Access: The TAC Blog

Leading experts report from the intersection of affordable housing, health care, and human services policy.

April 2020: Housing Vouchers for People with Disabilities — A Valuable Resource during the COVID-19 Crisis

Posted Thursday, April 23, 2020 by Lisa Sloane, M.P.A.,
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Recent events make it clearer than ever that housing equals health. TAC’s comprehensive database of Housing Choice Vouchers targeted to people with disabilities has been updated this month to reflect new awards from HUD. Read More

 

A SAFE, AFFORDABLE HOME is physically and emotionally the healthiest place for any individual or family — not only during this crisis, but any time. The U.S. Department of Housing and Urban Development’s (HUD) targeted voucher programs can help people with disabilities (including those who are experiencing homelessness, at risk of homelessness, or living in nursing facilities or other institutions) move into an affordable apartment in the community. TAC’s comprehensive database of Housing Choice Vouchers (HCVs) targeted to people with disabilities has been updated this month to reflect new awards from HUD.

Recent events make it clearer than ever that housing equals health. TAC hopes this database of HUD resources will help to improve the health and housing situation for you or those you serve.

How can the database be useful during this crisis?

This is a difficult time for many local public housing agencies (PHAs); administering voucher programs remotely is challenging. However, HUD has recently issued COVID-19 statutory waivers that strongly encourage PHAs to conduct critical operations that can be done remotely, and that help families use vouchers to lease-up safe, affordable housing.

The database provides information about programs targeted to specific populations:

  • Mainstream vouchers are Housing Choice Vouchers targeted to non-elderly persons with disabilities. HUD made awards of these vouchers in 2018 and 2019, and is expected to make additional awards this year. In recent funding rounds, PHAs were strongly encouraged to target these vouchers to non-elderly people with disabilities who were homeless, living institutions, or at risk of either of these situations.
  • Nonelderly Disabled (NED) Vouchers assist non-elderly individuals and families with disabilities to access affordable housing on the private market. NED Category 2 vouchers are specifically targeted to non-elderly persons with disabilities who reside in nursing homes or other health care institutions to transition into the community.
  • The HUD-Veterans Affairs Supportive Housing (VASH) program combines rental assistance for homeless Veterans with case management and clinical services provided by the Department of Veterans Affairs (VA). The VA’s HUD-VASH staff prioritize and select Veteran households for a HUD-VASH voucher and refer the Veteran to the local PHA. (Note that to be eligible for VASH, Veterans must be homeless but do not have to have a disability.)
  • The Family Unification Program (FUP) provides rental assistance for two populations: (1) Families for whom the lack of adequate housing is a primary factor in the imminent placement of the family’s child or children in out-of-home care, or the delay in the discharge of the child or children to the family from out-of-home care. (2) Youth ages 18 to 24 who have left or will be leaving foster care.

Aren’t all these vouchers already in use?

There is a broad range of utilization across these programs. HUD’s data for the end of December 2019 indicates that some PHAs had leased 100 percent of their units while others had leased none of their units. That means that thousands of vouchers across these different targeted programs remained available at the end of 2019. While HUD reports increasing utilization of Mainstream vouchers, each PHA will differ — so the possibility is worth exploring.

How can I find out whether these vouchers are available in my community?

To find out which agencies administer these vouchers in your community, select your state in the online TAC Database, and look for your specific area. If you learn that your community does have a special voucher program, use the data on page six of the HUD HCV Data Dashboard to check your PHA’s recent voucher utilization rate.

What if all the vouchers in my community are already in use?

Public housing agencies are required to maintain a single waiting list for the HCV program. Even if the waiting list is generally closed, it may be open for a specific voucher type. Contact your PHA to ask how to apply for the special voucher program. For HUD-VASH, contact the HUD-VASH staff at your local VA facility to find out how a Veteran would apply.

 


News, Resources, & Happenings at TAC: October 2019

Posted Wednesday, October 2, 2019
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An international mental health leadership exchange and a learning collaborative on housing and hospitals both offer valuable opportunities for peer-to-peer education. Read More

An International Gathering to Strengthen Behavioral Health Leadership

Kevin Martone, TAC's Executive Director, recently joined colleagues from eight other countries for a Knowledge Exchange on Mental Health Policy, one of three tracks in the International Initiative for Mental Health Leadership Exchange in Washington, DC. Peer to peer, participants shared perspectives, questions, and solutions on common challenges in their very different countries - such as coordinating effective collaborative advocacy, making mental health parity a reality, and exploring the potential of telehealth. In addition to his presentation "That Was (Not) Easy!: Implementing Science to Policy," Kevin also participated in an invitation-only group focused specifically on rural mental health issues in different countries.

Housing and Healthy Communities: A Learning Network

Safe, decent, affordable housing is known to be a significant "social determinant of health" that can contribute to improved management of physical and behavioral health conditions. Affordable housing with supportive services is recognized for its potential to reduce emergency department visits and hospital admissions, as well as shortening average length of stay in inpatient settings. In growing recognition of these facts, hospitals and health systems across the country are considering their role in improving access to affordable housing in the communities that surround their facilities.

TAC has convened a peer-to-peer learning network of hospital systems from across the country to facilitate this important exploration. Subject matter experts and participants share knowledge and ideas in monthly calls focused on topics such as leveraging hospital resources, building multi-hospital partnerships and community collaboratives, identifying priority populations, setting performance measurements, evaluating short- and long-term outcomes, sustaining partnerships, and designing communication strategies to convey community impact.

TAC is proud to bring nationally recognized innovators to this monthly series to address the needs of both urban and rural hospitals as they design community-specific plans that meet the needs of priority patient populations. To learn more about this project, be on the lookout for a December post on Access: The TAC Blog. Should your hospital system be interested in joining a future learning network to explore or facilitate planning for housing partnerships, email TAC Senior Associate Rachel Post

STAFF ACTIVITIES

TAC Associate Jennifer Ingle conducted a series of trainings with the Cambridge (MA) Multi-Service Center on the Principles of Housing First, Motivational Interviewing, Co-Occurring Disorders & Trauma, and De-escalation Techniques; Senior Associate Lauren Knott led off a panel discussion on "Innovations in Youth Collaboration: Best Practices in Creating and Engaging a Youth Action Board" at this year's Point Source Youth symposium; Senior Associate Nicole LiBaire was interviewed about post-disaster community resilience for the article "Dedicated to Recovery" in the Chico News & Review; Executive Director Kevin Martone co-authored, with Human Services Director Francine Arienti and Senior Consultant Sherry LerchOlmstead at 20: Using the Vision of Olmstead to Decriminalize Mental Illness; Senior Consultant Lisa Sloane facilitated the panel "Mainstream Vouchers: Overcoming Obstacles" at the 2019 NAHRO Summer Conference; together with two additional co-authors, Senior Consultant John O'Brien and Senior Associate Tyler Sadwith published "Leveraging Medicaid to Combat the Opioid Epidemic: How Leader States and Health Plans Deliver Evidence-Based Treatment" on the Health Affairs blog; Senior Associate Rachel Post presented in a SAMHSA webinar on "Housing First and Permanent Supportive Housing: Funding and Policy Considerations," and on "Using Peer Providers in Supportive Housing Programs"at the Washington State Peer Pathways Conference; and an article by TAC consultant Naomi Sweitzer, "Building Relationships between HUD Multifamily Property Owners & CoCs," was published by the United States Interagency Council on Homelessness.

STAFF TRANSITIONS

Congratulations to Lauren KnottAshley Mann-McLellan, and Douglas Tetrault, who have all advanced to become TAC Senior Associates. And a round of applause to Senior Associate Melany Mondello, who has completed her M.B.A.!


October 2018: Recovery Housing and the Importance of Choice

Posted Wednesday, October 10, 2018 by Rachel Post, L.C.S.W.
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With growing recognition of housing as a critical determinant of health and recovery, we must thoughtfully consider what kinds of housing can best help people with addictions optimize their potential for recovery and re-stabilize their lives. Read More

The destructive nature of substance use disorders and the influence of active addiction on people’s behavior can often lead to homelessness. In fact, The Substance Abuse and Mental Health Administration (SAMHSA) estimates that 38 percent of individuals experiencing homelessness are dependent on alcohol, while 26 percent abuse other drugs, including opioids. With growing recognition of housing as a critical determinant of health and recovery, we must thoughtfully consider what kinds of housing can best help people with addictions optimize their potential for recovery and re-stabilize their lives.

Two recognized housing approaches intended to help people with substance use disorders (SUDs) transition from homelessness are “recovery housing” and Housing First. These approaches operate differently and have unique histories — yet rather than advocate for one over the other, I suggest that fully supporting both approaches should be our priority.

Alcohol and drug-free (recovery) housing is a critically important and currently under-resourced intervention. It can be operated with tiered levels of supports that are matched with the needs of residents, including more intensive supportive services for those exiting homelessness to self-governed Oxford Houses or Recovery Homes. Many residents of recovery housing attest to their need for this safe and supportive living environment in order to promote their long-term recovery from addiction, their health and wellness, and their ability to stay stably housed. 

In the Housing First model, the top priority for service providers is to help individuals and families secure permanent housing. Often the term “low-barrier” is applied in this model, indicating that there are no conditions on tenancy, such as sobriety or participation in treatment. Housing First is based on evidence that stable, lease-based housing plus voluntary acceptance of services can help people make progress on addressing their mental health and addiction disorders.

My advocacy for both models is rooted in 17 years of work on programs designed to help this population. Indeed, my work starting Housing First programs at Central City Concern (CCC) in Portland, Oregon and at Colorado Coalition for the Homeless in Denver was inspired in part by wanting to make sure we were "throwing everything that worked” at ending chronic homelessness and addiction. At CCC, the idea of adding Housing First programming was initially met with some resistance, especially by colleagues who were themselves in long-term recovery. Over time, however, people began to see the value and successful outcomes of offering housing that was paired with individuals’ choices.

Recovery housing can be very effective for clients who are self-initiating detox and treatment. When evidence-based supported employment services, peer recovery mentors, and coordinated outpatient treatment were incorporated into CCC’s recovery housing, we found that high percentages of individuals with primary SUDs who had been homeless completed treatment and remained housed and employed one year post-exit.

With evidence supporting both approaches to housing for people with SUDs, providers and policymakers must be open to a range of approaches to address the diverse preferences and needs of the individuals they hope to serve. For this reason, when I shared the effectiveness of CCC’s recovery housing programs with federal agencies and stakeholders around the country, I also spoke (and still do) about the importance of ensuring housing choice for homeless people with SUDs.

Likewise, the Department of Housing and Urban Development (HUD) discussed in its 2015 Recovery Housing Policy Brief the value of promoting individual choice among housing options for homeless individuals. The brief encouraged expanding the supply of permanent supportive housing and other models that use a low-barrier, Housing First approach, so as not to exclude a large number of people who are unprepared to meet sobriety or abstinence requirements. But HUD also affirmed the importance of providing recovery housing options for people who want and need a sober-living environment. HUD’s Policy Brief outlines the characteristics, practices, and outcomes it expects from recovery housing funded with its homeless dollars.

The expansion of recovery housing received broader federal support in the 2016 Surgeon General’s Facing Addiction in America report, and in another report issued in 2017 by the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Earlier this year, the National Council for Behavioral Health (NCBH) issued a Recovery Housing Guide to help states include high-quality recovery housing among the options offered by their behavioral health systems. NCBH followed this guide with a letter to every Single State Agency, alerting them to SAMHSA’s unprecedented decision to allow State Opioid Response Grants ($930 million) to fund supportive services for individuals with opioid use disorders in recovery housing. 

Research is needed on the long-term effectiveness of both recovery housing and Housing First programs for people with primary SUDs. For now, states and local jurisdictions can use the practices described in the HUD and NCBH policy briefs to expand the capacity of recovery housing and improve the practices of existing programs. Recovery housing can promote housing tenure, long-term recovery, reunification with families and children, economic and educational advancement, improved health and wellness, and community involvement. Many of my colleagues whose experience of recovery housing helped cultivate my understanding of the model also report perhaps the most significant outcome of all: They say they owe their lives to it.

Current legislation in Congress addressing the nation’s opioid crisis has wide bipartisan support and includes several provisions to provide housing-related assistance for people in recovery from SUDs. As the final bill becomes law, states and communities working to combat both addiction and homelessness will become better able to offer housing choice that includes robust recovery housing programs.


March 2018: Significant Affordable Housing Opportunities for People with Disabilities in the FY 2018 Omnibus Spending Bill

Posted Wednesday, March 28, 2018 by Lisa Sloane and Gina Schaak
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Thanks to the hard work and dedication of advocates across the country, the FY 2018 Omnibus Spending Bill passed by Congress and signed by the president offers the chance at permanent housing for thousands of people with disabilities. Read More

 

THE OMNIBUS BUDGET BILL for Fiscal Year 2018, passed by Congress and enacted by the president last week, includes a ten percent ($4.6 billion), one-year increase to the U.S. Housing and Urban Development (HUD) budget overall and gives especially strong support to housing programs serving people with disabilities.

Affordable Housing for People with Disabilities — Highlights

  • $400 million (est.) will go to new Section 811 mainstream vouchers for non-elderly people with disabilities. TAC estimates these funds will provide nearly 50,000 new vouchers for people with disabilities!

  • $82.6 million for new Section 811 Project Rental Assistance (PRA) capital advances and Project Rental Assistance. This increase may provide an opportunity for states that have not yet received PRA funds to benefit from this program!

Other Good News

  • $130 million increase for Homeless Assistance grants. The National Alliance to End Homelessness estimates that this increase will be enough to move 20,000 to 25,000 more people from homelessness to permanent housing.

  • $40 million for new supportive housing for homeless veterans with disabilities, through the HUD-Veterans Affairs Supportive Housing (VASH) program.

  • $20 million for new Family Unification Program vouchers that target two populations: (1) families unifying with children who were placed or are at imminent risk of placement out of the home due to lack of adequate housing for family, and (2) youth (18 to 24 years old) who are aging out of the foster care system.

  • A 12.5% increase in the Low Income Housing Tax Credit allocation and a 30% increase in the HOME Investment Partnerships Program (HOME), both of which will help states and localities to increase affordable housing production.

Thanks are due to all of the disability, homelessness, and affordable housing proponents across the country whose hard work and advocacy have ensured that thousands more people with disabilities will have the chance to live in safe, affordable apartments — rather than in institutions, in shelter, or on the streets. Thanks especially to Rep. Rodney Frelinghuysen, outgoing chair of the House Appropriations Committee, who has been a steadfast supporter of housing for non-elderly people with disabilities.


December 2017: Affordable Housing for People with Disabilities

Posted Tuesday, December 12, 2017 by Kevin Martone, L.S.W.
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Over the last decade, increased rental demand combined with development primarily at the high end of the market has led to record-low vacancy rates, higher rents, and increased competition for affordable and subsidized housing. This overall market trend is reflected in the ever-worsening affordability gap for extremely low-income renters with disabilities. Read More

The tenth edition of the Priced Out: The Housing Crisis for People with Disabilities report, released today by TAC and our partners at the Consortium for Citizens with Disabilities Housing Task Force, once again demonstrates that non-elderly adults with disabilities who rely on Supplemental Security Income (SSI) are among the groups most severely affected by the extreme shortage of affordable rental housing across our nation.

Over the last decade, increased rental demand combined with development primarily at the high end of the market has led to record-low vacancy rates, higher rents, and increased competition for affordable and subsidized housing. This overall market trend is reflected in the ever-worsening affordability gap for extremely low-income renters with disabilities. 

Supplemental Security Income is the federal income maintenance program that assists people with significant and long-term disabilities who have virtually no assets and — in most instances — no other source of income. The national average rent for a studio/efficiency unit in 2016 was $752, equal to 99% of a monthly SSI payment. In thirteen states and the District of Columbia, areas with the highest housing costs in the nation, the average studio/efficiency rent exceeded 100% of the income of an SSI recipient.

This housing affordability crisis deprives hundreds of thousands of people with disabilities of a basic human need: a place of their own to call home. Because of the disparity between SSI income and rental housing costs, non-elderly adults with significant disabilities in our nation are often forced into homelessness or segregated, restrictive, and costly institutional settings such as psychiatric hospitals, adult care homes, nursing homes, or jails.

Ideally, there would be enough job opportunities that match the skills of people with disabilities and pay a livable wage so that all could afford housing in their communities. However, as the National Low Income Housing Coalition documents in its 2017 Out of Reach report, it would require more than two full-time jobs at the federal minimum wage to pay for a one-bedroom apartment at fair market rent.

Federal rental assistance — meaning a subsidy that helps renters pay no more than 30% of their income for housing — is the key to solving the housing crisis that has been documented in Priced Out reports over the past 19 years. Unfortunately, because of funding limitations that have grown worse in recent years, federal rental subsidy programs currently reach only 35 of every 100 extremely low-income households; with incomes equal to only 20% of area median income, one-person households receiving SSI fall within this category. This shortfall translates into long waiting lists at Public Housing Agencies and affordable housing developments, and a critical shortage of permanent supportive housing opportunities for people with significant disabilities who have SSI-level incomes.

A unified advocacy effort by the disability community is needed to support and potentially expand permanent supportive housing programs along with other rental assistance strategies. Providing housing assistance to people with the most significant and long-term disabilities is not only the right thing to do, but is also more cost-effective than perpetuating the alternatives: costly institutional care, uncontrolled expenses to the health care system, and homelessness.


August 2017: News, Resources, and Happenings at TAC

Posted Thursday, August 17, 2017
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TAC joins coordinated actions to protect federal funding for housing, while states take steps to make community integration accessible to all. Read More

Our Homes, Our Voices — No Housing Cuts!

TAC staff headed over to historic Faneuil Hall a few weeks ago, where we joined hundreds of other housing and disability rights advocates, subsidized housing residents, and community leaders to tell the federal government: NO CUTS TO HOUSING! The Boston rally was organized by our friends at the Citizens' Housing and Planning Association in coordination with events held around the country. Check out our Facebook photo album to see a few of the speakers we cheered for, and take a look at #OurHomesOurVoices on Twitter for a national snapshot.

 

New Action Plan Launched for Permanent Supportive Housing in North Carolina

Many of the strategies in North Carolina's 2017 Permanent Supportive Housing Action Plan are based on a Permanent Supportive Housing Assessment with Recommendations to Comply with the Olmstead Settlement produced by TAC. The shared vision for permanent supportive housing in North Carolina connects people to affordable, integrated, and supportive housing by leveraging resources and collaborating with all levels of government and private agencies.

CMS Helps States to Foster Community Living Opportunities

The Centers for Medicare and Medicaid Services (CMS) has announced a second round of the State Medicaid-Housing Agency Partnerships track in its Medicaid Innovation Accelerator Program (IAP). The goals of this track are to develop public and private partnerships between state Medicaid and housing systems and to support states in creating detailed action plans that foster community living opportunities for Medicaid beneficiaries. TAC is part of the IAP technical support team that will work from August 2017 through April 2018 with eight states: Alaska, Massachusetts, Michigan, Minnesota, Nebraska, Texas, Utah, and Virginia. Visit the CMS website to learn more.

TAC Staff in Action

STAFF ACTIVITIES

TAC Associates Phillip AllenEllen Fitzpatrick, and Ashley Mann-McLellan and Senior Associate Melany Mondello attended the National Conference on Ending Homelessness in Washington, D.C. last month, with presentations by Phil on the SSVF System Assessment Toolkit and by Ashley on the intersection of housing, mental health, and substance abuse; Jon Delman, Senior Associate, was an invited participant in SAMHSA's expert resource meeting on "Advancing Behavioral Health Treatment & Recovery through Technology" and led a workshop on "Fighting for our Livelihoods: Developing Job Opportunities for Economic Self-Sufficiency" at the National Empowerment Center's Alternatives Conference; Associate Lauren Knott and other experts helped out at a forum for SAMHSA's 10 Youth Homelessness Demonstration communities; Executive Director Kevin Martone described the importance of affordable housing for people with disabilities at a #NoHousingCuts Congressional reception organized by Monarch Housing Associates of New Jersey; Kevin also spoke on the role of community-based mental health services and housing in reducing reliance on emergency and inpatient care in his address to mental health authority leaders gathered at the National Association of State Mental Health Program Directors' annual conference; and Senior Consultant Jim Yates was promoted to the rank of Colonel in the Army National Guard - congratulations, Jim!

STAFF TRANSITIONS

We are happy to welcome Hawo Osman as a TAC intern this summer. Hawo is a rising senior at Medford High school and joins us through the Boston Center for Independent Living’s Transition Internship Program.


April 2017: News, Resources, and Happenings at TAC

Posted Thursday, April 27, 2017
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TAC and Boston leaders build partnerships between affordable housing developers and service providers to end homelessness. Read More

Appealing to Affordable Housing Developers in Boston

When affordable housing developers and service providers collaborate, new possibilities open up for people who have been homeless to make the transition to being long-term, successful tenants. TAC, together with the Boston Department of Neighborhood Development and Mayor Marty Walsh, led a convening at City Hall on April 13 to foster such partnerships and specifically to encourage the implementation of homeless veteran and “move on” preferences in affordable housing properties. Speakers described the key role that prioritizing vacant units for populations such as homeless veterans and supported housing residents plays in Boston’s efforts to end homelessness. TAC Associate Ashley Mann-McLellan, who helps communities across the U.S. build public-private partnerships to implement homeless preferences in HUD-assisted housing, explained how developers can adopt homeless preferences with the support of service providers to ensure successful results for everyone: new tenants, their neighbors, and property staff.

TAC Staff in Action

Senior Associate Jon Delman has joined the board of the Association for People Supporting Employment First – MA chapter; Senior Consultant Sherry Lerch presented to the leadership of AbbeHealth in Cedar Rapids, IA on ways to maximize the effectiveness of permanent supportive housing; Associate Ashley Mann-McLellan led a two-day, customized workshop on Housing First for providers in Long Island, NY, and a training on property owner engagement for organizations serving homeless veterans in Denver, CO; Executive Director Kevin Martone taught a class this semester to 3rd and 4th year medical students at Tufts University Medical School, on “Mental Health Systems and Public Health”; at the National Council for Behavioral Health Conference in Seattle, WA, Senior Consultant John O’Brien presented on Medicaid strategies for supportive housing and co-led a recovery housing workshop; Senior Policy Advisor Lisa Sloane and Associate Ellen Fitzpatrick — plus a film crew — headed to Maryland, Minnesota, and Louisiana to work on our forthcoming videos about the HUD 811 Project Rental Assistance program; Senior Consultant Jim Yates presented on “National Trends in Supportive Housing” at the Housing Leadership Group Summit in Albuquerque, NM, and on the National Housing Trust Fund at the National Low Income Housing Coalition’s Legislative Forum in Washington, DC; Jim has also been conducting strategic planning sessions in communities that are part of HUD’s Vets@Home initiative;  the TAC Supportive Services for Veteran Families team was instrumental in planning and delivering eight regional meetings for SSVF grantees and their community partners, as well as together with key partners at Abt Associates eight locally driven community meetings around the country to help Continuums of Care in their efforts to end veteran homelessness.


February 2017: Can States Take On the Fiscal Responsibility that Federal Policymakers Are About to Hand Them?

Posted Wednesday, February 8, 2017 by Kevin Martone, M.S.W.
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A few weeks ago, I had the opportunity to explain to a roomful of congressional staffers the profound impact that a repeal of Medicaid expansion would have on individuals with substance use disorders - and on the systems that serve them. In the questions that followed, an underlying theme was evident: Would lost Medicaid revenue and other federal resources be replaced by state funds to pay for such services? This issue has far-reaching implications for all of our nation's safety net programs. Both my current work with state systems across the country and my experience as a former state commissioner of behavioral health make clear to me that states are in no position to absorb the transfer of fiscal responsibility they are about to receive from federal policymakers. Read More

A FEW WEEKS AGO, I had the opportunity to explain to a roomful of congressional staffers the profound impact that a repeal of Medicaid expansion would have on individuals with substance use disorders - and on the systems that serve them. In the questions that followed, an underlying theme was evident: Would lost Medicaid revenue and other federal resources be replaced by state funds to pay for such services? This issue has far-reaching implications for all of our nation's safety net programs. Both my current work with state systems across the country and my experience as a former state commissioner of behavioral health make clear to me that states are in no position to absorb the transfer of fiscal responsibility they are about to receive from federal policymakers.

Systems Work Better Together

In every state, there are vulnerable populations whose complex challenges require coordinated solutions that use federal and state funding. In recent years, awareness has grown in both the health care and affordable housing communities of the positive outcomes to be attained by leveraging these resources together. State Medicaid directors have become educated on the costs to their programs of individuals with chronic health conditions who are homeless, at risk of homelessness, or living in substandard housing. Likewise, affordable housing leaders have learned that lack of access to health insurance, and especially to integrated behavioral and primary health care services, jeopardizes housing stability. States are becoming sophisticated in their use of interventions that build on this new understanding, such as supportive housing - an approach that combines affordable housing assistance with wraparound supportive services. Such states have increasingly demonstrated cost savings in their systems.

The availability of federal funding has afforded states the opportunity to improve the lives of millions of children and adults. The option to expand Medicaid through the Affordable Care Act (ACA) allowed states to increase access to care for populations with many health needs, create better health care delivery systems, and save taxpayer dollars. Federal funding was the incentive needed for 31 states and the District of Columbia to expand coverage, while states that did not expand Medicaid still rely on significant federal support to operate their traditional Medicaid programs. Federal housing assistance programs have been a critical resource for millions of seniors, people with disabilities, and people living on very little income - though a significant gap remains between available assistance and need.

Shifting the Burden to States

The imminent repeal of Medicaid expansion and the ACA, and proposals to convert Medicaid to a block grant or per capita program, threaten millions of people's access to health care, with disproportionate consequences for vulnerable populations. While these changes will create significant savings for the federal government, states will in turn experience both immediate and long-term pressures to fill the void - allegedly in exchange for more control and "flexibility." Under a block grant plan previously proposed by former House Budget Chair and Health and Human Services Secretary nominee Tom Price, the Medicaid and Children's Health Insurance Program would receive 34 percent less funding in 2025 than under the current federal law.

Decreases in affordable housing assistance resulting from cuts to non-defense discretionary (NDD) programs like those at HUD will disproportionately affect the same populations impacted by cuts in Medicaid. We don't have to look too far back to see how this plays out: the March 2013 sequestration cuts forced state and local housing agencies to decrease the number of households using tenant-based vouchers by more than 80,000. About half of all voucher recipients are seniors or people with disabilities, most of whom live on fixed incomes such as Social Security or Supplemental Security Income (SSI) and rely on Medicaid. In not a single rental housing market in the country can a person with a disability who is living on SSI afford housing at the "fair market rent" determined by HUD. According to the National Low Income Housing Coalition, the United States has a shortage of 7.2 million rental units affordable to extremely low-income renter households. Yet President Trump has proposed a one-percent reduction to NDD each year for the next ten years. Even a simple freeze, suggested by several members of Congress, would result in the defunding of housing vouchers currently used by more than 100,000 families in 2017 alone.

Faced with such a significant loss of federal support, Democratic and Republican governors, legislators, and mayors will have to make some very difficult budgetary decisions. Will these leaders, as many have suggested, find ways to sustain access to health benefits, affordable housing assistance, and social services once federal policymakers shift the financial burden onto states?

Hard Choices

Recent history shows that as resources are squeezed, many states are unable or unwilling to prioritize vulnerable populations. Most Medicaid expansion states were in a position to increase coverage only because of significant federal matching. Without such support, states have generally opted to provide only limited benefits to people who are traditionally ineligible for Medicaid, and several states have established highly restrictive eligibility criteria. Economic downturns can create added challenges for states as tax revenues decrease while unemployment and enrollment in Medicaid increase. According to the U.S. Government Accountability Office (GAO), during the nation’s last recession, Medicaid enrollment grew by 14.2 percent from October 2007 through February 2010. During the same period, total Medicaid expenditures grew nearly 21 percentfrom $332.2 billion in 2007 to $401.5 billion in 2010.

To reduce program spending, the GAO noted, states generally make certain changes to their Medicaid programs, such as altering payments to providers, limiting eligibility, eliminating optional services, or reducing the amount, duration, or scope of services covered. Even as need rose, states cut funding for a range of services by 4.2 percent in fiscal year 2009 and an additional 6.8 percent in 2010, according to estimates by the National Association of State Budget Officers (NASBO). In 2011, two-thirds of states cut provider payments, and 18 states reduced Medicaid benefits. The recession of 2009–2012 resulted in losses of over $4 billion from public behavioral health systems across the country, losses from which they have still not fully recovered.

Most states have allocated resources to support housing assistance for low-income populations. A report prepared by the Technical Assistance Collaborative in 2014 indicated that 34 states offer some type of rental assistance or homelessness prevention funds (e.g. security deposits). However, there is wide variation in the number of individuals such programs can support, and program funding tends to fluctuate annually due to state budget pressures. Indeed, a NASBO survey conducted in the fall of 2016 indicated that in 24 states, general fund revenues for 2017 are coming in below projections, the greatest number of states expecting revenue shortfalls at this time in the fiscal year since 2010. Nineteen states reported net mid-year budget reductions in fiscal 2016, a historically high number outside of a recession period.

There is indisputable evidence that the availability of health insurance and access to health care and affordable housing improve people's lives. As lawmakers contemplate dramatic reductions that will hurt people and economically burden states, we find ourselves at a pivotal point. There is little evidence to suggest that state governments can or will assume the financial responsibility offloaded by the federal government under current proposals. Yet, it is state and local budgets that must absorb the preventable economic consequences when individuals engage costly, crisis-oriented health care, correctional, and homelessness systems. Federal policymakers must understand that a cost shift to states under the guise of flexibility and efficiency will have dramatic and unfortunate consequences for vulnerable individuals and their families.


News, Resources, & Happenings at TAC: February 2017

Posted Thursday, February 2, 2017
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TAC consultants educate leaders on the vital importance of housing and health care. Read More

Core Principles for Housing and Health Care Policy: A Statement from TAC

TAC's Board of Directors met on December 8, 2016, to discuss the ways our organization can help ensure that leaders make informed decisions about proposed changes to health care and insurance, affordable housing, social and economic policies, and the other programs that form our country's safety net. On January 10, we issued a statement of the principles that will guide our work and advocacy in the months and years ahead.
Read the full statement.

Educating Congress on the Important Role of Medicaid in Preventing and Treating Substance Abuse Disorders

On January 25, TAC Director Kevin Martone and other panelists addressed some 70 congressional staffers representing legislators of both parties. Organized in partnership with the National Council for Behavioral Health, this event offered lawmakers the opportunity to learn that decreased federal support would have a devastating effect on state substance use treatment systems - and showed them why preservation of coverage for individuals with substance use disorders is crucial.

Melville Charitable Trust Roundtable Highlights Housing Program Progress

Since 2012, HUD has awarded Section 811 Project-based Rental Assistance (PRA) funds to 28 states and the District of Columbia. By establishing state-level partnerships among housing, Medicaid, and human services agencies, these state grantees have been able to develop integrated, affordable, accessible housing opportunities - with access to voluntary supports - for people with disabilities who have extremely low incomes. Under contract with the Department of Housing and Urban Development (HUD), TAC is a provider of TA for these Section 811 PRA grantees. On January 12, TAC facilitated a Melville Charitable Trust-sponsored roundtable event to discuss the demonstration program's progress. The roundtable included participants from six states (MN, NJ, PA, MD, TX, and LA), HUD staff, the National Council of State Housing Agencies, the National Low Income Housing Coalition, and the Center on Budget and Policy Priorities. A lively discussion focused on recommendations to increase access to affordable housing, leverage resources effectively, and identify best practices in service delivery.

TAC Staff in Action

Staff Activities

Associate Ashley Mann-McLellan recently led a workshop for funders in Seattle/King County, WA on how to incorporate Housing First principles into their requirements, contracts, and monitoring processes - and, together with Associate Lauren Knott, conducted a Housing First training for the Cambridge (MA) Continuum of Care;Working with the Supportive Services for Veteran Families (SSVF) program and the U.S. Interagency Council on Homelessness, TAC Associate Doug Tetrault helped plan and facilitate a community meeting for 60 local stakeholders focused on effectively ending veteran homelessness in Orlando, FL; Senior Associate Jon Delman's symposium on "Successfully Employing Young Adult Peer Mentors: From Research to Practice with the Employer Toolkit" has been accepted by the Psychiatric Rehabilitation Association for its 40th annual Wellness and Recovery Summit; Kevin Martone, TAC's Executive Director, spoke at a Congressional briefing this month on "Expanding Access to Care," hosted by the National Council for Behavioral Health; Kevin also spoke at the National Press Club on December 12 as part of the National Governors' Association event "Housing as Health Care: A Roadmap for States"; and in December, Senior Policy Advisor Lisa Sloane presented on Louisiana's Section 811 PRA program at a public workshop hosted by the National Academies of Sciences, Engineering, and Medicine; and Associate Amy Horton and Senior Associate Gina Schaak volunteered at Boston's Homeless Count the night of January 25.

TAC Transitions

Congratulations to Liz Stewart on her promotion to Senior Associate with the TAC housing team!