Why can’t they get along? Agencies need to come together on supportive housing

Despite encouragement from the U.S. Supreme Court’s Olmstead decision and the increasing restlessness of advocates for the disabled, there still is very little of the interagency collaboration and policy development that is needed to bring about the level of supportive housing required to serve multiple populations, a new study says.

On June 22, 1999, the Supreme Court held in Olmstead v. L.C. that the unnecessary segregation of individuals with disabilities in institutions may constitute discrimination based on disability, according to the Bazelon Center for Mental Health Law in Washington, DC. The court ruled that the Americans with Disabilities Act may require states to provide community-based services rather than institutional placements for individuals with disabilities.

As a result of the Olmstead decision, thousands of people who now live in restrictive settings such as public institutions and nursing homes must be offered housing and community-based supports that are consistent with the Americans with Disabilities Act’s integration requirements.

But most states aren’t prepared to take bold steps in this direction, especially since such steps will require diverse agencies to work together on planning and funding, including finding the very large amounts of money needed despite a down economy.

The lack of effort is documented in a report, Olmstead and Supportive Housing: A Vision for the Future, issued by the Center for Health Care Strategies and echoed by advocates for the mentally and physically disabled.

Shift in approach

One of the challenges, according to Ann O’Hara of the Technical Assistance Collaborative in Boston, the group hired by the Center for Health Care Strategies to research and write its report, is to move public policy from thinking in terms of an older "continuum" model of housing to thinking of mainstream housing with supports as needed.

"The old housing model fit with a theory of disability that intended to move people through a progression of treatment to the point that they would no longer be disabled and need help," Ms. O’Hara tells State Health Watch. "But in the last 20 years we’ve come to realize that many people with disabilities always will have their disabilities and it’s best to offer them help and support. Why should we shove people through different housing situations predicated on their getting better? It’s better if we help them live in normal housing with the level of support they need."

The unbundling of housing from supports creates a new imperative for coordination, Ms. O’Hara says, and it’s important that the need for coordination not result in people being unable to get service. "Without bundling, the service system is under less of an obligation. The service system needs to do the right thing when people are in normal housing. We have to stay in touch and respond as needed."

The push for supportive housing, she says, is a disability rights issue that flows out of the desire of people who have disabilities to live in their own homes. It goes along with the move toward educational mainstreaming, treating those with mental illness episodically rather than confining them to institutions, and providing community living arrangements for the physically disabled rather than placing them in nursing homes.

A few states, such as Connecticut, Maryland, Ohio, and Oregon, began working on supportive housing even before the Olmstead decision. The key, according to Ms. O’Hara, was leadership at the top of the human services system that made a commitment to do housing differently and was determined to find a way to make it work.

"They generally began by accepting that social service agencies had to put some housing money on the table as an incentive for the housing agencies to respond," she says. "When you unbundle housing and supports you have to figure out where the housing money will come from. Ohio, for example, started a capital fund for housing development for people with disabilities. They use it in combination with traditional affordable housing programs."

The capital funding comes from county mental health and mental retardation systems that have access to state agency capital funding for housing, "bridge subsidies," and county funded services to leverage permanent rental assistance resources from the Department of Housing and Urban Development (HUD).

Making money available from social service agencies is an important way to get the attention of the housing system, Ms. O’Hara says. Those working on supportive housing need to be prepared to hear that the housing system already is overburdened with need and already doesn’t have enough resources to serve all those who qualify. The problem, of course, in a time with budget shortfalls and increased demands for funds for homeland security and health care, is that many state social service agencies don’t have funds available to put up as bait to get their state housing agency’s attention.

Kathleen McGinley, deputy director for public policy for the National Association of Protection & Advocacy Systems in Washington, DC, tells State Health Watch that the need for additional housing is becoming more acute as housing prices go up and people with disabilities don’t have the income they need to compete in the housing market.

If the problem is to be solved, she says, HUD must recognize that people with disabilities are their customers. "HUD has never focused on people with disabilities. Until they start to think of this constituency with a broad view, the message won’t be passed to states and communities that they need to be active in developing adequate housing."

Use plan to make changes

One path to action, according to Ms. McGinley, can be the "consolidated plan" that is required to obtain some HUD funding. Communities are supposed to file the plans and people with housing needs, including the disabled, are to be involved in plan development. But too often those with disabilities have been left out because planners believe that all they need are group homes. "HUD requires that people with disabilities be included, but it doesn’t enforce that requirement," Ms. McGinley says. "The disability community has spent years learning the disability system. Now we need to learn a generic system so we can get our fair share from a variety of programs."

Despite the economic slowdown, the Bush administration has indicated an interest in addressing the problem and there is some congressional support as well.

Ms. McGinley says that for the first time, an administration is talking about putting some money into a HUD voucher program for people with disabilities that is on the books but never got funded under the Clinton administration.

She says she is putting her faith in that kind of effort from HUD because she says she can’t conceive of a time when agencies actually will work together cooperatively on an integrated funding stream.

While the dollars being sought by the Bush team may not be sufficient, she says, it’s a step in the right direction. "The overall HUD budget request seems very reasonable, although there are some holes in it. I think the administration’s voucher request will be funded, and there may be some congressional interest in increasing the level of funding. Whether we can get a major change in the next three to five years will depend on the economy. The disabled are moving to 100% community-based. When you look at all the [funding] streams involved, much of what is being done now could be lost if our country’s financial problems continue."

Strong congressional support for housing supports also is predicted by Andrew Sperling, director of legislative affairs for the National Alliance for the Mentally Ill in Arlington, VA. He praises the Bush administration for a budget proposal to end chronic homelessness over the next decade through two approaches: (1) development of interagency cooperation to the point that HUD is taken out of the business of funding services and there is reliance on resources from other agencies that should more appropriately be paying for services, and (2) continuing support for permanent housing in existing programs.

Mr. Sperling says that while there is considerable support for renewing existing programs, it’s harder to get members of Congress to buy into the notion of forcing other agencies to put some of their funds into housing services. "Funds now go out mostly in block grants that have significant deference to states," he explains. "It’s hard to mandate that states use some of the funds for housing services."

In predicting what will happen in the budget debate, he sees some form of compromise after the House agrees to the president’s request but the Senate Democrats won’t go along.

Ms. O’Hara says one goal for the report is to encourage states to become players in the housing debate. "The ideal target for our report is policy-makers at the state level who need to see strategies about where the money is and how linkages can be made," she says. "We’re trying to be careful not to prescribe just one way to address the problem because states have different situations. Everything is subject to the unique opportunities and barriers that present themselves in each state."

One thing that may hasten state action, she says, is increased agitation from advocates for the disabled. "Most advocates have been working with states on their Olmstead responses and waiting to see what the states do," O’Hara says. "States haven’t felt the pressure from advocates that they might feel if the Olmstead planning doesn’t get to its intended result. My sense is that some groups that have been waiting and watching are reaching the end of their patience.

"We need to realize that this is much bigger than just Olmstead. It’s about how people with disabilities want to live in communities today. Major changes are needed in state housing policy so that the needs of the disabled are included. So far, we don’t have a movement sweeping the country. It’s just happening in pockets here and there."

[Contact Ms. O’Hara at (617) 742-5657, Ms. McGinley at (202) 408-9514, and Mr. Sperling at (703) 576-7222.]