1. Permanent Supportive Housing: A Key Ingredient to Recovery for Consumers Presentation to the NAMI Maryland Conference Andrew Sperling Director of Legislative Advocacy NAMI National andrew@nami.org October 18, 2013

2. Permanent Supportive Housing (PSH) A cost effective intervention Numerous studies document cost effectiveness of providing permanent housing for people with disabilities: –New York/New York Culhane study on permanent supportive housing –University of Washington study in JAMA on “Housing First” –Massachusetts study on chronically homeless people –Health Affairs study on Medicaid long-term care costs

3. 3 Legs of the PSH Stool 1.Capital –Investment to acquire or rehabilitate a property, “bricks and sticks” 2.Ongoing rent or operating subsidy –Difference between tenant contributions and housing operating costs (utilities, insurance, contribution to reserves, etc., NOT supportive services) 3.Housing related support services –Case management, peer support, rehabilitation, etc., NOT medication or therapy Can be financed through the Medicaid Rehabilitation option

4. Housing First Effective tool in ending chronic homelessness Avoids “managing” chronic homelessness through institutional costs such as shelters, corrections, public and emergency services Building flexible, individualized services such as medical, mental health, substance abuse and vocational services around housing

5. Housing First (continued) Studies demonstrate that cost savings are dependent on housing stability Three major features 1.Simple expeditious application process, 2.No requirement for tenant to participate in or complete treatment prior to obtaining structured housing, intensive case management available once housed, 3.Conditions of tenancy do not exceed normal conditions for other leaseholders.

6. Where do People with Disabilities Live? TAC “Worst Case” Needs Report –1.1 - 1.4 million non-elderly adults renters with disabilities with very low incomes have “worst case” housing needs Paying more than 50% of income for rent and/or Living in seriously substandard housing 412,000 adults ages 31-64 in nursing homes –125,000 adults between ages 22-64 have mental illness (41% increase since 2002) In Adult Care Homes = 330,000 adults with mental illness In Group Homes = 500,000 adults with disabilities In Emergency Shelters = 180,000 adults with disabilities 6

7. Priced Out in 2012 Study Compares SSI income to HUD Fair Market Rents SSI = $698 monthly 1 Bedroom rent of $758 = 104% of monthly SSI Studio rent of $655 = 90% of monthly SSI In 17 states, average one-bedroom rents were higher than monthly SSI payments SSI = 19.2% of average national AMI 70,815 non-elderly people with disabilities in Maryland on SSI http://www.tacinc.org/knowledge-resources/priced- out-findings/http://www.tacinc.org/knowledge-resources/priced- out-findings/

8. Priced Out 2012 - Maryland State and Metropolitan Statistical Area SSI Monthly Payment SSI as % Median Income % SSI for Efficiency % SSI for 1- Bedroom Baltimore-Towson$698.0014.0%121.0%143.0% Hagerstown$698.0016.5%76.0%92.0% Salisbury$698.0016.5%77.0%96.0% Montgomery-Prince Georges$698.0011.1%162.0%171.0% State Average$698.0013.4%134.0%150.0%

9. SSI Income Median Income 50% of Median Income SSI Benefits 18% of Median Income 30% of Median Income

10. Rent Subsidies Are Essential 30% of income towards housing costs according to federal housing affordability guidelines 30% of SSI = $200 National Average 1 BR rent = $758 “Housing Affordability Gap” = $558 “Gap” must be filled by an on-going rental subsidy Big challenge – Section 8 is NOT an entitlement like Medicaid & SSI –PHA waiting lists are long and often closed Priced Out Message

11. HUD Rent Subsidy Programs Total units = 4.8 million Section 8 Housing Choice Vouchers = 2 million vouchers. –Only 19% assist people with disabilities Section 8 vouchers set aside for non-elderly disabled –Poor tracking, ineffective targeting upon turnover, no link to supportive housing Clarification is needed regarding targeting of vouchers and establish preferences for priority populations – including people with serious mental illness – without violating civil rights laws (Section 504) or having to prove that the preference is to remedy past discrimination Addressing the “Affordability Gap”

12. –50,000 “Frelinghuysen” vouchers linked to “elderly only” designation – can be project-based 100 – Baltimore County Housing Authority 100 – Carroll County Housing Authority 175 – Baltimore City Housing Authority 50 – Frederick Housing Authority 660 – Montgomery County Housing Authority 100 – St. Mary’s County Housing Authority –14,000 811 “mainstream” vouchers – cannot be project-based 100 – Anne Arundel County Housing Authority 75 – Arc of the North Chesapeake –NED Category 2 Vouchers 40 – Baltimore City Housing Authority HUD Rent Subsidy Programs Addressing the “Affordability Gap”

13. Veterans Supportive Housing Vouchers: tenant-based, project-based and sponsor- based Targeted to veterans experiencing chronic homelessness $75 million in new funds expected in 2013 and beyond Combined with services from the VA VASH Vouchers in Maryland: 275 – Baltimore County Housing Authority 305 – Baltimore City Housing Authority 80 – Montgomery County Housing Authority VASH

14. Public housing units =1.1 million units (affect of “elderly only” housing policies) –Only 16% assist people with disabilities HUD “Assisted Housing” = 1.2 million units (affect of “elderly only” housing policies) –Only 17% assist people with disabilities Other programs = 443,000 units –Section 811 = 30,000 units –Homeless programs = 50,000 HUD Rent Subsidy Programs Addressing the “Affordability Gap”

15. Rent Subsidies Section 8 Vouchers targeted to people with disabilities –Three types of Section 8 vouchers: tenant-based sponsor-based project-based HUD Homeless Assistance programs HUD VASH Section 811 What Works

16. Section 811 Project-Based Rental Assistance Demonstration Authorized by the Frank Melville Supportive Housing Investment Act to promote integrated housing Goal: Sustainable, state-driven strategies to expand PSH Created the new PRA option administered by State Housing Agencies through a formal partnership with the State Human Service/Medicaid agency State Housing agency commits PRA funding to either new or existing units. No 811 capital is used. HHS/Medicaid makes service commitments No more than 25 percent of the units in any property can be set-aside as supportive housing

17. Integrated PRA Approach Modeled from successful efforts in NC, LA, and PA 5 PRA units in a 100 unit property financed with LIHTC 10 barrier free PRA units in a 40 unit non-profit owned property jointly financed by the State Housing Agency and local government 2 PRA units in a 20 unit rental housing development financed with HUD HOME funds 20 PRA units in a 100 unit “mixed income” public housing revitalization project. Highly cost-effective PRA subsidy ensures deep affordability

18. PRA Demo Formal Partnership State Housing and HHS/Medicaid agencies must have formal agreement before submitting the PRA application to HUD The agreement must specify: –Target population(s) to be assisted with PRA funds –Methods of outreach and referral to assure PRA units are occupied by the target population in a timely manner –State commitments of voluntary supportive services for people receiving PRA assistance

19. First PRA Demo NOFA Competition First PRA NOFA published on May 15, 2012 Applications were due on August 2nd NOFA included $85 million in PRA funding for an estimated 2,800 units 35 States plus DC submitted applications Awards announced on Feb. 12, 2013 13 States – including Maryland – were awarded a total of $98 million 3,530 new PRA units will be created (compared to 948 over 2 years in FY10-FY 11)

20. Maryland’s 811 PRA Program $10,917,383 to serve 150 individuals with disabilities, age 18 and over and below 62 years of age at selection, with income at or below 30% of AMI who are Medicaid recipients Tenants will be referred by DHMH and MDOD, under the following prioritized criteria: 1.Institutionalized Medicaid Recipients 2.Households At Risk of Institutionalization Due to Current Housing Situation 3.Developmental Disabilities Administration (DDA) Community Pathways Waiver Participants moving from Group Homes, Alternative Living Units (ALUs) to independent renting and Mental Hygiene Administration (MHA) Residential Rehabilitation Program participants moving to independent renting, and 4.Homeless persons who are Medicaid recipients.

21. Maryland’s 811 PRA Program 50/50 split between Baltimore and DC Metropolitan areas DHCD and local Public Housing Authorities (PHAs) are also committing to provide local preferences for up to 97 Housing Choice Vouchers (HCV) or public housing units to support non-elderly disabled clients. DHMH will make available the following voluntary support services to tenants in PRA units who are eligible for Medicaid funded services, including : –Psychiatric Rehabilitation Program Services, and other State Plan behavioral health services –Community Pathways Waiver –New Directions Waiver –Medical Day Care Waiver –Medical Assistance Personal Care

22. Critical ElementSourceExamples CapitalHFA State or local govt. Private foundation Low Income Housing Tax Credits Bonds/Trust Funds HOME Foundation Funds Operating SubsidyHUDSection 811 PRA Demo S+C PBA Section 8 PBV Support ServicesState Medicaid Agency State Human Services Agency Money Follows Person Home and Community-based Waiver Services State services funds Rehab option Supportive Housing Partnership Source: TAC

23. More Information http://811resourcecenter.tacinc.org/ http://www.tacinc.org/knowledge- resources/vouchers-database/