Health, Housing, and Service Supports for Three Groups of People Experiencing Chronic Homelessness. Notes


  1. Some homeless persons with a qualifying mental illness may not be enrolled in Medicaid but they are likely to be eligible for Medicaid enrollment. Providers of services in PSH can usually assist these people to establish eligibility for Medicaid benefits, so our description of these three groups assumes that these people will be included in Group 3.

  2. PSH is a phenomenon of the 1990s and 2000s, when homeless assistance systems evolved and their goals shifted and changed. PSH beds available to end people’s homelessness went from about zero in the late 1980s to estimates of 114,000 beds in 1996 (Burt et al., 1999), 177,000 beds in 2006, and 236,000 beds in 2010 (DHUD 2011, chapter 5). The number of PSH beds added to the stock for the 10 years between 1996 and 2006 was about 6,300 beds a year, while for the 5 years between 2006 and 2010 almost 12,000 beds were added annually. The increased production reflects the push by many communities since the mid-2000s to use PSH to end homelessness, and especially to end it for those who have been homeless the longest.

  3. A person can lose SSI and/or Medicaid benefits by being incarcerated, hospitalized, or residing in some other institution for a specified period of time. Benefits loss may also occur through failure to respond to requests from the Social Security Administration (SSA) or Medicaid offices for information about current income, and residential status, and Continuing Disability Reviews.

  4. The “chronic AND vulnerable” people comprised 34 percent of all homeless people surveyed.

  5. The states of Connecticut, Maine, and Rhode Island; Los Angeles County; Portland/Multnomah County, Oregon; and Seattle/King County, Washington.

  6. If a disabling impairment would still exist if the person stopped using drugs or alcohol, it is acceptable as a basis for SSI eligibility. If, however, drug abuse or alcoholism is deemed “material” to the disability because evidence establishes that the person would not be disabled if the drug or alcohol use stopped, the condition is not a basis for SSI eligibility, and an application would be denied (Post et al., 2007).

  7. Since they do not have SMI, they are not eligible for PSH run by mental health agencies that operate programs that rely on funding that can be used only to serve people with SMI.

  8. Eligibility is never guaranteed, however, because SMI can be a moving target--both state mental health authorities and SSA, which administers SSI, have gone through periods of greater and lesser inclusiveness in the level of severity and the duration of the condition they require to qualify someone for benefits (Livermore, Stapleton, and Zueschner, 1998; Rupp and Stapleton, 1998). These pendulum swings are usually in response to either budget considerations, which push in the direction of tighter controls and fewer people being approved for benefits, or concerns that people who are “eligible on paper” are being denied, which push in the direction of more-lenient cutoffs and greater inclusiveness.

  9. "Operating" housing means doing whatever it takes to keep rental units and buildings functional and the financial structure sound. This includes setting and collecting rents; maintaining the premises; making repairs; attending to security; assuring that heat, light, and other utilities function; paying taxes; and, if necessary, evicting tenants. The costs associated with doing these things are operating expenses. Tenant rents are one source of funds to cover operating expenses, but most PSH projects need additional funds to supplement rents if they are to cover most of their operating costs.

  10. Generally psychiatric emergency and inpatient services are delivered by public systems and not by PSH service providers.

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