Medicaid is a critical source of health coverage for homeless individuals and for the providers who serve them. More than half (55%) of the 1 million Health Care for the Homeless (HCH) patients rely on Medicaid, and Community Health Centers (CHCs) served approximately 1.5 million homeless individuals in 2024 —about 5% of all CHC patients. This makes Medicaid a foundational component of the health care safety net and a critical tool for ensuring care for populations with limited access.
H.R. 1, the federal law mandating Medicaid expansion beneficiaries meet new Community Engagement requirements (through work, education, or volunteerism), includes exemptions for certain groups. These include individuals who are medically frail, are engaged in drug/alcohol treatment, and/or have serious and complex medical conditions or behavioral health conditions. However, the law does not define these terms, and the Centers for Medicare & Medicaid Services (CMS) has yet to issue further guidance, creating significant uncertainty for states as they plan for implementation and adapt their eligibility systems. [Note: CMS must issue regulatory guidance by June 1, 2026, that outlines how states can establish criteria or pathways—such as specific diagnoses or patient codes—to determine eligibility for these exemptions.]
Utah’s Strategy: Building Protections for Populations with Limited Access to Care
Community engagement requirements have historically led to significant coverage losses, often driven by administrative barriers rather than actual non-compliance. For homeless individuals —who often lack internet access, documentation, or reliable mailing addresses—these risks are amplified. As a population with higher rates of chronic illness, behavioral health conditions, and supportive service needs, as well as higher use of hospitals and emergency departments, Medicaid is especially important for accessing care and reimbursing providers. Without clear exemptions or safeguards, states will likely see homeless beneficiaries disenrolled from Medicaid and greater strain on the safety-net providers who serve them, including CHCs and HCH programs.
Utah’s House Bill 471 codifies Medicaid work requirements while exempting homeless individuals. The state’s support for H.R. 1 and its requirements reflects its traditionally conservative policy approach. At the same time, it tailors implementation to local needs and state-level goals to address homelessness. This strategy is deeply informed by its Targeted Adult Medicaid (TAM) program, a pre-Medicaid expansion initiative that provides coverage to homeless individuals, involved in the justice system, and/or with a substance use disorder or serious mental illness. TAM has gained broad, bipartisan support and is widely viewed as an effective and viable model of care.
Primary Care Association (PCA) and CHC collaborations with state legislators allowed this policy to move forward. Legislative leaders with deep experience in behavioral health and homelessness policy raised early concerns about the impact of federal changes on this population and helped shape a proactive legislative strategy. They worked closely with the Association for Utah Community Health and the Fourth Street Clinic in Salt Lake City to ensure this targeted exemption would help protect homeless patients from disenrollment while also promoting financial stability for providers.
State-level Decisions at an Uncertain Time
Utah’s actions are part of a broader national trend. Five additional states—Arizona, Georgia, Iowa, Kentucky, and Montana—have submitted 1115 waiver requests seeking to exempt homeless individuals from the work requirement. These actions (again from more traditionally conservative areas) reflect an increasing recognition that work requirements place disproportionate burdens on people without stable housing and undermine broader goals for addressing homelessness in local communities.
It is unclear whether CMS will approve exemptions for homeless individuals. While further federal guidance is still forthcoming, states should not be deterred from moving forward. Advancing policies—through legislation, waiver requests, or administrative action—serves a critical purpose beyond immediate approval: it signals to federal policymakers the real-world impact of policies and underscores the importance of tailoring solutions to protect high-need populations.
Advocacy Strategies
For advocates, Utah’s experience highlights a clear path forward. Effective advocacy strategies include:
Frame the Issue Strategically: Position Medicaid community engagement requirements as both an access-to-care issue and a system-level concern. Highlight how coverage disruptions affect patient health outcomes, continuity of care, and the financial and operational stability of safety-net providers.
Elevate Trusted, Bipartisan Messengers: Engage CHC and HCH patients, staff and leadership; state officials; and legislators from both parties, especially those with expertise in behavioral health, homelessness, and Medicaid policy, to build credibility and broaden support.
Pursue Multiple Policy Pathways: Advance a coordinated strategy that includes state legislation, Section 1115 waivers to CMS, and administrative actions. Using multiple approaches helps mitigate the risks during federal uncertainty.
Advance Policy Even Amid Uncertainty: Submitting waiver requests and pursuing legislative changes can help build a policy record, demonstrate state priorities, and create opportunities for future federal engagement.
Act Quickly and Leverage Legislative Timing: Identify and capitalize on narrow legislative windows. Strategic timing, bill placement, and rapid stakeholder coordination can be decisive in advancing policy changes.
Conclusion
As states continue to implement Medicaid work requirements, Utah’s approach demonstrates that proactive, coordinated advocacy can help protect coverage for homeless individuals, even amid evolving, uncertain federal policy. By continuing to pursue these exemptions, states can build momentum, elevate the issue nationally, and strengthen the case for ensuring that homeless individuals are not disproportionately harmed by coverage restrictions.