President's New Freedom Commission: Report on Housing and Homelessness

President's New Freedom Commission:
Report on Housing and Homelessness

NYAPRS Note: Following is an introductory excerpt from the newly released full version of the Report on Housing and Homelessness that guided the President's New Freedom Commission on Mental Health in these areas. The report can be found in its entirety at

http://www.mentalhealthcommission.gov/papers/Homeless_ADA_Compliant.pdf.

The President's New Freedom Commission on Mental Health appointed 15 subcommittees to assist in its review of the Nation's mental health service delivery system. The full Commission appointed a Chair for each subcommittee. Several other Commissioners served on each subcommittee, and selected national experts provided advice and support.

The experts prepared initial discussion papers that outlined key issues and presented options for consideration by the full subcommittee. The subcommittee reported to the full Commission only in summary form. On the basis of this summary, the full Commission reached consensus on the policy options that were ultimately accepted for inclusion in the Final Report, Achieving the Promise: Transforming Mental Health Care in America. Therefore, this paper is a product of the subcommittee only and does not necessarily reflect the position of the full Commission or any agency of the United States Government.

SUBCOMMITTEE ON HOUSING AND HOMELESSNESS: BACKGROUND PAPER

Defining the Issues

The ability to choose a home without discrimination, to live in a home without interference, to seek and be granted reasonable accommodations where they are necessary, and to find and acquire accessible housing are essential first steps for people with serious mental illnesses and other disabilities to live in the mainstream of our society.

The mission of the President's New Freedom Commission on Mental Health was to recommend improvements to enable adults with serious mental illnesses and children with serious emotional disturbances to live, work, learn, and participate fully in their communities. To live and participate in the community, one must have a place to live, a place to call home.

Housing

Housing is more than a basic need. Living in one's own home also brings new freedoms and responsibilities and marks the transition to adulthood in contemporary American culture. Finding and maintaining a home is a fundamental indicator of success in community life (Pitcoff, Schaffer, Dolbeare, & Crowley, 2002).

The lack of decent, safe, affordable, and integrated housing is one of the significant barriers to fully participating in community life for people with serious mental illnesses (DHHS, 1999). Today, many people with serious mental illnesses do not have decent, safe, and affordable housing that meets their preferences and needs.

Consumers also want access to services and supports that reinforce their dignity, independence, and ability to live in the community.

Homelessness is the most visible manifestation of the housing and support service problems of people with mental illnesses.

The lack of affordable housing and accompanying support services often causes people with serious mental illnesses to cycle between jails, institutions, shelters, and the streets; to remain unnecessarily in institutions; or to live in large, segregated facilities or substandard housing.

People with serious mental illnesses also make up a large percentage of those who are repeatedly homeless or who are homeless for long periods of time (Burt, 2001; Culhane, Metraux, & Hadley, 2002; Levy, 2002). People with mental illnesses who are precariously housed are at risk of becoming homeless and face the constant stress of losing their housing or living in dangerous and unsafe housing conditions.

Even when consumers access affordable housing, keeping that housing may be difficult. While some State and local mental health systems are learning the complexities of government-subsidized housing programs, often, too little attention is paid to providing the supportive services that can ensure long-term housing retention and community stability. This absence of ongoing supports has left many consumers with troubled tenant histories and higher rates of incarceration, both of which can lead to long-term ineligibility for Federal housing programs, such as Section 8 vouchers and public housing (Tsemberis & Eisenberg, 2000).

Homelessness

Homelessness is the most visible manifestation of the housing and support service problems of people with mental illnesses. People with mental illnesses and, in particular, people with co-occurring mental illnesses and substance use disorders, make up a significant percentage of people who are chronically homeless (i.e., they have been either continuously homeless for a year or more or have had at least four episodes of homelessness in the past three years).

People who are chronically homeless and have mental illnesses are likely to have acute and chronic physical health problems; exacerbated, ongoing psychiatric symptoms; excessive alcohol and drug use; and a higher likelihood of victimization and incarceration (Tsemberis, 2000).

To help people who are homeless and have mental illnesses as well as those at risk of homelessness access decent and affordable housing and supportive services, mental health systems must call on the leadership, commitment, resources, and efforts of all stakeholders in both the mental health and affordable housing systems.

Issues Descriptiion and Analysis

Understanding and addressing the housing and homelessness issues that confront people with serious mental illnesses requires analyzing six key issues:

1. HOUSING AFFORDABILITY

People with severe mental illnesses, including those who receive Supplemental Security Income (SSI) benefits, often have serious difficulties affording housing (HHS, 1999; TAC, 2003).

2. CORRELATION BETWEEN MENTAL ILLNESSES AND HOMELESSNESS

There is a strong correlation between mental illnesses and homelessness. A recent study by the Urban Institute found that approximately 46% of people who are homeless have a mental illness (Burt, 2001).

3. INCREASED HOUSING DEMAND FROM THE OLMSTEAD DECISION

The U.S. Supreme Court Olmstead decision, which affirmed the integration mandates of the Americans with Disabilities Act (ADA) will likely increase the demand for integrated and affordable housing for people with serious mental illnesses (Allen, 2001).

4. STIGMA, DISCRIMINATION, AND NIMBY ATTITUDES

Stigma, housing discrimination, and "Not in My Back Yard" (NIMBY) attitudes are barriers to accessing integrated, community-based housing (National Council on Disability, 2001; HHS, 1999).

5. RESPONSE FROM THE AFFORDABLE HOUSING SYSTEM

Historically, the nation's affordable housing system has not been responsive to people with serious mental illnesses (U.S. DSSS General, 1999; TAC and CCD Housing Task Force, 2000).

6. RESPONSE FROM THE MENTAL HEALTH SYSTEM

Mental health systems vary in how successfully they have addressed consumers' housing needs, housing choices, and access to community-based supports to sustain tenure in housing (Emery, 2001).

In the remainder of this chapter we describe and analyze each of these six issues in detail.

ISSUE 1 Housing Affordability

Although some mental health consumers may have additional issues related to housing, they share the same housing affordability problems experienced by all low-income households in the United States.

The generally accepted standard of housing affordability for very low-income households is that total housing costs should not exceed 30% of monthly income. According to the Federal government, very low-income households paying more than 50% of their income for housing are "seriously rent burdened" and have "worst case" housing needs (HUD, 2001).

The U.S. Department of Housing and Urban Development (HUD) reports that as many as 1.4 million adults with disabilities who receive SSI have worst-case housing needs, approximately 25% of the total number of households with worst-case housing problems (HUD, 2001).

A new study by the Technical Assistance Collaborative (TAC) finds that people with serious mental illnesses and other disabilities relying solely on SSI benefits (currently $545 per month) have incomes equal to only 18% of median income and cannot afford decent housing in any of the 2,703 HUD-defined housing market areas of the United States (TAC, 2003). TAC found that in 2002, people with serious mental illnesses receiving SSI would need to pay, as a national average, 105% of their monthly SSI benefit to rent a modest one bedroom apartment, clearly impossible (TAC, 2003).

The decline in the number of affordable housing units being produced has exacerbated affordability problems (Millennial Housing Commission, 2002). The Millennial Housing Commission appointed by Congress recently documented the growing mismatch between the number of extremely low-income renter households and the number of units available to them with acceptable quality and affordable rents. The Millennial Housing Commission noted that despite "persistent and growing need, it has been more than 20 years since an active Federal housing production program was designed to serve extremely low-income households."

ISSUE 2 Correlation Between Mental Illnesses and Homelessness

Homelessness in the United States endures as a significant problem despite Federal, State, and local initiatives. Approximately 637,000 adults in the U.S. are homeless on any given night, with 2.1 million people experiencing at least one episode of homelessness over the period of a year (Burt, Aron, Lee, & Valente, 2001).

Characteristically, people who cycle in and out of homelessness or are homeless for long periods of time tend to have disabling health and behavioral health problems. In What Will It Take to End Homelessness?, Burt (2001) states that 31% of individuals using homeless services reported a combination of mental health and substance-use problems within the previous year. An additional 15% reported mental health problems only. It is clear from this self-reported data that people with serious mental illnesses and substance-use disorders are particularly vulnerable to becoming homeless.

The symptoms resulting from serious mental illnesses also increase vulnerability to homelessness. Without appropriate services and supports, people with mental illnesses may exhibit behaviors that threaten housing stability,e.g., they may disturb neighbors, miss rent payments, and neglect their housekeeping, any of which may lead to eviction. They may also have difficulty with relationships, resulting in conflicts with landlords and neighbors. These conflicts can result in homelessness, unless appropriate services and supports are made available.

Fragmentation, a lack of resources, and the continuation of traditional models of service delivery have all contributed to the difficulties that mental health systems have meeting the multiple needs of mental health consumers who are homeless. These needs cross many service systems and include adequate food, clothing, income support, and physical health care. None of these services are effective unless safe, decent, affordable housing is also available and sustained.

ISSUE 3 Increased Housing Demand from the Olmstead Decision

On June 22, 1999, the Supreme Court of the United States issued its decision in Olmstead v. LC, a case brought by two women with mental illnesses who, despite their treatment team's decision that they were ready to live in the community, continued to be confined to a State psychiatric hospital in Georgia. The court described Georgia's action as "unjustified isolation" and determined that States may be violating Title II of the Americans With Disabilities Act (ADA) if they provided care to people with disabilities in institutional settings when they could be appropriately served in a community-based setting (Allen, 2001).

The Olmstead decision has been widely interpreted to apply to people with mental illnesses living in institutions or other restrictive settings, as well as to people at risk of institutionalization. The Court was also clear that State discharge policies that result directly in homelessness could also violate the ADA.

Given the broad scope of the decision, mental health authorities will undoubtedly face a greater demand for community-based housing and support services from people living in institutions, overly restrictive board and care homes, nursing homes, homeless shelters, and other settings (Allen, 2001).

ISSUE 4 Stigma, Discrimination, and NIMBY Attitudes

When discrimination and NIMBY ("Not in my backyard") attitudes intervene, they stigmatize, isolate, and remove free choice and the opportunity to live as part of the community of all Americans (National Council on Disability, 2001).

By the end of the 1980s, two sets of policies were enacted to provide the Federal government the necessary tools to combat housing discrimination: the Fair Housing Amendments Act of 1988 and HUD regulations enforcing Section 504 of the Rehabilitation Act of 1973.

The latter policy, Section 504, required recipients of Federal funds (including State and local housing agencies receiving HUD funds) to ensure that their programs and activities were accessible to people with disabilities.

Despite the protections provided in these laws, housing discrimination is still a serious problem for people with disabilities and, in particular, for people with mental illnesses (Abt Associates, 2000). People with disabilities file 42% of the housing-discrimination complaints that HUD receives and were the largest single group of complainants in 1999 and 2000.

Despite this increasing demand for HUD action, HUD's fair-housing enforcement activities diminished during the 1990s. The average age of complaints at their closure was 497 days in FY 2000, nearly five times the 100-day period that Congress set as a benchmark. While HUD has developed important guidance and resources to support enforcement of Section 504, this information is not widely disseminated to individuals or entitie affected by the law (National Council on Disability, 2001).

ISSUE 5 Response from the Affordable Housing System

Federal housing programs and policies are administered primarily, although not exclusively, through HUD. The Federal government also has:

Rural housing programs administered by the U.S. Department of Agriculture, Federal Low Income Housing Tax Credits administered through the U.S. Department of the Treasury-IRS, Veterans Affairs mortgages for single family homes, and Loans and grants offered through the Federal Home Loan Bank.

Only a few States and localities put their own funds into housing for extremely-low income households.

Several major barriers prevent people with serious mental illnesses from obtaining more access to government housing programs.

Affordable housing programs are extremely complex, highly competitive, and difficult to access. During the 1990s, the Federal government devolved decisionmaking for most housing programs to State and local housing officials, State Housing Finance Agencies, and Public Housing Agencies who may not understand or prioritize the needs of people with mental illnesses.

The flexibility within many Federal programs means that State and local officials can provide a range of homeownership and/or rental housing opportunities for households with incomes up to 80% of median income. People with incomes as low as SSI benefits cannot afford many of these options.

While some States and cities have created policies to assist people with the most severe disabilities, including mental illnesses, other jurisdictions need assistance in developing relevant and responsive policies.

Also, less Federally funded housing is available for people with mental illnesses and other disabilities. Since 1992, approximately 75,000 units of HUD public housing have been converted to "elderly only" housing, and more units are being converted every year.

Federal public housing reform legislation adopted in the late 1990s makes it more difficult for people with poor tenant histories, substance use disorder problems, and criminal records to qualify for Section 8 vouchers and public housing units. Consumers who are fortunate enough to receive Section 8 vouchers sometimes cannot use the vouchers because:

1. The cost of available rental units may exceed voucher program guidelines, particularly in high-cost housing markets;

2. Private landlords may refuse to accept vouchers; and

3. Comprehensive housing search assistance may not be available to consumers.

Unfortunately, State and local mental health agencies sometimes find it difficult to establish effective partnerships with housing agencies.

ISSUE 6 Response from the Mental Health System

Housing and the services consumers need to access and retain housing are not always a high priority for State and local mental health systems. Conventional categorical funding streams, bureaucratic program requirements, administrative approaches to resource allocation and management, and even staff skills are often not geared toward rigorously supporting consumers in normal housing (Carling, 1992).

Persons who are chronically homeless must often navigate a fragmented service system, often leading to gaps in the social services safety net (HHS, 2003). Mainstream social services, including mental health systems, traditionally have not been responsive to the needs of persons who are homeless (Schwab Foundation, 2003).

Coverage gaps are a critical issue. Mainstream payers who cover mental health services typically prefer traditional office-based care.

This approach does not provide the flexibility and mobility necessary to support and sustain consumers in their housing.

In addition, traditional case managers must deal with larger caseloads, leaving them less time to provide the more intensive support typically needed by persons with serious mental illnesses, such as found in the Assertive Community Treatment (ACT) case management approach (Morse, 1999).

Although Medicaid law permits States to cover a full array of comprehensive community-based services, many States have not used options, such as targeted case management and the rehabilitation option, to help with housing supports.

Categorical or "silo" funding streams make it difficult to serve the multiple needs of people who are homeless and have serious mental illnesses. Many have more than one diagnosis, requiring the coordination of many separate funding streams. Although some service providers have become quite creative at putting together coordinated funding sources, coordination doesn't solve the problem of funding inflexibility or duplication that exists across systems of care.

The mental health system is responsible for providing services to consumers who are homeless, as well as to those who are not. In practice, systems actually have duplicate support programs, one set of programs for consumers receiving mainstream mental health services and another specifically for consumers who are homeless.

The mainstream systems may have had some prior contact with some individuals who are homeless and have mental illnesses and may still be in contact through inpatient and emergency room services. As consumers become chronically homeless, the mainstream service system often does not have the readiness, flexibility, or desire to stay involved. If consumers who are homeless are fortunate enough to obtain permanent housing, mainstream staff are often unprepared to deliver the services that are necessary for them to maintain stable housing.

Individuals who are homeless and have mental illnesses are eligible for a plethora of mainstream health, social services, and income support programs that are available for all low income people. However, they often face significant enrollment barriers, such as the lack of a fixed address. Although States have the authority to allow certain health care providers to "presumptively" enroll individuals who appear to be eligible in Medicaid (e.g., children and pregnant women), this authority has not crossed over into the adult mental health system.

Consumers who are homeless may wait six months or more to be eligible for Medicaid, and, in the meantime, they may be unable to access permanent supportive housing and/or some of the services provided in permanent supportive housing.

Finally, the mental health system has not been overly responsive to a client-centered approach to service delivery. Many mental health systems are based on a medical model and do not see housing as their responsibility.

The findings from a recent demonstration program of SAMHSA's Center for Mental Health Services clearly indicate that: Consumers prefer a housing-first approach that houses the individual or family immediately and involves aggressive outreach, placement in permanent housing, and the availability of appropriate support services; and Consumers are much more responsive to accepting treatment after they have housing in place (Rosenheck, Morrissey, & Lam, 1998; Shinn & Baumohl, 1999).

Source: New Freedom Commission on Mental Health

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