The Commission on Affordable Housing and Health Facility
Needs for Seniors in the 21st Century
January 16th, 2002
Sandra J. Newman, Ph.D.
Johns Hopkins University
Institute for Policy Studies
Good afternoon, and thank you for the invitation to address the Commission. I am Sandra Newman, Professor of Policy Studies at Johns Hopkins University, and Director of the Johns Hopkins Institute for Policy Studies. One focus of my research is the intersection of housing and long-term care for vulnerable populations, including the frail elderly.
I am pleased to share my five minutes of thoughts with the Commission about what I believe are the next steps we should be taking on supportive housing for the elderly. And I'd like to begin with some key empirical findings in order to establish a foundation for my subsequent comments on policy directions and other action steps.
The first set of empirical findings consists of some new information that updates our understanding of the elderly who have a need for supportive housing:
- nearly 20 percent of the elderly living in the community require assistance with basic daily needs;1
- (b) nearly 18 percent of these frail elderly live in housing that is considered to be substandard;2
- while about half of these frail elderly live in housing with at least one dwelling modification, such as grab bars, 50 percent of these individuals still reported that they had an unmet need for some modification in their dwelling;3 and,
- (although unmet need for dwelling modifications declined between the period before 1990 and passage of the American's with Disabilities Act (ADA) and 5 years after the ADA, some needs were actually less likely to be met in 1995 than prior to 1990.4
A second important empirical result is that there is huge variability in the in-home and community-based services that comparably frail elderly persons receive. Variation across states is understandable in the Medicaid program, where states have considerable discretion about a range of optional services they provide. But it is surprising in Medicare, which is a national program. Just one illustration of Medicare variability is the huge difference in the number of home health visits across states (for example, Louisiana has a tremendous number, while Maryland has relatively few).
Let me now highlight just two policy directions that I believe are both important and within the realm of feasibility. And I want to begin with something unconventional for a hearing on supportive housing, but that I believe could have a substantial impact, and that is a vigorous concentrated housing code enforcement program.5 These are the locally-enforced standards that set the basic quality of housing in a community.
Why is this sort of program important? My argument is based on three key points. First, the large majority of the elderly--including those who have some frailties--live in private-market housing, and about one-fifth of the disabled are renters in multifamily properties. Second, as I noted, roughly 18 percent of the elderly living in the community who have a disability are living in physically inadequate housing. Finally, housing inadequacies are likely to impede the efficient delivery of in-home services.6
Because many cities operate under very tight budgets, they don't allocate the resources necessary to inspect all--or even most--residential properties each year. There are also serious inadequacies reported about follow-ups when an inspected unit fails code compliance. Inducing a vigorous enforcement program would, therefore, affect a very large number of elderly households, and doesn't rely solely on the vagaries of congressional actions regarding appropriations for the programs of the U.S. Department of Housing and Urban Development or other agencies. This could be done through matching grants to communities willing to allocate some percentage of their Community Development Block Grant monies to implement a multi-year, "tough love" code program, with everyone knowing their rights and their responsibilities.
A second policy direction concerns housing modifications and assistive devices. The most recent evidence suggests that these technologies promote independent living. But despite growth in the use of these technologies over the last 25 years, there is still substantial unmet need, as I noted at the outset. The problem here may not necessarily be lack of funding but rather the difficulty in accessing the funding that is available because it is decentralized, making it difficult for the consumer to find the right source of help, and the inconsistent standards of need and little coordination among funders.
While state and local initiatives to make such assistance more widely available are certainly to be applauded, arguably the best way to improve access to needed technologies is through amendments to Medicare and Medicaid, which would also have spinoffs on private insurance.7 Such amendments would broaden the currently quite narrow and limited eligibility, which relies on the sole criterion of being "medically necessary," and gives no weight to either increasing an individual's ability to function more independently or potentially preventing secondary disabilities.8
Finally, I'd like to turn to three action steps. First and most fundamentally, housing has been an "orphan issue" in health and long-term care. A clear manifestation of this characterization is that none of the major demonstrations pertaining to housing and service supports, such as Channeling or the Medicaid Home- and Community-Based Waivers, nor the major ongoing surveys in the field, such as the National Health Interview Survey and the National Long-Term Care Survey, include housing measures. This is of much more than academic concern, because it means that almost none of the big policy questions regarding the impacts of supportive housing, or the contribution of housing to key outcomes, have been answered, and certainly not to the satisfaction of a skeptical policymaker or taxpayer.
To address this important deficiency, an initial action step that could be taken immediately would be to convene a group to develop a minimum dataset on housing, and to strongly encourage its incorporation in future relevant surveys by census, the Department of Health and Human Services, and others.
Second, we must be concerned about the disconnect between the impending dramatic surge in demand for publicly-supported long-term care including service-linked or enriched housing for the elderly, on the one hand, and the apparently low level of concern or priority assigned to this issue by most Americans. One reasonable response to this disconnect is to vastly increase the visibility and understanding of this topic. And one way to accomplish this goal, which I fully endorse, was recently proposed by Jim Callahan of Brandeis University, namely, the preparation of a Surgeon General's report.9 As Callahan argues, if the recent Surgeon General's report on mental health is any indication, this document would have the potential of substantially raising the profile of the issue, elevating the level of understanding and debate, and, ideally, generating viable policy proposals. There would, of course, be many additional beneficial byproducts of such a report including bringing together a wide range of experts and stakeholders, synthesizing research results on outcomes and impacts of supportive housing, (which, as I indicated, would highlight significant gaps), and very importantly, potentially resolving fundamental issues that have characterized debates in this field dating back at least to the 1970s, including whether housing and service funding should be linked or delinked, and most basically of all, the role of housing in long-term care.
A third action step concerns the variability in services provided to comparably frail individuals under the two main programs, Medicaid and Medicare. Because these programs account for the lion's share of publicly-funded community-based long-term care, it is essential that we take the necessary steps to better understand the impacts of this variation in services, and to ultimately develop a model of what services are appropriate for what elderly individuals living in what sort of residential setting; that is, this model should take account of the individual's disabilities, living arrangements, and other relevant risk factors. Developing this level of understanding of where variations make sense--and where they do not--would go a long way to improving the efficiency, equity, and effectiveness of the full array of housing settings for the frail elderly.
1 Committee on Ways and Means 1998; McNeil 2000.
2 Newman, S. (2000). The Living Conditions of America's Disabled. Final Report to the Robert Wood Johnson Foundation and the U.S. Departments of Health and Human Services and Housing and Urban Development. Baltimore, MD: Johns Hopkins Institute for Policy Studies, mimeo.
5 See Newman, Sandra (1995). "Housing and Home-Based Care." The Milbank Quarterly, vol.73, no. 3, pp. 407-441.
6 For example, see Newman (2000), op cit.
7 Medicare Part B currently allows reimbursement for durable medical equipment, but grab bars, stair lifts and accessible hardware are typically ineligible. As of the mid-1990s, 26 states allowed Medicaid payments for home modifications and 19 states allowed waivers for assistive devices (Duncan, R. (1998). "Funding, Financing and Other Resources for Home Modifications," Technology and Disability, vol. 8, pp. 37-50).
8 National Council on Disability (2000). Federal Policy Barriers to Assistive Technology. Washington, DC: May.(http://www.ncd.gov/newsroom/publications/assisttechnology.html)
9 Callahan, J. (2001). "Do We Need a Surgeon General's Report on Home and Community Based Services: A Personal and Policy Journey," The Gerontologist, vol. 41, no. 2, pp. 149-152.