On Monday, December 10, The Department of Housing and Urban Development (HUD) released national numbers from the January 2012 Point-In-Time (PIT) Counts, which give an estimate of the number of people sleeping in shelters and other housing for homeless people and also in places not meant for human habitation (aka “the streets”) at a single point in time. In this case, that point in time was mid-January, 2012.
Since a lot of people around the country are entering the final month of preparation for the 2013 PIT count, I want to start by saying that having these numbers every year has turned out to be extremely important. The enumeration is not perfect. But PIT Counts have become more rigorous over the years, and we believe they provide a reliable and worthwhile estimate. We have to thank everyone who works so hard to make these numbers as reliable as they are. The PIT numbers remind everyone that continued high unemployment leaves hundreds of thousands in shelters and on the streets every night, and that service providers and system managers around the country have worked heroically to keep the numbers from skyrocketing.
Looking at the overall PIT counts, here’s the trend in overall homelessness from 2005 to 2012:
As has been the case since the national unemployment rate skyrocketed above 7 percent in early 2009 (and over 10 percent by late 2009), the number of homeless people stayed about the same between early 2011 and early 2012. Given the continued problems with the job market and the fact that rents started to rise again in many communities that year, holding the line is a remarkable accomplishment.
Less reassuring is the fact that 2011 was the last full year when funding under the Homelessness Prevention and Rapid Re-Housing Program (HPRP) was available. When HPRP first passed as a three-year program, we all hoped that, by the time it expired, the economy would be in better shape. The first HPRP grants were released right around the time the national unemployment rate topped out over 10 percent, but it’s only in the last few months that it’s dropped below 8 percent. By contrast, during most of the period 2005 to early 2007 when the number of homeless people dropped so substantially, it was around 4.5 percent, “full employment” by most accounts.
Here are trends for some of the most discussed subpopulations from 2005 to 2012:
Veteran numbers only go back to 2009, the first year when HUD and the Department of Veterans Affairs (VA) worked together to establish a solid methodology for including veterans in the PIT counts. The number of homeless veterans went down largely due to the HUD-Veterans Affairs Supportive Housing (HUD-VASH) program, the beginning of the Supportive Services for Veteran Families (SSVF) program, and an increasingly intense focus by VA staff in headquarters and around the country.
With the full implementation of SSVF and continuing work on effective implementation of housing and prevention strategies, this curve could move sharply downward in the next couple years, as long as implementation is strong and employment numbers continue to improve.
Chronic homelessness also declined in 2011, at a somewhat faster rate than in the previous two years. Some of this is due to HUD-VASH, since the PIT numbers for chronic homelessness include veterans experiencing chronic homelessness. Some of it is due to coming online of Continuum of Care (CoC) program-funded permanent supportive housing that Congress funded before recent fiscal tightening.
Some of the progress on ending chronic homelessness is no doubt due to communities using other resources like Section 8 to get the most vulnerable people off the street, part of the work of the 100,000 Homes campaign, and displayed in a recent report from Los Angeles showing over 2,300 chronically homeless people housed there in the most recent three months.
To end chronic homelessness by the end of 2015, the goal of the federal strategic plan, “Opening Doors,” declines like these will need to accelerate over the next few years. If communities and Congress make ending homelessness enough of a priority, that’s a possibility. If one of the results of fiscal face-offs in Congress is continued reduction in HUD funding, efforts to end chronic homelessness will be severely hampered.
For families, as for homeless people overall, the story is still one of holding the line. We’ve always known that, compared to other subpopulations, families experiencing homelessness are affected most by widespread joblessness. This is an area of particular concern for the future as well, since families overwhelmingly benefited from HPRP. If the Homeless Emergency Assistance and Rapid Transition to Housing Act (HEARTH) of 2009 is funded at the level Congress said it intended in the Act, families would benefit from expanded Emergency Solutions Grant (ESG) funding. So far, that hasn’t happened. It will be a high priority for the Alliance in 2013.
As a final note, this is the last annual point-in-time count that will lack an overall count of youth homelessness. HUD has already issued guidance to communities that they should note the number of young people aged 18-24, as well as unaccompanied minors. This is an important step that will increase both the political pressure and the capacity to make more serious progress on ending youth homelessness.
I hope all our readers have a happy holiday season and new year. I’ll have another blog right after the first of the year, talking about some of the things we at the Alliance are resolving to do in 2013.
Today’s guest blog post was contributed by Paul Gionfriddo, a former Connecticut State Representative and Mayor, who also served as a nonprofit CEO for more then fifteen years. Gionfriddo currently works as a consultant and writes a health and mental health policy blog, Our Health Policy Matters.
Many people think that people are chronically homeless because they have serious mental illness or addictions. They are wrong. They are homeless because of the way we treat their behavioral illnesses. Or fail to treat them.
Recently, I argued this point in an essay for Health Affairs that later appeared in the Washington Post. I wrote that the mistakes of an earlier generation of policy makers – a generation of which I was a part – caused so much of the problem.
Many years ago, we emptied our state psychiatric institutions for good reasons. They were often monuments to neglect or abuse. But when we emptied them, we failed to put in place the community-based service delivery system we needed.
Perhaps we had an excuse. We were in over our heads. No one knew much about the importance of behavioral health and primary care integration in the 1970s and 1980s. We had little understanding of PTSD as a debilitating mental illness. We had even less experience with educating children with serious behavioral illnesses in regular schools.
All we did was create a new revolving door, from brief hospitalization to incarceration to homelessness. I learned firsthand about this revolving door when my oldest son Tim entered it when he was just a teenager, after his behavioral health needs were often ignored or neglected throughout his school years.
This revolving door – this system that isn’t – is the reason people like my son become homeless. And, unless our policies change, it is the reason why young men and women like Tim will continue to become homeless.
For Tim and people like Tim, finding housing is not a start; it’s the end of a long process. And policymakers today have no excuse; they know what this process must be.
It should begin in our pediatricians’ offices, by mandating periodic screening of every child for mental illness and its risk factors. It should continue in our schools, by providing every student who has a mental illness with a meaningful special education program (and paying for it, as the law requires) that ensures they will graduate from a high school or vocational school.
It must be carried on by behavioral health service providers in the community, who can offer families all the supports they need when their children are living at home, and who can offer young adults like Tim all the treatment and supports they need when they are on their own.
And we must do everything we can to keep courts, sheriffs, and jails out of the treatment mix. After all, we don’t send people with cancer to jail just because they are symptomatic and noncompliant with their treatment, do we?
Doing these things will help to prevent chronic homelessness. And they will do something else, too – give some people who happen to be homeless today a real opportunity to become well and housed.
It will be a challenge for this generation’s policy leaders. Let us hope that they are up to it.
Alliance and CEO Nan Roman delivered the following remarks at the Common Ground Alliance/Council of Homeless Persons Pre-conference Convening on in Melbourne, Australia on Wednesday, September 5, 2012. (For our American readers, in Australia permanent supportive housing is referred to as “common ground housing.”)
Ending Long Term Homelessness: Taking Permanent Supportive Housing to Scale
Thank you to the Common Ground Alliance and Felicity Reynolds and the Council of Homeless Persons and Jenny Smith for holding this forum and for inviting me to join you today. When I first came to Australia in 2007, permanent supportive housing and Common Ground housing were quite a new idea, at least by those names. Certainly there were people like Bryan Lippman at Wintringham here in Melbourne who were already doing it – combining housing and services. But it wasn’t the norm; it was not a well-established intervention. Now, as heard this morning, there are quite a few models. That is good, as a variety of models are needed.
But the next step, as the title of this session indicates, is going to scale – moving from the occasional permanent supportive housing program to an adequate supply of permanent supportive housing to meet the need and end homelessness among people with chronic disabilities.
We have not gone to scale on permanent supportive housing in the U.S., but we have certainly ramped up. There are currently nearly 200,000 units of permanent supportive housing in operation. So we have some experiences to share – some good and some bad – that may be relevant here in Australia. Let me start with a few definitions and a little history of permanent supportive housing and why it became such a big thing in the U.S.
In the U.S. you know that we define homeless as people living on the streets, etc. or in programs – not people doubled up or in poor accommodation. When homelessness first emerged in the 1980s, for a long time we thought that everyone who was homeless was a single adult male with a mental health or substance abuse disorder. This seemed an overwhelming problem with no clear solution.
Eventually we discovered, through data and research, that actually most people – 80 percent – who became homeless were homeless briefly and only once. There was a minority (the remaining 20 percent) who had the more serious problems of the stereotype – mental health and substance abuse – and who stayed homeless for long periods of time. This latter became known as the chronically homeless population. When Dr. Dennis Culhane did this typology in the mid-1990s, the size of the chronically homeless population was estimated to be about 250,000. So this new research changed the dynamic and the problem seemed more manageable.
In the earlier part of the twentieth century in the U.S., there was an abundance of what we call single room occupancy housing or hotels (SROs): over 2 million units by the 1960s. These units – though not the optimum as they were very small with shared facilities – nevertheless housed a tremendous number of very poor, often disabled single men, allowing them to pay by the night or week and providing a roof over their heads. Much of this SRO housing was lost between the 1960s and the 1980s, and it’s almost all gone today; which some think can, in and of itself, explain much of the growth of homelessness among single men. But by the 1980s some urban pioneers in New York, Oregon, and elsewhere began to rehabilitate these decrepit SROs into much more decent housing and enrich them with services for the often disabled tenants living in the neighborhoods where they remained. This was the precursor to permanent supportive housing.
Fairly quickly a few national leaders, like the Alliance, the fledgling Corporation for Supportive Housing, and a high ranking housing official in the Bush Republican Administration, saw the potential in this. Clearly it made more sense to provide these vulnerable people with housing than with shelter. A long story follows, but the bottom line is that over time, research showed that this PSH ended homelessness for even the most disabled people.
Thus, by the mid-1990s we had a problem of solvable size AND we had a solution.
I am going to get to the scaling up in a minute, but first I want to reflect just a moment on the different models of permanent supportive housing we have. We heard here today about a number of really great models, and we have many models in the States.
There is the conventional single site, dedicated model in which all the units in a building are devoted to permanent supportive housing. Such buildings tend to have modest studio apartments, often with a kitchenette and/or bathroom (although sometimes in the older buildings the facilities are shared). Some have a fair amount of common area, but others – especially new construction – have very little because of cost. Sometimes fairly intensive services are on-site, but other times the services are really just case management, which links tenants to other services in the community.
There is what you call the Common Ground model in which some of the units are for permanent supportive housing and others are market rate or affordable for other members of the community. Again, the units tend to be small and simple, and the services vary.
Increasingly there is a scattered site model in which people rent units in apartment buildings and the services are mobile or provided off-site. There has been discussion today of the Pathways model. This employs the Assertive Community Treatment or ACT team method of providing services. There are other models that primarily use the intensive case management design to link consumers to other service providers, while ensuring that they get the services they need to reside in the community.
These models are all largely for people with serious mental illness, substance abuse disorders, physical disabilities, age-related issues, or a mixture of these. The story of permanent supportive housing is hugely positive and it is solving vexing problems and generating enormous bipartisan political will nationally and in virtually every city in America. This is a huge success story that is influencing how other social problems are handled.
How did we go from a program model with a scattered set of practitioners to nearly 200,000 units that have significantly reduced chronic homelessness and are targeting the hardest to serve people in literally every community in the country? I think that the recipe for scaling up, for us, is not that complicated, and it is one that we have replicated for other homelessness problems.
The first step was being able to size the problem, and having a problem that is of solvable scale. We had been speaking in the U.S. about a homeless population of millions, which felt too big to solve. But research revealed a problem of a solvable scale – 250,000 people who were chronically homeless, very ill, and clearly should not be on the street or in shelter.
The second step was having a solution to the problem. A fair amount of research had been done on permanent supportive housing, and much more has been done now. It is clear that it works. Generally speaking a minimum of 80 percent of people with disabilities can be successfully housed in permanent supportive housing, and frequently that percentage is much higher.
The third part of the equation was having a solution that is affordable. Cost studies had shown that it costs the public sector at least as much to leave someone with serious mental illness on the street as it costs to house them with services. Subsequent cost studies on people with HIV/AIDS and chronic street inebriates have found significant cost savings from housing high cost people. By shifting money that was being spent on not solving the problem to solving the problem, we could get there. Of course, that is more easily said than done as a practical matter.
These three things together – a problem of solvable scale, for which we had a solution that was effective and cost effective – provided us with a framework for solving the problem. If there are 200,000 chronically homeless people whose homelessness can be ended with permanent supportive housing that costs less than what we do now, by providing 20,000 more units per year for the next ten years, we can solve the problem in ten years. So this was less about program models and more about the overall framework of solving the problem.
This framework allowed policy makers and practitioners to see a way forward. By going to scale, they could solve a problem, not just endlessly address it. And they could do it cost-effectively.
I want to point out that these three factors all involve something very important, and that is data and research. Without data and research: we would not have known the number of chronically homeless people; we would not have been able to verify the effectiveness of the solution; and we would not have been able to make the cost argument.
One other essential ingredient in getting this going was advocacy. I can promise you that this research, once it emerged, did not just automatically cause policymakers to say, “Let’s create 200,000 units of permanent supportive housing and end chronic homelessness!” It was a few key national organizations with strong credentials and good capacity that moved the agenda forward through advocacy.
Once the scaled problem and a cost-effective solution were in place, what were the steps in scaling this up? There was no single thing that happened, but a series of things.
On the political will side, there were commitments made by the Administration and by Congress to end chronic homelessness. In both cases, these commitments were expressed in budget terms, so there were some dollars behind it. That was the beginning. Over time, at the federal level:
- Congress targeted 30 percent of the nation’s largest homeless assistance grant program to permanent supportive housing. This essentially required that every community in the nation begin to provide permanent supportive housing, and created a steady stream of funding over time.
- The Department of Veterans Affairs (VA) started funding thousands of units of permanent supportive housing for homeless military veterans; a large group in the U.S. The federal housing department provides rent vouchers for scattered site housing and VA provides the services.
- The goal setting continued, with the current Administration vowing to end chronic and veteran homelessness by 2015.
In this way, federal leadership and a pipeline of resources were established.
States and localities also began to take up the challenge:
- Some State housing finance agencies – public entities that fund affordable housing – began to require that a percentage of multi-family housing units they financed be permanent supportive housing, or to target a percentage of funds to permanent supportive housing each year.
- New York State and New York City created the New York/New York agreements to provide thousands of units of permanent supportive housing.
- Plans to end homelessness, which exist in nearly every major city in the nation, almost all contain commitments to end chronic homelessness.
And the private sector has gotten on board:
- There is a consortium of foundations dedicated to getting their peers to fund permanent supportive housing.
- The new Social Impact Bond movement in the U.S. is focused on ending chronic homelessness through permanent supportive housing because of the cost savings.
We also had to increase our capacity to provide permanent supportive housing. Many homeless organizations were initially disinclined to engage in the strategy: they had no will or expertise to develop housing or provide sophisticated services. Some felt that their mission lay in helping people who were homeless – not in ending people’s homelessness. But the federal leadership, expressed through money, pushed the development of will and capacity among nonprofit providers. National intermediary NGOs emerged to help with financing, technical assistance, and training. Eventually the capacity developed.
All of these elements are geared to increasing the scale of the intervention. Certainly individual organizations still have to have the mission and the gumption to do the deals and put up the housing, and in the U.S. as here that is a gargantuan effort. But increasingly the systems are being created that will provide and sustain enough of this housing to meet all the needs.
All of this is not without challenges, some of which I have identified. You might ask, for example, if we had 200,000 chronically homeless people and we created 200,000 units of permanent supportive housing, shouldn’t the problem be solved? And yet there are 107,000 chronically homeless people remaining. Why?
The main challenge has been that the permanent supportive housing units do not all go to chronically homeless people. Some of this is policy, in that the agencies do not require that every unit go to chronically homeless people. Some of it is the providers, who may not take the high-need tenants, either because they just don’t feel they have the service supports for the most needy people; because they really don’t want to take them; or because performance benchmarks disincentivize that.
Some of these targeting issues are being handled by changes in policy, and also by things such as the vulnerability index, and the 100,000 Homes Campaign, which I know have been here in Australia. These campaigns – sort of like the Ten Year Plan campaign of early 2000s – get people geared up to identify and house the hardest to serve.
There are other issues as well. There are mismatches between where the units are and where the people who need them are. Funds are given out by formula and go to every community. But the majority of the chronically homeless population is in the big cities like New York and Los Angeles. So we don’t have the units where we need them.
And a significant lesson we’re learning is the importance of different models. Not every one of us wants to live in the same type of housing with the same type of people. I have noticed that where there is a proliferation of one type – say single site – there is more failure because if that model doesn’t work for someone, there is no option. Let a thousand flowers bloom and don’t get too caught up in the purity of any model. Different models means there is more choice for consumers and if you want to end homelessness, you will need someplace that works for every single person.
At the end of the day, we have not ended chronic homelessness in the U.S. nor solved all of the problems related to providing permanent supportive housing. But we have cut chronic homelessness significantly. And some communities have essentially ended it.
Since we started a little earlier than you, there might be some things to learn from us. I would summarize them as follows.
- Data is critical to building the case and then measuring progress and adjusting as you go along.
- Having a framework for how you’re going to end the problem works.
- Setting numerical goals is important.
- You need strong, talented advocacy.
- You need technical assistance and capacity building.
- You need sustained funding.
- Targeting is critical – otherwise you won’t reduce your numbers.
- Use a lot of models, but stay focused on the population you want to address.
- Try to get the money moving in this direction – if every project is a one-off it will never scale up. You need a pipeline.
I appreciate and admire the terrific work that is going on here in Australia. I commend the efforts of the Common Ground Alliance to bring you all together. And I very much I look forward to the discussion about how you could scale up in Australia. Thank you.
Mention post-traumatic stress disorder (PTSD) as it relates to homelessness, and most people will probably think of military veterans, but other homeless populations struggle with PTSD. Indeed, the experience of homelessness itself is a trauma that can lead to PTSD.
PTSD is an anxiety disorder that can occur after an individual has experienced a traumatic event, particularly one that involves the threat of injury or death. It is still unclear why a particular trauma may lead to PTSD for some individuals but not for others, or why some individuals are traumatized by a particular event when others are not.
We do know that:
- PTSD changes the body’s response to stress;
- An individual with a history of trauma may be more susceptible to experiencing PTSD from a future traumatic event; and
- Symptoms of PTSD may not appear for weeks or even months after the triggering traumatic event.
There are a number of ways in which the traumatic experience of homelessness can lead to PTSD:
- The actual event of becoming homeless can lead to trauma through the loss of stable shelter, family connections, and accustomed social roles and routines;
- The ongoing condition of homelessness creates stressors that include the uncertainty of where to find food and safe shelter and the potential for experiencing violence and victimization, which can erode a person’s coping mechanisms; and
- Homelessness might serve as a breaking point for those who have preexisting behavioral health conditions or a history of traumatization.
According to the U.S. National Library of Medicine, symptoms of PTSD fall into three main categories:
- “Reliving” the event, which disturbs day-to-day activity, including, for example, flashbacks and nightmares;
- Avoidance, which includes emotional numbing and feeling detached; and
- Arousal, which might include difficulty concentrating, sleep disturbances, and outbursts of anger, amongst other symptoms.
One of the greatest challenges for homeless service providers is that the PTSD is post-traumatic, not co-occurring-traumatic. Its symptoms may not manifest until after a person is stably housed. Another challenge for providers comes from the fact that delaying the housing component can create more psychological barriers to housing stability.
Fortunately, research shows that post-trauma resiliency can be learned through effective training programs for both consumers and providers.
At a minimum, homeless assistance providers should ensure that programs and policies reflect the needs of people suffering from PTSD:
- Housing should be provided as quickly as possible to provide safety and stability while minimizing the potential for associated traumatic experiences;
- Since symptoms may be delayed, people receiving homeless assistance should be counseled about psychological changes they may experience in the future, and offered referrals for psychiatric help; and
People suffering from PTSD need ongoing support to reach a successful recovery and reintegration into social routines.
Image “Homeless and Cold” courtesy of Ed Yourdon’s photostream.
Today’s guest blog post was written by Kristin Pazulski, Development Director and Managing Editor for the Denver VOICE. It includes an excerpt from the 2012 issue of the Denver VOICE, written by Raelene Johnson.
Raelene Johnson spent years living on the streets of Boulder. The shady space under a bridge was her home. She scraped by on the money earned the typical way on the street, her drug habit keeping her in a cycle of poverty and homelessness.
In 2008 Johnson discovered the Denver VOICE, a street paper in Colorado. As soon she walked through the vendor office door, she was given the opportunity to work. She received one hour of training and a badge with 10 free papers in exchange for the promise to conduct herself professionally while selling the VOICE.
Grabbing her first paper and ducking into the lanyard that held a tag with her face, name and vendor number, Johnson had no idea she was embarking on a journey very different from the one she’d been on.
There are 122 street papers around the world, more than 30 in North America. These papers are connected through two large networks—the International Network of Street Papers and the North American Street Newspaper Association.
Some are volunteer-based, while others have large staffs and monthly circulations exceeding 100,000. A wire service similar to the Associated Press allows street papers around the world to share their stories. Thanks to this service, smaller street papers can produce quality content on a shoestring budget.
Many individuals on the street battle daily with substance abuse, mental illness, disability or other obstacles that prevent them from working a typical job or connecting with services available to people experiencing homelessness.
Street papers can give people like this the opportunity to earn money in a manner more dignified than panhandling, and can even provide them with an opportunity to express themselves.
As of this fall, Johnson is two years sober and clean and she’s celebrating her fifth year anniversary with the VOICE.
Here is her story in her own words.
A Life Change by Raelene Johnson (Excerpted from The Denver VOICE, August 2012)
July 14, 2012 marked my four-and-a-half year anniversary with the Denver VOICE. My life has really changed since I started working with the VOICE. Most of my life, I was told I was dumb, I was stupid, I was no good. I have had many head injuries, so trying to hold down a real job was very hard for me. I had no self-esteem or self-worth. I have been homeless most of my life.
On Jan. 14, 2008, I started selling the VOICE. When I first started, I was sleeping under a bridge. At first, it was hard for me to sell papers. After the first three or four months, I started to do well. It felt good that for the first time in my life, I was making money.
One of the best things about the VOICE is even if you have no high school diploma, no job reference, no home, no ID, a felony or whatever it may be, you walk into the distribution office and you walk out with a job. I could not believe how easy it was to get a job!
By the time it came to my year anniversary of working for the VOICE, I was the top female vendor. I felt good about myself for the first time in my life. People started telling me how good of a job I was doing. It felt great because all of my life I was told I was no good and couldn’t do anything right.
As my second anniversary came, I was the best female vendor and placed first or second in the top ten over everyone for two years! Boy, did that make a change in me. At that time, I was very tired of doing drugs.
The last two years have been the best so far in my life. We build self-esteem, self-worth and self-confidence. Most of the vendors you see have gotten off the streets. Not bad for a $2 donation.
As of July 1, I am 22-months clean of a crack cocaine habit and two years clean of alcohol. I never knew how happy I could be once I believed in myself and became drug-free.
By telling people my story, I am doing what I can to help others. The best thing that I can say to everyone is, believe in yourself. Don’t let anyone tell you that you are worthless or no good. Everyone is God’s child. Treat everyone with kindness. Help someone; even just a kind word can change someone’s life.
I wanted to tell my story about what the VOICE has done for me. I wanted to let the buyer of the VOICE know how this paper has changed so many lives, not just mine, but thousands of people since 1997. So, for all of us, we thank you for caring about the VOICE and all us vendors.
The Alliance is proud to be a partner in From Housing to Recovery, a conference running from Sept. 19 through 21 in Tulsa, Okla.
In many ways, this three-day event exemplifies the kind of collaboration and focus we need if we are to address the problem of chronic homelessness and meet the goal of ending it by 2015, as set in the Federal Strategic Plan to Prevent and End Homelessness.
From Housing to Recovery, though initiated by private and non-profit champions in the Tulsa mental health community, is more than a local affair. It’s a national meeting as well, co-sponsored by Mental Health America. The event is about recovery, and it’s about housing, featuring policy, practice and partnership in equal measure. It’s about solutions that work for people and for communities.
Tulsa is an apt setting for a conference of this scope and vision. The 100,000 Homes campaign has recognized the city as a leader among communities making progress in ending chronic homelessness.
At the Alliance’s 2012 National Conference on Ending Homelessness, Greg Shinn from the Mental Health Association in Tulsa presented on the ingredients of Tulsa’s success in the workshop, Chronic Homelessness: Getting to Zero by 2015. According to Shinn, they include:
- Community planning and housing investment
- Integrated recovery for people experiencing mental health and housing crises
- Housing First approaches with person-centered services and coordinated care
- A focus on economic impact and sustainability
- An outcome-oriented, data-driven system redesign
The Alliance agrees with Tulsa that communities dedicated to ending chronic homelessness need to incorporate these vital steps in their plans. We look forward to participating as a partner in the conference next month, and getting better acquainted with the great work going on in Tulsa. It’s not too late to join us!
Photo by Justin Cozart.
In his highlights of the themes of our 2012 National Conference, our Vice President Steve Berg touched on the implications of the U.S. Supreme Court’s interpretation of the Americans with Disabilities Act (ADA) in its 1999 Olmstead decision.
The Supreme Court ruled that the Act requires states to grant people with disabilities the choice of where to live, and that states must avoid placing them in living situations that segregate them from the rest of society. The Olmstead decision, and a number of cases that followed, spoke specifically about state Medicaid programs. However, the Olmstead decision is about “community integration” broadly, and has continues to shape the ways in which state programs and services promote the rights of people with disabilities, particularly their right to live in the least restrictive settings of their choice.
The Department of Housing and Urban Development (HUD) has an interest in upholding Olmstead principles, as it does all federal fair housing provisions. While HUD’s purview may raise thorny questions about what kinds of housing are suitable for disabled people who are experiencing homelessness, an important, practical implication of the Olmstead decision is that it makes more resources available to house people who are experiencing chronic homelessness.
Recently, HUD published guidance about the role of public housing agencies (PHAs) in reducing inappropriate institutionalization of persons with disabilities. It is worth reading the entire document, for it gives needed context to local decision-making that can affect plans to end chronic homelessness.
For example, “persons at serious risk of institutionalization” can be included, along with those who are exiting institutions, in a local preference providing subsidies for people with disabilities. The guidance describes how such a preference can work, and offers other examples of actions a PHA can take to leverage resources and programs to realize Olmstead goals.
When states and localities make Olmstead decisions that affect mainstream housing and services programs, homeless service advocates should be involved. Participation in Delaware, for instance, resulted in people experiencing chronic homelessness being included among other groups of persons with disabilities as a target population.
Here are some ways advocates can connect with Olmstead efforts:
- Learn more about the history of the ADA and Olmstead in your state. Most states have developed ADA compliance plans, with stakeholder consensus. The National Center for Personal Attendant Services tracks Olmstead matters, and updates state-specific plan information. To find these resources, search Olmstead on the main page. Also, the web-based resource, HCBS Clearinghouse, offers information and tools for state Medicaid reform.
- Reach out to statewide disability groups, including state affiliates of the National Alliance on Mental Illness. Look for ways to collaborate on ADA and Olmstead enforcement.
- Advocate for people who are chronically homeless within the diverse communities of people with disabilities people in your state and locality. Describe the systems of care and proven interventions for homeless people, the role of permanent supportive housing, and collaborative possibilities.
U.S. Department of Justice website dedicated to Olmstead.
U.S. Department of Health and Human Services, Office for Civil Rights, Olmstead website.
Image Courtesy of Kate Mereand-Sinha
This past Sunday, July 22, marked 25 years since President Ronald Reagan signed into law the Stewart B. McKinney Homeless Assistance Act, named after congressman from Connecticut who poured a lot of his time and energy into doing something about what was then the new problem of mass homelessness. The final vote in Congress was 65-8 in the Senate and 301-115 in the House. Years later the Act was renamed the McKinney-Vento Homeless Assistance Act, adding the name of Bruce Vento, a congressman from Minnesota whose commitment to the issue matched Representative McKinney’s.
Everyone involved in getting the act passed regarded it as a first step. The bill provided funding that allowed program operators to try out a variety of approaches to solving the problem. With these resources, for more than 10 years, program operators around the country worked to construct an impressive array of shelters, supportive services, and temporary and permanent housing.
Yet when a major federal research study in the late 1990s showed that the number of people experiencing homelessness had not gone down, few people were surprised. If anything, even more people were homeless at that time than in 1987, the year the act was signed into law.
The new resources and new programs had allowed advocates to improve the lives of individuals experiencing homelessness and serve communities where homelessness existed, but the problem of homelessness remained. So a movement to end homelessness began.
It started in the late 1990s and picked up steam in the early years of the new millennium: a data-driven approach that allowed people at the community level to see more clearly what was working and what was not. Homeless assistance practitioners employed annual counts and HMIS, and their emphasis was on getting people back into housing quicker and in greater numbers.
The results, particularly in the years leading up to the recession in 2008, were striking. And thanks to improved methods at the local level and HPRP funds from the federal government, the number of people in shelters and on the streets has continued to decline, even in the midst of widespread unemployment.
We’re living through period of great change in the U.S. On that point we all seem to agree. But we cannot agree on the form that change should take. We agree that people can and should work collectively to make our country better, but how? And what should the role of the federal government play? The continued presence of homelessness in our country calls to everyone for a response.
Can we agree on the answer?
Today’s post was written by Christian Brandt, Federal Policy Intern for the Alliance.
Chances are you’ve heard about the recent instances of violence against homeless people. These attacks are part of the often violent reality of life on the street. On Tuesday, July 10, the Congressional Caucus on Homelessness convened to discuss this growing trend of violence against people experiencing homelessness. Among the panelists were Maria Foscarinis, executive director of the National Law Center on Homelessness and Poverty (NCH), Richard Wierzbicki, Broward County Sheriff’s office captain, and David Pirtle, a man who himself was a victim of violence while living on the street. The panel was moderated by Neil Donovan, executive director of the National Coalition for the Homeless.
In the discussion that took place all panelists agreed that the reason such violent incidents have proliferated is the increasingly de-humanizing lens through which the public sees people experiencing homelessness. Evidence of this can be seen in the rash of so-called anti-homeless laws recently passed in Denver and throughout the country, which criminalize homelessness or make being homeless that much more difficult. These laws contribute to the perception that people experiencing homelessness are somehow less deserving of the dignity, rights and freedoms that people with permanent housing enjoy, a perception many of the perpetrators of anti-homeless violence appear to hold.
Between 1999 and 2010, NCH has documented 1,184 acts of violence by housed perpetrators against people experiencing homelessness.
Following a brief video featuring disturbing footage of attacks, which provided those in attendance with a visceral reminder of the trend of rising violence, Wierzbicki discussed his role in the passage of a piece of legislation in Florida that added homelessness to the state hate crimes law. The bill was inspired by a similar act passed in Maryland a year earlier. Then David Pirtle related his experience with several violent encounters during his period of homelessness, and Maria Foscarinis concluded with comments on current legislation being passed.
The panelists also heard remarks from Representatives Judy Biggert, Alcee Hastings, Geoff Davis, and Eddie Johnson, who are to be commended for launching the Congressional Caucus on Homelessness.
The discussion was not all bad news, however. Panelists lauded the recent passage of the Rhode Island Homeless Bill of Rights as a model for legislation granting more security and humanity to the state’s individuals without homes. Foscarinis emphasized, though, that these kinds of bills will not solve the problem of homelessness. Access to affordable housing, she reminded the panelists and audience, is the best way to help individuals exit homelessness.
The next critical step involves a discussion about how to end homelessness, and how legislation can ensure that individuals experiencing homelessness gain access to the services they so desperately need.
What does the Supreme Court decision on the Affordable Care Act mean for communities poised to use new Medicaid funding to bolster their homeless assistance? First and foremost, communities have to engage more intensively with the state policymaking process – this, actually, was true before the ACA ruling came down. And it will be true no matter what the results of elections in November.
Since the decision, we now know that Medicaid will not expand nationally to cover virtually all uninsured people who earn less than $15,000. Therefore, the presumption no longer holds that virtually all people experiencing chronic homelessness will be able to enroll in Medicaid beginning in 2014. But states do have the option to expand in 2014, taking advantage of substantial federal Medicaid subsidies to do so. The ACA cannot require states to expand their programs, but still offers to pay them 90-100% of the cost of covering all uninsured adult citizens who earn around $15,000 or less annually.
Access to health care services – including behavioral health and recovery support – can be a key part of successful housing outcomes for the 107,000 people who experience chronic homelessness on any given night. Without funding for health care, many communities struggle for sustainable solutions – specifically, adequate permanent supportive housing (PSH), which is proven effective to address chronic homelessness. Since Congress passed the ACA in 2010, homeless assistance systems have anticipated the Medicaid expansion – to help individuals and to enhance safety net capacity.
Full Medicaid coverage will not be a “given” in every state. The Supreme Court ruling means additional challenges for the national agenda to end chronic homelessness by 2015. According to the U.S. Interagency Council on Homelessness, 60 percent of the nation’s chronically homeless population is concentrated in six states – California, Florida, Georgia, Louisiana, New York and Texas. Four of these – California, Florida, Georgia and Texas – were projected to have the highest increases in Medicaid enrollment as a result of the ACA. Only two, New York and California, have indicated an intention to move forward with Medicaid expansion.
To see what might happen in your state, this map and this map from Think Progress are handy starting places. A note of caution: There are many unknowns about how this part of ACA implementation will actually unfold. To name a few:
- How many states will take up the expansion, despite what their governors said in the wake of the Supreme Court decision?
- In the states that do expand, what services and supports will be covered?
- Will ACA implementation really take place as soon as 2014?
- Can a state opt in after 2014?
While these and other questions are sorted out, it is more important than ever for homeless advocates to inform state leaders and community partners in the full debate about health care priorities. The necessary policy choices to support communities will be steps that integrate housing, health care, and behavior health/recovery resources at the community level.
- For chronically homeless populations, permanent housing is the first prescription, with person-centered services and supports to stabilize housing.
- Opting into the ACA Medicaid expansion will bring federal resources directly to these vulnerable individuals – who otherwise are among the highest users of state and local safety net resources.
- Failing to opt in means continued pressure on the capacity of state mental health programs and public safety operations.
Further, a number of promising Medicaid provisions remain in effect, including those meant to improve community supports for especially vulnerable enrollees, including those who are eligible because of a qualifying disability. These options were designed to be targeted to those most in need, and they tend to be less politicized. One example is the Medicaid health home. This optional benefit for people with severe mental illness (and other chronic conditions) pays for broadly-defined service coordination.
Several states, including New York, Missouri, Oregon and Rhode Island, have already opted to set up health homes. States can also offer home and community based services (HCBS) without applying for a federal waiver. In a recent proposed rule, Medicaid officials indicated that permanent support housing qualifies as a “community setting” for HCBS. Homeless advocates can join forces with advocates for older and disabled people, to press for their states to adopt these options in a way that adds to the capacity of homeless assistance.
Many states and communities have already embraced health care reform since the ACA passed in 2010. Often, homeless advocates have been at the table with Medicaid leaders, forging new strategies to integrate housing solutions with health care services to address chronic homelessness. The Alliance is paying close attention to successful new approaches and emerging best practices, especially in supportive housing. Speakers with hands-on experience and up-to-date policy knowledge will present on these topics at the July 16-18 National Conference on Ending Homelessness in Washington, DC.