Penn Medicine researchers have observed, "many who struggle with addiction are multiply marginalized, making access to these medications a potential concern." The VA study data came largely from older white males, and robust research across demographics remains necessary. Breakthrough treatments mean little if the people who need them most cannot obtain them.

Meaningful Progress

Credit where due: the administration has taken concrete steps to expand medication access for opioid use disorder. On February 2, the Administration for Children and Families announced that buprenorphine, methadone, and naltrexone now qualify as prevention services eligible for Title IV-E funding. States and tribes can receive a 50% federal match to provide these medications to parents when children are at imminent risk of entering foster care. The policy reflects sound reasoning: keeping families together through effective treatment generally serves children better than separation.

The December 2025 reauthorization of the SUPPORT Act extended substance use disorder programs through fiscal year 2030 after the original legislation had languished since its 2023 expiration. The bill passed with strong bipartisan support, 366-57 in the House and by unanimous consent in the Senate.

There is also useful historical precedent from the first Trump administration. In May 2020, HHS Office for Civil Rights Director Roger Severino secured an agreement with West Virginia establishing that people in recovery using medication-assisted treatment are entitled to ADA protections. "People in recovery from opioid use disorder should never be stigmatized for seeking appropriate medical treatment that can save their lives," Severino stated at the time. That principle should guide current policy.

Where Policy Contradicts Evidence

Against these advances stands a pattern of actions that undermine the stated goal of connecting people with treatment.

The Substance Abuse and Mental Health Services Administration has lost approximately one-third of its roughly 900 employees over the past year. In January 2026, the administration briefly cancelled nearly $2 billion in SAMHSA grants before bipartisan backlash forced a reversal within 24 hours. Providers report an environment where planning for the future feels impossible.

The administration proposed folding SAMHSA into a new "Administration for a Healthy America." Congress rejected this in the FY2026 LHHS appropriations package and added structural protections requiring 60 days' advance notice before HHS reorganizations affecting CDC functions and three days' notice before grant terminations. These guardrails exist because they proved necessary.

On harm reduction, the gap between evidence and policy is particularly troubling. The July 2025 executive order "Ending Crime and Disorder on America's Streets" directed SAMHSA to defund "so-called harm reduction" programs. A subsequent SAMHSA letter drew an explicit line between acceptable overdose reversal tools like naloxone and the "ideological concept of harm reduction."

This framing ignores the government's own evidence. In December 2025, the VA published an analysis of its harm reduction programs describing syringe services programs as "one of the most effective public health interventions ever devised." The data: SSPs decrease new HIV and HCV infections by up to 67%, increase the likelihood of achieving abstinence five-fold, and "do not enable or increase drug use, nor do they cause increases in crime."

The FY2026 appropriations bill maintains Section 525, the longstanding prohibition on using federal funds for sterile needles or syringes outside narrow outbreak exceptions. Report language frames harm reduction through an abstinence-first lens, treating harm reduction and recovery as opposing forces when the evidence shows they are complementary. Meeting people where they are is how you eventually connect them with treatment.

The Syndemic Reality

These policy contradictions have real consequences for communities facing intersecting epidemics. Syringe services programs are foundational infrastructure for preventing HIV and HCV transmission among people who inject drugs. Cutting STI prevention funding by $10 million while syphilis and congenital syphilis remain at historically high levels makes no public health sense.

The approach to homelessness reveals similar contradictions. The July 2025 executive order abandons Housing First, the evidence-based model that prioritizes stable housing as a foundation for recovery. In its place, the order directs agencies to prioritize jurisdictions that enforce bans on urban camping, loitering, and open-air drug use when awarding federal grants. It encourages states to expand involuntary civil commitment and conditions housing assistance on participation in behavioral health treatment. The Bipartisan Policy Center notes this approach may invite Fair Housing Act lawsuits, since conditioning housing on treatment could constitute discrimination against people with disabilities, including those with substance use disorder.

HHS’s $100 million STREETS Initiative operates within this enforcement-first framework. Kennedy described the model as finding people on the street and moving them "from crisis to detox treatment to housing to employment." Housing comes after treatment compliance, not before. The National Alliance to End Homelessness has been direct in its assessment: "Deinstitutionalization did not cause homelessness, and re-institutionalization will not solve it."

The 2024 Point-in-Time count recorded over 770,000 people experiencing homelessness, an 18% increase from the previous year and the largest annual jump ever recorded. Those most affected include people with mental illness or substance use disorder, LGBTQ youth, and veterans, as Harvard's Howard Koh has noted. A $100 million pilot serving eight cities cannot address a crisis of this scale, particularly when the broader policy framework criminalizes the people it claims to help.

Access barriers to existing treatments compound the problem. The Cato Institute reports that 80% of U.S. counties have no opioid treatment programs, and only 600,000 of the 8 million people meeting criteria for opioid use disorder received methadone in 2024. The bipartisan Modernizing Opioid Treatment Access Act would have enabled primary care prescribing of methadone; it was not reintroduced in the current Congress.

The Path Forward

The promise of emerging treatments like GLP-1 agonists cannot be realized without the infrastructure to deliver them. A breakthrough medication for stimulant use disorder means nothing to someone cycling between encampments and emergency rooms because Housing First was abandoned in favor of treatment mandates they cannot access. Flat funding for SAMHSA, restrictions on harm reduction, and criminalization of homelessness create gaps that no medication can bridge.

"If we want to create a world where there's opioid recovery, we need to also offer affordable housing and access to affordable food and improved access to health care," Dr. Sadie Elisseou of Harvard told Behavioral Health Business. This syndemic framing should guide policy. It currently does not.

The administration cannot simultaneously expand medication access, gut the agency responsible for treatment infrastructure, restrict the harm reduction programs that keep people alive and connected to care, and criminalize the circumstances of those most in need of help. These policies do not form a coherent strategy. They form a contradiction.

Congress rejected the administration's most extreme proposals through the passage of the L-HHS funding package, but holding ground is not progress. Advocates should monitor SAMHSA implementation closely, push for evidence-based harm reduction funding that aligns with the VA's proven model, defend Housing First against ideological attack, and ensure that new treatments reach marginalized communities rather than only those with private insurance and stable housing.

The tools to address substance use disorder exist. What remains absent is a policy framework that treats people who use drugs as deserving of care rather than punishment. Until that changes, the Great American Recovery will remain a slogan, not a strategy.

Beyond Medicine: Medicaid's Role in Bridging Healthcare and Housing

The evolving landscape of healthcare now acknowledges housing as a crucial element of well-being, marking a significant shift in public health recognizing certain goals advocates have trumpeted for decades - housing can be healthcare. Highlighted by a California Healthline article, this shift challenges old paradigms by recognizing stable, affordable housing as essential for optimal health outcomes. With states like California, Oregon, and New York at the forefront and thanks to a slew of waiver opportunitjes offered from the Biden Administration, some Medicaid programs are increasingly integrating housing services, reflecting a broader understanding that health is inextricably linked to our living conditions.

The Case for Housing as Healthcare: A Closer Look at the Evidence

The role of housing as a fundamental component of healthcare is being increasingly recognized among policymakers and supported by a growing body of evidence that underscores the critical impact of stable living conditions on health outcomes. The American Medical Association (AMA) has highlighted the essential nature of stable housing, pointing out that its absence significantly elevates the risk of various health issues, including severe infections that may necessitate amputation, and an increased likelihood of experiencing violent trauma.

Research featured in Health Affairs strengthens this viewpoint by establishing a clear link between housing stability and better health outcomes, emphasizing housing's non-negotiable position within a comprehensive healthcare framework. The benefits of stable housing can extend beyond physical health, with some studies showing significant mental health improvements through housing stability interventions, such as rental and foreclosure assistance.

The AMA further notes that people with access to stable housing are less prone to the stressors that lead to physical and mental health issues. Such environments reduce the risk of infectious diseases by providing a clean and secure living space conducive to health, facilitating easier access to medical care. Moreover, stable housing is linked to better chronic condition management, as it encourages an environment in which people can adhere to treatment plans and maintain regular contact with healthcare providers and is often accompanied with other medication necessities, such as food security and potable water.

Cost Savings and Healthcare Efficiency Through Housing

Integrating housing services into healthcare significantly enhances health outcomes and generates notable cost savings. By transitioning towards stable housing, reliance on high-cost healthcare services, such as emergency visits and hospital admissions, markedly decreases. A compelling study in Oregon demonstrated that providing affordable housing to nearly 10,000 individuals with unstable living situations resulted in a 12% reduction in Medicaid expenditures. Furthermore, this initiative increased outpatient primary care utilization by 20% and reduced emergency department visits by 18%, highlighting a shift towards preventive care.

This approach not only improves the health of Medicaid beneficiaries but also leads to more judicious healthcare spending. Allocating resources to housing services supports preventive care and vital services, amplifying the impact of stable housing on individual health and the overall healthcare system. Medicaid's strategic involvement in providing housing may prove a crucial tool for achieving better health outcomes and optimizing healthcare expenditure.

Medicaid Waivers and Housing Initiatives: Navigating New Pathways

The integration of housing services within Medicaid, facilitated by Section 1115 waivers and the innovative In Lieu of Services (ILOS) guidelines, represents a transformative approach to healthcare. These policy mechanisms are enabling states to address housing as a fundamental social determinant of health, acknowledging its critical impact on health outcomes.

Section 1115 Waivers: Expanding Medicaid's Reach

Section 1115 waivers grant states the flexibility to use Medicaid funds in novel ways that can include addressing housing instability, a key factor affecting health. The Kaiser Family Foundation reports on various state initiatives that leverage these waivers to directly tackle the housing needs of Medicaid enrollees. For example, some states have received approval to use Medicaid dollars for supportive housing services, such as helping people find and maintain stable housing. The programs with the best outcomes not o ly provide a method of entry but also work to ensure continuing housing stability. These waivers are instrumental in demonstrating how targeted housing support can lead to better health outcomes and reduced healthcare costs by minimizing the need for emergency care and hospital readmissions.

ILOS: Streamlining Support for Housing Needs

The Centers for Medicare & Medicaid’s (CMS) recent guidance on ILOS marks a significant policy shift, allowing Medicaid programs to offer housing-related services as enhancements to traditional medical interventions. This guidance enables states to provide a range of housing supports, including housing navigation assistance and one-time financial aid for security deposits or first month's rent. Importantly, while ILOS does not cover ongoing housing costs, it addresses critical barriers to stable housing for Medicaid enrollees, emphasizing the role of housing stability in achieving health equity.

State-Led Innovations in Housing and Health

States are at the forefront of integrating housing solutions within Medicaid, driven by the opportunities presented by Section 1115 waivers and ILOS guidelines. Shelterforce highlights innovative state programs that are setting precedents for how Medicaid can be utilized to support housing needs. For instance, initiatives that fund temporary housing for individuals transitioning out of hospital care not only provide immediate shelter but also contribute to better health outcomes and lower the likelihood of readmission. These programs exemplify the potential of Medicaid to address the holistic needs of its enrollees, underscoring the necessity of stable housing for overall health and well-being.

Through the strategic use of Section 1115 waivers and ILOS, Medicaid is evolving to meet the complex health and social needs of its enrollees. By recognizing housing as a critical component of healthcare, these policy innovations are paving the way for more integrated and effective approaches to improving health outcomes and advancing health equity. The success of state-led initiatives in leveraging these tools to address housing instability highlights the significant role of Medicaid in not only providing medical care but also in addressing the broader determinants of health.

Applying a Harm Reduction Perspective to Housing

Harm reduction in housing services adopts a compassionate approach, recognizing the varied challenges and needs of those facing housing instability. It emphasizes meeting people "where they are," providing flexible support without coercion, and respecting each person's autonomy and circumstances. This strategy is crucial for addressing the spectrum of housing stability, which ranges from homelessness to permanent, secure living situations. Each stage has unique health implications, with instability often worsening health conditions and hindering access to consistent healthcare.

Harm reduction aims to alleviate these health impacts by offering immediate, sometimes temporary, support to navigate towards more stable housing. This approach is vital for those with chronic health issues, mental health concerns, or substance use disorders, where a stable home can significantly influence health outcomes and quality of life. By tailoring services to meet personal needs—including healthcare access, mental health support, and substance use treatment—harm reduction in housing can effectively reduce the harms of instability and facilitate a path to stable living conditions.

Navigating Oversight in Medicaid's Housing Initiatives

The expansion of Medicaid to include housing services, aimed at addressing social determinants of health, introduces significant management and oversight challenges. A key concern is the potential for program exploitation, where resources meant for the most vulnerable are diverted or misused. The AIDS Healthcare Foundation (AHF) case, reported by the Los Angeles Times, exemplifies such risks, highlighting the need for stringent oversight to prevent organizations from prioritizing performance over patient care, qualityof life, and more permanent outcomes for program participants.

Ensuring Transparency and Accountability:

To counteract exploitation risks and guarantee the effective delivery of housing services, a strong emphasis on transparency, accountability, and comprehensive oversight is essential. The Center on Budget and Policy Priorities (CBPP) provides strategies for overseeing housing initiatives, stressing the importance of clear objectives, performance metrics, and consistent audits. These measures are vital for tracking service implementation, assessing health outcome impacts, and promoting ethical, efficient fund use.

Developing Robust Oversight Frameworks:

Implementing effective oversight requires layered scrutiny, including internal audits, external reviews, regular site audits, and autonomous, third-party feedback mechanisms for beneficiaries. Building partnerships across Medicaid programs, housing providers, healthcare entities, and community organizations can enrich oversight through varied insights and expertise. Such collaborative oversight efforts are pivotal in identifying and disseminating best practices, learning from experiences, and crafting innovative solutions to the intricate challenges of merging housing with healthcare services.

As Medicaid ventures into housing services, its success in enhancing health outcomes for vulnerable groups hinges on overcoming oversight hurdles. Committing to transparency, accountability, and strong oversight will protect against misuse, optimize resource allocation, and ensure housing's role as an integral part of comprehensive healthcare.

The Path Forward: Enhancing Medicaid's Role in Housing and Health Integration

As Medicaid evolves to more fully recognize housing as a crucial component of healthcare, a strategic and multifaceted approach is essential to ensure the effective integration of housing services. This approach should leverage the insights from recent policy developments and successful state initiatives, focusing on policy adjustments, increased funding, cross-sector collaboration, and robust oversight mechanisms.

Policy Adjustments and Increased Funding: A Foundation for Success

1. Policy Adjustments: Recent guidance on In Lieu of Services (ILOS) and the innovative use of Section 1115 waivers illustrate the potential for Medicaid to directly address housing instability. States should be encouraged to explore these and other policy tools to expand Medicaid's capacity to fund housing-related services, thereby acknowledging the profound impact of stable housing on health outcomes. Legislative and regulatory frameworks must evolve to support these changes, ensuring Medicaid can effectively contribute to housing stability for its enrollees.

2. Increased Funding: The expansion of housing initiatives within Medicaid necessitates substantial investment. This includes not only funding for direct housing assistance but also for the development of infrastructure that facilitates the delivery and coordination of services. Advocacy efforts are crucial to secure increased federal and state funding, aiming to bolster Medicaid's ability to meet the housing and health needs of its beneficiaries comprehensively.

Cross-Sector Collaboration: Building Bridges for Better Health

The success of housing initiatives within Medicaid is significantly enhanced by cross-sector collaboration. Partnerships among Medicaid agencies, housing authorities, healthcare providers, and community organizations are vital. These collaborations can draw on the strengths and resources of each sector to address the multifaceted challenges at the nexus of health and housing, creating integrated solutions that improve outcomes for individuals and communities alike.

Implementing Comprehensive Oversight and Adaptive Management

1. Comprehensive Oversight: To safeguard the integrity of housing initiatives and ensure resources are used effectively, a framework for comprehensive oversight is imperative. This framework should include clear implementation guidelines, success metrics, and regular evaluations to monitor impact and guide continuous improvement.

2. Adaptive Management: Effective management strategies are critical to navigate the complexities of integrating housing services within Medicaid. This includes ongoing training for program administrators and service providers, as well as the development of care models that seamlessly coordinate healthcare and housing services, ensuring that Medicaid enrollees receive the support they need to achieve and maintain stable housing.

The path forward for Medicaid's integration of housing services presents a unique opportunity to significantly improve health outcomes and advance health equity. By adopting a strategic approach that includes policy innovation, increased funding, cross-sector collaboration, and rigorous oversight, Medicaid can play a pivotal role in addressing the housing needs of its enrollees. This comprehensive strategy not only meets immediate housing challenges but also lays the groundwork for a healthier, more equitable future.

A Call to Action for Housing as Healthcare

The journey towards integrating housing into healthcare through Medicaid is not just a policy shift; it's a moral imperative. As we've seen, stable housing is not merely a foundation for individual well-being; it's a cornerstone of public health. The evidence is clear: when people have access to safe, stable housing, their health improves, healthcare costs go down, and communities thrive.

The Time Has Come to Centralize HIV Services in West Virginia

My name is Marcus J. Hopkins, and I have been living with HIV since 2005. While I’m not considered a “long-term survivor” of HIV—a term deservedly ascribed to People Living with HIV/AIDS (PLWHA) since the 1980s or 1990s—my experiences receiving treatment for HIV through the Ryan White HIV/AIDS Program (RWHAP) and AIDS Drug Assistance Program (ADAP) have run an interesting gamut across five states: Georgia, Florida, Tennessee, California, and West Virginia. Across those five states, I have experienced a wide variety of HIV services provision over the course of being in HIV treatment since 2007, and can truly attest to the adage, “When you’ve seen one ADAP, you’ve seen one ADAP.”

Over the course of sixteen years of receiving services through the RWHAP and ADAP programs, several things have changed:

• Providers no longer wait until a patient receives an AIDS diagnosis to initiate HIV Antiretroviral Therapy (ART)

• Treatment regimens have largely transformed from multi-pill regimens to single-pill regimens and even long-term injections requiring once monthly or every other month injections

• The emergence of Pre-Exposure Prophylaxis (PrEP)—a once-daily pill or once-monthly or every other month injection to prevent the transmission of HIV between serodiscordant sex partners—means that the possibility of no new diagnoses is a distinct possibility within our lifetimes

• The threat of waiting lists to receive treatment and services is largely a thing of the past

• The passage of the Affordable Care Act (ACA, or “Obamacare”) allowed state ADAP programs to pay the premiums and co-pays for private insurance for eligible clients

• The passage of the ACA also allowed states to expand Medicaid in such a way that PLWHA are now automatically covered by state Medicaid programs, rather than ADAP. To date, 39 states have expanded their Medicaid programs (Kaiser Family Foundation, 2022)

And yet, despite all of these advancements, issues remain, particularly in rural parts of the country where even basic medical services are limited, much less HIV-specific services. Such is the case for my home state of West Virginia.

Since returning to West Virginia from Los Angeles in 2013, my experience with this state’s HIV services has been…fraught, at best. I can’t complain about the quality of care I’ve received, here; I can say that qualifying and recertifying for the various RWHAP parts is made extremely cumbersome.

You see, in the state of West Virginia, there is one organization that handles Ryan White Part B (basically, the ADAP program) for the entirety of the state. This entity is separate from the clinics that provide Part C and Part D services (outpatient care and the provision of medical care and support services for low-income women, children, and youths with HIV and their families, respectively). And THOSE entities are entirely separate from the Part F services, which cover education, HIV treatment projects, dental programs, and the Minority AIDS Initiative. And even THOSE entities are entirely separate from the ones that provide services for the Housing Opportunities for People with AIDS (HOPWA) program that provides various housing and utility assistance services for PLWHA.

So, let’s do a quick recap: in order to receive the full breadth of services to which most PLWHA are eligible in the state of West Virginia, one must engage with at least four separate entities. This doesn’t even address nutrition assistance, non-emergency medical transportation for visits, and other supportive services.

This is a problem.

It is a problem for patients; it a problem for providers; it is a problem for the HIV Care Continuum (United States Department of Health and Human Services, 2021); it is a problem for HIV surveillance and prevention.

As far as I can tell, this problem seems kind of unique to West Virginia. West Virginia never saw the proliferation of AIDS Service Organizations (ASOs) that most of the rest of the country saw during the 1990s and early-2000s. While the rest of the country and especially surrounding states saw an influx of new 501(c)(3) non-profit organizations and clinics step in to provide the wide swath of HIV case management, clinical, behavioral health, and supportive services, West Virginia’s services developed in inefficient siloes that left patients scrambling to figure out the veritable pantheon of providers necessary to get the services for which they are eligible.

By comparison, in the northeastern region of the state of Tennessee (still deep in Appalachia), Ryan White caseworkers went out of their way to assist with every aspect of HIV care, from enrollment in the program to clinical services to mental health services to dental services to HOPWA services to enrolling in nutrition assistance programs—they did it all. The same was true of my experiences in California and Florida.

In West Virginia, however, every aspect of seeking and qualifying for HIV services requires patients to perform an intricate and ever-changing ballet, the steps for which they are never taught. Because there are so few providers of these services, when patients experience issues, there aren’t really any other avenues to turn to for assistance.

This has become the case with one of West Virginia’s terribly mismanaged HOPWA grantees.

Again, unlike virtually every other state in the U.S., HOPWA services in West Virginia are not seated within the HIV treatment and services infrastructure, insufficient as it is, but within various organizations dealing with homelessness, such as Covenant House and the West Virginia Coalition to End Homelessness. Comparatively, in other states, referral to and enrollment in the HOPWA program is handled by ASOs, who work in concert with state housing agencies to assist with housing issues.

Over the course of the past few years, when one of West Virginia’s HOPWA service providers stopped paying housing and utility payments in a timely manner, patients had nowhere to turn without having to go through multiple channels to resolve their issues…but not even really resolve them; just lodge a complaint. Those HOPWA clients would have had to complain, first, to the very agency that failed to return their panicked calls, as they lost their housing or their electricity was cut off; instead, they had to jump through several different hoops just to find out where to go to complain—the regional office in Pittsburgh, PA, which initiated an investigation which, frankly, doesn’t do anything for those who are trying to get their rent paid or their electricity reconnected.

The time has come for the formation of not one, but several ASOs in the state of West Virginia to centralize these services. It is unconscionable that a state with a burgeoning HIV infection rate should have such a disorganized and disjointed service provision landscape. The time has come to centralize services at these ASOs, lest we continue to beat numerous dead horses and fail to serve those living with HIV.

Sources:

• Kaiser Family Foundation. (2022, April 26). Status of State Medicaid Expansion Decisions: Interactive Map. Washington, DC: Kaiser Family Foundation: Medicaid. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/

• United States Department of Health and Human Services. (2021, June 21). What Is the HIV Care Continuum? Washington, DC: United States Department of Health and Human Services: HIV [dot] gov: Federal Response: Policies & Issues. https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum

The Most Meaningful Public Health Intervention: Housing

A note on the language used in this article: Some housing advocates reference a difference between “homelessness” and “houselessness” with exceptional, nuanced conversations on individual experiences with housing instability, connection to community, and personal autonomy. While some advocates may opt to consider a frame of “home is where the heart is” as an issue of empowerment, I, as an author and advocate, use these distinctions because of well-established links between housing instability and uncertainty in situations of domestic violence. A roof does not necessarily a “home” make. For the stakeholder targets of this blog, the link between intimate partner violence/domestic violence and HIV is so notable, the Department of Housing and Urban Development has recently announced funding opportunities for joint demonstration projects between HOPWA and VAWA (Housing Opportunities for People with AIDS and the Violence Against Women Act, respectively).

For 30 years, people living with HIV have advocated “housing is health (care)” religiously. A drumbeat of nearly every action, the inevitable topic of any roundtable or meeting, even if housing isn’t an agenda item – or especially if housing isn’t an agenda item. Arguably, when it comes to issues of “social” Justice and policies impacting the notion of equity, outpacing even health care is housing. Housing is the lone sustainable investment any person or family in the United States can make and, generally, expect to last well beyond their own time. Housing is the basis of both defeating and maintaining systems of inequity and oppression. Housing is such a significant factor in individual and collective outcomes it had its own carve out, separate and apart from the Ryan White Care Act, via the program known as Housing Opportunities for People with AIDS.

Indeed, the housing’s impact on health care is so exceptional, in 2019, the American Medical Association built upon limited calls to improve identification access for people experiencing houselessness and expanded their policy position for more comprehensive and collaborative resources aimed to bring care to this population and called for decriminalizing houselessness. In the same year, the Department of Housing and Urban Development’s annual “point in time” data estimated about 568,000 people were experiencing houselessness on any given night in the United States, a near 10% increase of “unsheltered persons” from the prior year.

Late last month, the University of Bristol published in The Lancet a systemic review and meta-analysis of housing instability and houselessness finding among people who inject drugs (PWID), recent houselessness and housing instability were associated with a 55% and 65% increase in HIV and HCV acquisition, respectively. Additional findings include of the global 15.6 million PWID, over 1 in 6 have acquired HIV and over half have acquired HCV at some point and an astounding estimation that half of PWID in North America actively experiencing houselessness or housing instability.

None of the studies included data collect prior to the start of the COVID-19 pandemic. While several states near immediately began introducing short-term eviction moratoriums and the CARES Act provided for federally backed mortgage holders to seek forbearance or deferment, these protections were short-lived, with many states looking toward the federal government for guidance. As with many issues, the summer of 2020 brought the country little comfort due to a lack of cohesive and coordinated public health response to the emergency. A paper published by housing heavy-weight, Emily Benfer, and HIV champion, Gregg Gonsalves, among others, found this failure to uphold and maintain meaningful and enforceable state-based eviction moratoriums contributed to racial health inequity and cited research finding that lifting moratoriums prematurely, triggering displacement, is associated with an additional 10,700 preventable COVID-19 deaths and 433,700 excess cases. In fact, an organization Benfer serves with, Eviction Lab, rates nearly every state in the country as “one star” in terms of housing protections for renters.

Under this frame, tens of millions of people in the United States are at extraordinary risk of contracting COVID-19. Which is part of why the Centers of Disease Control attempted to flex some public health muscle by issuing an eviction moratorium for public health purposes in October, 2020. Like with other investments made in the fight against COVID, the move was bittersweet for public health advocates at the intersection of housing and HIV, HCV, and SUD syndemics – where was this before now?

“Among the Biden administration’s first priorities is the advancement of racial equity and support for underserved communities,” Benfer said. “This requires redress of the structural and systemic discrimination in housing. As an immediate measure, the federal government should bolster the nationwide moratorium on evictions to apply to all stages of eviction, all forms of eviction, and all renters who face housing instability. At the same time, to prevent an avalanche of evictions and protect small property owners from harm once moratoria lapse, policy makers must provide the rental assistance necessary to address the accumulating back rent and sustain renters, state and local governments, and the housing market—and direct it to the communities at the greatest risk of housing instability.”

“Preventing COVID-19 eviction alone could save the U.S. upwards of $129 billion in social and health care costs associated with homelessness,” Benfer added.

However, the CDC’s moratorium is on shaky ground and implementation/access is not automatic – those seeking to use this protection most pro-actively notify their landlords and express intent to seek cover of the moratorium in eviction court. Several states and localities have not evenly implemented the moratorium or setting up “eviction kiosks” to expedite the process, because so many cases were in que, and some going so far as to list children as defendants in eviction actions. Which, according to Benfer, is not an uncommon occurrence. And due to the lack of protections for tenants and outdated credit reporting associated with eviction judgements, these legal actions can and often do follow people for at least a decade, compounding barriers to housing and drastically increasing the risk of houselessness. Because state-based protections have ended, Texas is allowing evictions to resume and the 6th Circuit Court of Appeals has recently allowed a challenge to the authority expressed by the CDC for the moratorium to move forward, even as some landlords are openly exploiting loopholes in the moratorium.

Landlords aren’t the only abusive persons seeking to take advantage of weaknesses in our housing protections. An unfortunate side-effect of the moratorium actions and our lack of investment in ensuring adequate resources for people experiencing intimate partner violence is perpetrators exploited stay-at-home orders and survivors, who are already at exceptional risk of housing instability, with an estimated 26% increase in domestic violence abuse calls made in some cities across the US during the strictest of those orders.

Additionally, with more people facing a lack of houselessness, even more are now at risk for “mobile homelessness” – or a lack of car to sleep in – an issue which may be masking just how many people are experiencing houselessness and housing instability, due to the design of some point in time surveys are conducted. And with an estimated 49% increase in chronic homelessness expected as a result of COVID-19 over the next 4 years, the potential exacerbation of the existing housing crisis in the US may well likely become an even larger, permanent feature without extraordinary action from all levels of government and, or even especially, private stakeholders. To put this figure into context, this would twice as much homelessness as was caused by the 2008 housing recession.

In The American Eviction Crisis, Explained, Benfer suggests there’s some basic policy moves to be made for longer-term successes:

“In the long term, federal, state, and local policymakers must reform the housing market in a way that provides equal access to housing, thriving communities, and areas of opportunity. Rental subsidies, new construction or rehabilitation, home ownership, and investment in long ignored communities would increase long-term affordable housing. Government-Sponsored Enterprises (GSEs) must remedy the current market conditions that can be traced to racially discriminatory lending policies. This means GSEs must address disparities in asset accumulation and the persistence of discrimination in mortgage lending and the siting of homes.

Where eviction is absolutely necessary, the eviction system itself must be reformed. Evidence-based interventions, such as providing a right to counsel, diversion programs, ‘just cause’ and ‘clean hands’ policies, as well as altering the eviction process, and sealing or redacting identifying information from eviction records, can prevent or mitigate the harm of eviction.”

That long-term investment is well past-due in addressing the needs of people living with and affected by HIV, HCV, and substance use disorder.

Benfer added, “Eviction prevention and the right to safe and decent housing must be the priority. As President Biden said while signing executive orders directed at ending housing discrimination: ‘Housing is a right in America, and homeownership is an essential tool to wealth creation and to be passed down to generations.’ It’s time the U.S. fulfilled the promises of the 1944 Economic Bill of Rights, which includes a right to a decent home, and the 1949 Housing Act that set the national housing goal: ‘the realization as soon as feasible of the goal of a decent home and a suitable living environment for every American family.’ Ultimately, our policies and budgets reflect our humanity and morality as a nation, and nothing could justify the continued denial of basic human needs and access to opportunity. If we are ever to call our society humane or just, we must finally redress housing disparities and discrimination and secure every American’s right to a safe and decent home.”

For far too long, housing as been placed on a shelf as an “unreachable” necessity in actionable advocacy. We cannot afford to “kick this can down the road” any longer. We’ve long known housing is one of the most effective interventions in prevention and in patient care. The oft-touted “it’s too expensive” excuse has manifested a broken dam with lives sifting through the cracks. We already pay for housing for PWID, it’s just most often manifested in the form of imprisonment. A far more meaningful investment in a person’s recovery and success, regardless of recovery, and in community health and in Ending the HIV Epidemic and in ending violence against women and interrupting cycles of generational poverty and answering our most sacred, moral promise and…and…and… would be to address the issue squarely: it’s time to invest in housing.