In 2009, the U.S. Department of Housing and Urban Development (HUD), in partnership with the Centers for Medicare and Medicaid Services (CMS), announced the availability of nearly 1,000 housing choice vouchers (HCVs) to low-income, non-elderly individuals with disabilities who were residing in institutions, with the intention of making rental costs affordable for those who wished to return to the community. This report presents the findings from an evaluation of the implementation and effects of this Non-Elderly Disabled Category 2 (NED2) HCV program.
The origins of the HUD HCV program for institutionalized non-elderly disabled (NED) individuals between the ages of 18 and 62 can be traced to the 1999 U.S. Supreme Court ruling in Olmstead v. L.C. (527 U.S. 581) that people with disabilities are entitled to receive services in "the most integrated setting appropriate."1 This ruling required states to expand options for individuals with disabilities to live in community residences rather than institutions. The availability of affordable, accessible housing is central to making community-based independent living possible for adults with disabilities. Yet, a decade after the Olmstead v. L.C. (527 U.S. 581) decision, the ability to make a transition from institutional care to the community continues to be hindered by the unavailability of appropriate housing.
Non-elderly Medicaid beneficiaries who are disabled and receiving institutional care--most of whom qualify for Medicaid through eligibility for and receipt of Supplemental Security Income (SSI)--have extremely low incomes; incomes of those receiving SSI averaged less than $8,100 a year in 2011 (Social Security Administration 2011). These beneficiaries also need a wide range of health care and social services and supports. Medicaid institutional care is costly, however, and studies have shown that, by comparison, home and community-based care produces an average savings of nearly $44,000 per individual among people of all ages (Kitchener 2006). Moreover, individuals who successfully make the transition from an institution to the community typically experience an improvement in quality of life (Simon 2011). Consequently, federal and state governments have sought to improve the capacity of long-term services and support systems to serve people with disabilities in the community rather than in institutions.
Since 1999, the Federal Government has authorized several grant and demonstration programs designed to help individuals residing in institutions move back to the community. One of the largest of these demonstration programs, administered by CMS, is the Money Follows the Person (MFP) Demonstration, initially enacted under the Deficit Reduction Act of 2005 and extended through 2016 by the Patient Protection and Affordable Care Act of 2010. By December 2011, the program had awarded MFP grants to 43 states and the District of Columbia and had helped nearly 20,000 disabled and elderly Medicaid beneficiaries make transitions to home or community residences. Nearly every state MFP program, however, has cited an insufficient supply of affordable, accessible housing and/or housing vouchers as persistent barriers to allowing more individuals to transition into the community (Lipson et al. 2011; Williams et al. 2012).
In 2010, the average one-bedroom apartment cost more in rent annually than the entire annual income of an individual receiving SSI, and "there was not one state or community in the nation where a person with a disability receiving SSI could afford to rent modest rental housing without a permanent rental subsidy" (TAC 2011). To help low-income individuals with disabilities obtain housing, the Federal Government has, over the years, authorized a variety of subsidy programs, including the Section 811 Supportive Housing for Persons with Disabilities program, which provides funds for the development of affordable housing linked with services and supports, and the HCV program, which provides direct subsidies to offset rental costs. Over the past decade, however, the Section 811 program has produced fewer units than needed to keep up with demand, and the demand for HCVs has far exceeded the supply, as well. As a result, individuals must often wait months or years for either type of housing assistance.
Through the 2009 federal Community Living Initiative, launched on the 10th anniversary of the Olmstead v. L.C. (527 U.S. 581) decision, the U.S. Department of Health and Human Services and HUD collaborated to identify ways to improve the NED population's access to housing, community supports, and independent living arrangements. In 2010, Congress passed the Frank Melville Supportive Housing Investment Act, which reformed and revitalized the Section 811 program to address many of its limitations and permanently designated 55,000 HCVs for NED individuals.
To address specifically the needs of people living in institutions or those at risk of long-term institutionalization, HUD, in collaboration with CMS, announced on April 7, 2010, a Notice of Funding Availability (NOFA) for Rental Assistance for Non-Elderly Persons with Disabilities [HUD NOFA, FR-5332-N-02].2 Its purpose was to expand the availability of rental subsidies for people who would be at risk of institutionalization or a long-term stay in an institution without such assistance.3 This funding ultimately supported 4,321 HCVs for NED households currently living in the community and at risk of institutionalization (Category 1) and 948 HCVs for NED individuals seeking to make a transition to the community from an institution (Category 2). The latter are the focus of this report.
To be eligible to apply for the NED Category 2 voucher program (henceforth referred to as NED2), HUD required local public housing authorities (PHAs), which handle local administration of HCVs, to partner with a state health and human services (HHS) agency or an MFP program (MFP) that would be responsible for arranging access to health and support services, including case management, needed by voucher recipients. HUD also required applying PHAs to demonstrate that they had experience in serving the NED population and resources for supportive services available to them through their partnership with the state HHS/MFP agency.
Of the more than 3,400 PHAs nationwide, 68 submitted qualifying applications for NED2 vouchers. Because the number of vouchers requested exceeded available funds, HUD used a lottery system to award 948 NED2 vouchers to 28 PHAs in 15 states, listed in Table I.1. When HUD made the awards in January 2011, it did not specify an official date by which unissued vouchers would expire or be recalled. It indicated to PHAs, however, that they were expected to issue and lease4 all NED2 vouchers within one year--that is, by January 2012.5 Throughout 2011, local HUD offices monitored PHAs' progress and provided guidance to those within their jurisdictions. To provide technical assistance (TA) to PHAs and to state HHS/MFP programs, CMS contracted with New Editions Consulting, which also provided TA separately to all MFP grantees. New Editions subcontracted with the Technical Assistance Collaborative (TAC), an organization that specializes in housing needs among low-income people with disabilities; together, the two entities provided limited general TA to all PHAs receiving awards, as well as more in-depth TA to five states to strengthen their housing-MFP collaborations.6
To receive a NED2 voucher, an individual must meet certain eligibility criteria. According to the NOFA, a NED family is one in which the head member, spouse, or sole member is a person under the age of 62 who has a disabling condition. HUD defines an individual with a disability as "any person who has a physical or mental disability that substantially limits one or more major life activities; has a record of such an impairment; or is regarded as having such an impairment" (24 Code of Federal Regulations 8.3). The applicant must also meet HUD's HCV income eligibility requirements.7 Although applicants are not required to be Medicaid recipients, those approved are likely to be Medicaid eligible, given HUD's low-income eligibility threshold. Finally, a potential voucher recipient must reside in an eligible institution at the time the voucher is awarded.8
In December 2011, nearly a year after the awards, only about one-third of the 948 vouchers had been leased (that is, used to rent a unit), with some PHAs reporting no vouchers in leased status. HUD officials urged the PHAs to step up efforts to issue and lease the vouchers, and HUD, CMS, and the TA providers focused their assistance on identifying and overcoming reported roadblocks.
In the next chapter, we explain the reasons for this unexpected result and examine how the program was implemented in 13 PHAs that were awarded more than 35 vouchers each to assess whether certain approaches to the implementation process appeared to contribute to greater or lesser success in leasing the vouchers within the original expected time frame. Then, in Chapter III, we examine the impact of the NED2 vouchers on the rate of transitions among the eligible population. In Chapter IV, we bring together results from both process and impact analyses to draw lessons to apply to similar programs and policies intended to help individuals in institutions move to and live independently in the community.
|TABLE I.1. Awarded NED2 HCBS, by State and by PHA|
|State||PHA||HHS/MFP Partner|| Number of
|Arizona||Pima County||Pima Health Systems, Department of Developmental Disabilities, Community Partnership of Southern Arizona||25|
|California||Orange County Housing Authority||Dayle McIntosh Center||50|
|City of Pasadena Community Development Commission||Alternative Home Care||40|
|County of Santa Barbara Housing Authority||Tri Counties Regional Center||25|
|County of Santa Clara Housing Authority||Silicon Valley Independent Living Center||10|
|Alameda County Housing Authority||East Bay Innovations||10|
|Florida||Collier County Housing Authority||David Lawrence & National Alliance on Mental Illness||25|
|Georgia||City of Decatur||Georgia Department of Medical Assistance||35|
|Illinois||Oak Park Housing Authority||Illinois Department of Healthcare & Family Services||15|
|Springfield Housing Authority||Springfield Center for Independent Living||10|
|Maryland||Baltimore County Housing Office||The Coordinating Center||50|
|Housing Authority of Baltimore City||The Coordinating Center||40|
|Maryland Department of Housing & Community Developmentb||Maryland Department of Health & Mental Hygiene||12|
|Howard County Housing Commission||The Coordinating Center||10|
|Massachusetts||Lynn Housing Authorityb||Massachusetts Executive Office of Health & Human Services||35|
|Michigan||Traverse City Housing Commission||Northern Healthcare||10|
|New Jerseya||New Jersey Department of Community Affairs||Division of Mental Health & Addiction Services, Division of Developmental Disabilities, Division of Disability Services||100|
|New York||Town of Amherst||Headway of Western New York, Western New York Developmental Disabilities Services Office; Erie County Department of Mental Health||20|
|North Carolina||Housing Authority of the City of Wilmington||Money Follows the Person||5|
|Ohio||Cincinnati Metropolitan Housing Authority||Ohio Department of Jobs & Family Services||100|
|Lucas, Ohio Metropolitan Housing Authority||Lucas County Department of Jobs & Family Services||60|
|Pennsylvania||Dauphin County Housing Authority||Center for Independent Living of Central Pennsylvania||10|
|Texas||Austin Housing Authority||Texas Department of Aging & Disability Services, Austin Resource Center for Independent Living||36|
|Washington||Housing Authority of the City of Tacoma||Department of Social & Health Services||100|
|Housing Authority of Snohomish County||Department of Social & Health Services||50|
|City of Longview Housing Authority||Department of Social & Health Services||35|
|Housing Authority of the County of Clallam||Department of Social & Health Services||15|
|Housing Authority of the City of Yakima||Department of Social & Health Services||15|
|Total NED2 Vouchers Awarded||948|