Residential Care and Assisted Living Compendium: 2007. Expanding the Supply of Assisted Living for Low Income Individuals

11/30/2007

Both federal and state governments recognize that, in order to reduce costly institutionalization, a range of supportive housing and service options is needed. An increasing number of persons 65 and older who can no longer live independently view assisted living as a preferred alternative to nursing home care, or as a means to forestall admission to a nursing home. But market-rate assisted living that provides private rooms and a high level of services is generally far beyond the means of most low income elderly persons.

There are several sources of funding available to finance the development or renovation of housing to create affordable assisted living. The Federal Government’s main vehicle for creating affordable housing is the low income housing tax credit program. Other sources of funding are programs in the U.S. Department of Housing and Urban Development (HUD) and USDA, and state programs. These departments provide funds to both finance new housing units and provide rental assistance in existing housing. However, not all programs that create and/or support affordable housing can be used for affordable assisted living.

Developing affordable assisted living is a complex undertaking. Different statutory authorities and administrative structures, and a lack of communication among those who manage housing and service programs, present major difficulties. A major issue for some housing subsidy programs is that the lenders and investors they depend on require evidence of a stable revenue source over the life of their commitment to protect their investment -- typically 15-30 years. But state service programs may be unable to provide a stable revenue source because they are subject to annual appropriations that depend on the state’s budget.

Additionally, despite targeting the same or similar populations, housing and service programs have different and often conflicting income, age, and functional eligibility rules that make it difficult to create the supportive housing plus services arrangements that frail elderly persons need. Medicaid program requirements can also pose barriers to the receipt of services in residential care settings (e.g., Medicaid’s rules regarding financial eligibility and post-eligibility treatment of income may limit an individual’s ability to pay for room and board).

Housing programs also have conflicting requirements. Yet, successful projects often need to combine funding from multiple housing finance programs (e.g., low income housing tax credits, HUD’s HOME program, the Federal Home Loan Bank’s Affordable Housing Program, conventional debt, and Housing Choice Vouchers), with two or more service subsidy programs (e.g., Medicaid state plan or waiver programs, state supplements to the SSI program, state-funded service programs).34

At the state level, some agencies that manage Medicaid waiver programs have begun working with state and local housing agencies and non-profit housing organizations to explore ways to combine housing subsidies with Medicaid services. At the federal level, HUD and HHS are currently looking at ways in which the agencies can work together to expand housing and service choices for people with disabilities.


34. Robert Jenkens, Deputy Director, Coming Home Program, Vice President, NCB Development Corporation. Personal communication, June 2004.

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