Why Medicaid Is Addressing Homelessness with Section 1115 Waivers: A Critical Examination of the United States’ Federalist Mental Health System

Abstract: Housing and health care are deeply interconnected, and their systemic relationship profoundly affects individual and societal well-being. Inadequate funding has undermined the American mental health system for decades, leading to gaps in care that have caused lasting harm to vulnerable individuals and society as a whole. This Comment examines the historical connections between homelessness and the American mental health system. It explores the benefits and criticisms of the United States’ federalist approach to health care, particularly focusing on Medicaid and its “section 1115 waivers,” which grant states flexibility to develop innovative, state-specific Medicaid programs. Recently, states began to utilize section 1115 waivers to provide housing-related services to vulnerable populations, including individuals with serious mental illness and substance use disorders. Washington pioneered this approach in 2018 when it launched “Apple Health and Homes,” a section 1115 waiver program that provides housing-related services through Medicaid. Drawing on this context, this Comment critiques the state-led approach and advocates for a more equitable and efficient federalized model—one that treats housing stability as a fundamental component of mental health care.