Blog: Homelessness Ends Here

By Stephen L. Day, Technical Assistance Collaborative

Today the Boston Globe and other newspapers nationwide published an Associated Press article about people with mental illness living in nursing homes posing a threat to frail elderly people who also reside there.  It is an unfortunate reminder of the pervasive stigma of mental illness that a few isolated events in nursing homes became newsworthy enough for national publication.  Fortunately, the article does reference the much more important story: that thousands of younger people with mental illness or other disabilities languish in nursing homes because states have failed to provide appropriate housing and services in the community.  The article points out that over 125,000 individuals under the age of 65 who have mental illness currently reside in nursing homes, an increase of over 40% since 2002.  It is highly likely that many of these individuals faced a Sophie’s Choice between inappropriate placement in a nursing home on one hand or homelessness on the other hand. 

A soon to be released study, entitled Priced Out in 2008 completed by the Technical Assistance Collaborative, documents that the average person with disabilities receiving Supplemental  Security  Income (SSI) in the United States would have to pay 112% of their entire income to rent a modest one bedroom apartment.  This is the stark fact: no one relying  on SSI for all their basic needs can afford a modest one bedroom apartment anywhere in the United States.  This is the single most important reason why people with disabilities end up homeless on the streets or in expensive and restrictive institutional settings such as nursing homes.

Of course, the safety and quality of life of elders receiving care in nursing facilities is an important policy goal.  We all can hope that states find ways to meet that policy goal by providing more cost-effective permanent supportive housing linked with flexible community services for people with mental illness in the community.   There are five reasons for this hope.  First, younger people with mental illness or other serious disabilities have spoken over and over again about their preference for living in integrated community settings as opposed to restrictive institutional settings.  Second, it is well known and documented in the research literature that when people with disabilities have a place of their own to live in the community they attain greater levels of quality of life and self-sufficiency and consequently use less overall services than those placed in inappropriate settings.  Third, many different studies have proven that permanent supportive housing is highly cost effective when compared to either institutional care or homelessness.  Fourth, because many younger individuals find nursing home or other institutional placement so inappropriate, they frequently ‘vote with their feet’ by avoiding or leaving a facility, thereby becoming homeless.  Finally, states face considerable risk under the American’s with Disability Act and the U.S. Supreme Court’s Olmstead decision if they continue to permit the placement of people with disabilities in restrictive institutional settings as opposed to fostering integrated living in the community.

In 2007 the federal/state Medicaid program spent over $46 billion on institutional care, and only $21 billion on community based services. (Data from Centers for Medicare & Medicaid Services, Form CMS-64).  The average cost of a nursing facility in the United States is between $50,000 and $60,000.  (Medscape Medical News, 2006). The 125,000 younger people with mental illness now residing in facilities cost the state and federal governments about $6 billion per year.  Imagine what could be done with that $6 billion to provide permanent affordable supportive housing linked with a comprehensive array of community services and supports for these individuals.  In this time of state budget cuts, wouldn’t it be better to save money while at the same time doing the right thing for younger people with mental illness who would rather live in the community?  By using the money in the right way, wouldn’t it also be better to reduce the rate of homelessness for younger people with disabilities while at the same time assuring that nursing facilities can do what they were designed to do: provide skilled nursing to elders?

About the Author
Stephen L. Day is co-founder and Executive Director of the Technical Assistance Collaborative, a national non-profit organization that works to achieve positive outcomes on behalf of people with disabilities, people who are homeless, and people with other special needs. Steve has provided consultation and technical assistance to 35 states, over 100 local jurisdictions, and numerous national policy and advocacy organizations.