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Commission delivered final report to Congress on June 28, 2002
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Endnotes

1. Title V, Section 525(b) of the Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies, Act of 2000, Public Law 106-74, October 20, 1999.

2. "A Profile of Older Americans: 2001," Administration on Aging, U.S. Department of Health and Human Services, Administration on Aging (2001). 

3. Stephen M. Golant, Ph.D., “The Housing Problems of the Future Elderly Population,” a Report Prepared for the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, January 2002. Table 18. 

4. Golant, Figures 42-47.

5. Golant, Table 17. 

6. Leonard Huemann, Winter-Nelson, and James R. Anderson, “The 1999 National Survey of Section 202 Elderly Housing,” Washington, DC: Public Policy Institute of the American Association of Retired Persons, 2001.

7. Michael Bodaken, "Preserving and Improving Subsidized Rental Housing Stock Serving Older Persons: Recommendations to the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century," National Housing Trust (2002), 8.

8. "The State of the Nation's Housing 2001," Harvard Joint Center for Housing Studies, (2001), 29.  

9. Golant, Table 8.  Based on projections using 1999 AHS data. 

10. "State of the Nation's Housing: 2001," 29.

11. "The Lewin Group Projections from the 1996 Survey of Income and Program Participation, Wave 5," prepared for the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, 2002.

12. See: Ada Helen-Bayer, Leon Harper, "Fixing to Stay: A National Survey on Housing and Home Modification Issues," AARP, (2000). 

13. See: Cushing Dolbeare, "Changing Priorities, The Federal Budget and Housing Assistance 1976-2006," (May 2001).  Washington DC: National Low-Income Housing Coalition.

14. A Profile of Older Americans 2001 AOA http://www.aoa.gov/aoa/STATS/profile/2001/1.html:
"Since 1900, the percentage of Americans 65+ has more than tripled (4.1% in 1900 to 12.4% in 2000), and the number has increased eleven times (from 3.1 million to 35.0 million).  The older population itself is getting older. In 2000, the 65-74 age group (18.4 million) was eight times larger than in 1900, but the 75-84 group (12.4 million) was 16 times larger and the 85+ group (4.2 million) was 34 times larger."

15. See: Cushing Dolbeare, "Changing Priorities, The Federal Budget and Housing Assistance 1976-2006," (May 2001).  Washington DC: National Low-Income Housing Coalition.

16. Dr. Stephen Golant of the University of Florida at Gainesville compiled much of the data presented here for the Commission.  Dr. Golant's report can be found in Appendix  G-1 of this report.   In addition to data compilation, Dr. Golant did original analysis of the 1999 American Housing Survey.

17. Administration on Aging, "A Profile of Older Americans: 2001," Washington, DC:  U.S. Department of Health and Human Services, Administration on Aging (2001). 

18. Golant, Table 18. 

19. Golant, Figures 42-47.

20. Golant, Table 17. 

21. Figure refers to vacancies in existing units.

22. Huemann, et.al, “The 1999 National Survey of Section 202 Elderly Housing,” Washington, DC: Public Policy Institute of the American Association of Retired Persons, 2001.

23. Michael Bodaken, "Preserving and Improving Subsidized Rental Housing Stock Serving Older Persons: Recommendations to the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century," Washington, DC:  National Housing Trust (2002), 8.

24. "The State of the Nation's Housing 2001," Harvard Joint Center for Housing Studies, (2001), 29.  

25. Golant, Table 8.  Based on projections using 1999 AHS data. 

26. "State of the Nation's Housing: 2001," 29.

27. "The Lewin Group Projections from the 1996 Survey of Income and Program Participation, Wave 5," prepared for the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century, 2002.

28. See: Ada Helen-Bayer, Leon Harper, "Fixing to Stay: A National Survey on Housing and Home Modification Issues," AARP, (2000). 

29. Golant, Table 17.  The Commission finds a requirement of 730,000 new units to be added to either the 1.2 million number found in the American Housing Survey or the 1.7 million found in subsequent studies, including:  Andrew Kochera "A Summary of Federal Rental Housing Programs, Fact Sheet #85" AARP, (2001), 4.  The basis for the difference in the two studies results from the age used in each study (i.e. 65+ in the Golant study and 62+ in AARP Fact Sheet study).

30. When speaking of current or “today’s” housing arrangements, the document is normally referring to conditions in 1999.

31. Golant, Table 1.   See also:  American Housing Survey for the United States: 1999" Table 7-12, 416. 

32. Golant, Figure 36. 

33. Federal Register, Vol. 67, No. 31, February 14, 2002, pp. 6931-6933. Different guidelines exist for Alaska and Hawaii.  SSI limits are available from CMS.  http://www.hcfa.gov/medicaid/ssi0102.htm.

34. Enid Kassner, Lee Shirey, "Medicaid Financial Eligibility for Older People: State Variations in Access to Home and Community-Based Waiver and Nursing Home Services," AARP, (2000) 7-8.

35. Only about 10% of rent-assisted households have incomes exceeding 50% AMI, Golant, Figure 36.

36. For a more detailed exposition of these data, see Appendix G-2.

37. For example, for Boston, MA, 50% of median annual income for a single person in 2002 is $25,950, while 300% SSI is $19,620. 

38. A 1999 HUD report estimated that the average waiting list for affordable rental housing was 33 months.  Although this data is not senior specific, it is a broad indicator of the length of time that eligible persons go unserved.  See:" U.S. Department of Housing and Urban Development, "Waiting in Vain: An Update on America's Rental Housing Crisis Washington, DC:  U.S. Department of Housing and Urban Development (1999). 

39. Although most seniors qualify for Medicare, the program does not provide the long-term care services offered by Medicaid.

40. Golant, Table 1. 

41. Golant, Figure 40.

42. Golant, Figures 40-48.

43. “State of the Nation's Housing 2001," 29. 

44. Housing costs for renters include contract rent, utilities, property insurance, and mobile home park fees. Housing costs for owners include payments for mortgages or installment loans or contracts, real estate taxes, property insurance, homeowner association fees, cooperative or condominium fees, and utilities. Dwelling costs do not, however, include costs for maintenance and repairs.

45. HUD Reports refer to this category as “other problems.”

46. Households with negative or zero income are not considered as housing cost burdened.  Housing costs are compared with the household’s income from the previous year. Households that reported their monthly costs as 100% or more of their past year’s income were included in the “serious cost burden” category.

47. See:  American Housing Survey, 1999, Appendix D.

48. American Housing Survey, 1999, Table 7-12, lines 64-66. 

49. Those receiving rent assistance are excluded from the analysis. 

50. Based on U.S. Census population projections and Harvard household projections.

51. Projections are the exclusive work of Dr. Stephan Golant, the Commission's demographic consultant. 

52. American Senior Housing Association, "Senior Housing: Solving America's Long-Term Care Crisis" (1999), 2.  According to the report, 82 % of senior homeowners own their homes outright.  If this trend continues, many senior homeowners will have a valuable asset to leverage to meet their needs. 

53. For a discussion of the challenges of remaining in one's own home, see: Kathryn Lawler, "Coordinating Housing and Health Care Provision for America's Growing Elderly Population," Cambridge, MA: Joint Center for Housing Studies, Harvard University, (2001). 

54. Timothy Waidmann, Kenneth G. Manton, "International Evidence on Disability Trends among the Elderly." Washington, DC:  Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging, and Long-Term Care Policy (1998).  Many studies such as the one cited indicate that while the total population of seniors is increasing, the percent of disabled seniors among them is decreasing.  The aggregate number of disabled seniors is increasing at a rate slower than the overall population of disabled seniors.

55. "Projections of the Resident Population by Age, Sex, Race, and Hispanic Origin: 1999 to 2100," U.S. Census Bureau, Population Projections Program. (NP-D1-A) (2000).

56. The model has two major components: 1) the Pension and Retirement Income Simulation Model  (PRISM), which projects work and family history, retirement income, disability, and nursing home use; and 2) the Long-Term Care Financing Model, which projects home care use, long-term care financing and policy simulations.

57. Data sets can be found in Appendix G-1.

58. As discussed earlier, the general maximum eligibility for Medicaid is 300% of SSI, which is roughly about 220% FPL. 

59. In 2002, the FPL for an individual in the continental United States was $8,860,250% of which would be $22,150.  Source: Federal Register, Vol. 67, No. 31, February 14, 2002, pp. 6931-6933.

60. Robert Mollica, "Personal Care Services:  A Comparison of Four States," (2001) 1. See also:  Normandy Brangan "The Medicare Program," AARP, (2001).

61. National Investment Conference. 2001. The Case for Investing in Seniors Housing and Long-term Care Properties. Annapolis, Maryland: National Investment Conference for the Senior Housing & Care Industries.

62. Evidence does not exist that the assisted living alternative will become less expensive over the next two decades (National Center for Assisted Living. 2001. Facts and Trends:  The Assisted Living Sourcebook 2001. Washington, DC: National Center for Assisted Living, American Health Care Association.)

63. In the third quarter of 2001, the mean assisted living occupancy rate was 85.5% (Robert Kramer, in an address to the national conference of the National Investment Center in Washington), December 13, 2001. In 1999, the mean occupancy rate was 89.4%.

64. The first three assumptions underlie the nursing home projections of The Lewin Group for the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century.

65. U.S. Census Bureau, Population Projections Program. 2000. (NP-D1-A) Projections of the Resident Population by Age, Sex, Race, and Hispanic Origin, 1999 to 2100. Washington, DC: U.S. Census Bureau, Department of Commerce.

66. Consistent with earlier tabulations, this report is primarily interested in the demand for assisted living units rather than the existing or future supply of assisted living units.  For any given year or period, the supply of assisted living units must be reduced by its occupancy rate and the percentage of units occupied by seniors as opposed to non-seniors.

67. The first three assumptions underlie the nursing home projections of The Lewin Group for the Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century.

68. U.S. Census Bureau, Population Projections Program, 2000.

69. National Investment Conference. 2001. The Case for Investing in Seniors Housing and Long-term Care Properties. Annapolis, Maryland: National Investment Conference for the Senior Housing & Care Industries.

70. These estimates are expressed in persons rather than units.  Thus, they should be somewhat larger than this report’s projections for that reason alone.

71. See: Cushing Dolbeare, "Changing Priorities, The Federal Budget and Housing Assistance 1976-2006," Washington DC: National Low-Income Housing Coalition (May 2001).

72. Robyn I. Stone, “Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the Twenty-First Century,”  Milbank Memorial Fund, 2000.

73. 12 U.S.C. 73 Stat. 654, 667.

74. Huemann, et. al, “The 1999 National Survey of Section 202 Elderly Housing,” Washington, DC: Public Policy Institute of the American Association of Retired Persons, 2001.

75. Housing Research Foundation.

76.   Abt Associates (Finkel and Buron), “A Study on Section 8 Voucher Success Rates.” Vol. 1:  Quantitative Study of Success Rates in Metropolitan Areas. Prepared for U.S. HUD, November 2001.

77. National Council of State Housing Agencies,  “State HFA Factbook: 2000 Annual Survey Results.”

78.    NCSHA.

79. Testimony by Sue M. Harris-Green, Deputy Director, Multi-Family Housing, Direct Loans, Rural Housing Service, U.S. Department of Agriculture, Baltimore, Maryland, 3/11/2002.

80. HUD Website.

81. H.R. 5640, passed December 5, 2000.

82. In 2001, waiver programs in 49 States and the District of Columbia served more than 560,000 individuals. Arizona is the only State that does not use the 1915(c) waiver because it provides comparable services under another demonstration waiver authority.

83.   Excerpted from the HCFA report: Nursing Home Transition Grant 2000, May 2000.

84.   CMS website.

85. HHS-AoA Website.

86. HHS-AoA Website.

87. "Senior Housing Construction Report," American Senior Housing Association, 2002.

88. “The Consumers’ Directory of Continuing Care Retirement Communities,”  1999-2000, American Association of Homes and Services for the Aging, 1999.

89. “Federal Housing Assistance: Comparing the Characteristics and Costs of Housing Programs”, GAO-02-76 Washington, DC: Government Accounting Office, Jan. 2002.

90. Lifecycle cost is the total cost of owning, operating, and maintaining a property over its useful life.  In this analysis, GAO assumed a useful life of 30 years.

91. David Smith, Recapitalization Advisors, Boston, MA.

92. Susan Coronel, “Long-Term Care Insurance in 1998-1999,” Washington, DC:  Health Insurance Association of America, 2002.

93. Michael Bodaken , “Preserving and Improving Subsidized Rental Housing Stock Serving Older Persons: Recommendations to the Commission on Affordable Housing and Health Facility Needs for the 21st Century.”  March 1, 2002, p. 2. (Appendix G-3 in this report.

94. Bodaken, Tab 3.

95. Bodaken.

96. Ability to refinance is defined any Section 236-insured property with rents at or below market (<=110 percent FMR) and other non-236 properties with interest rates of 9 percent.

97. Prior to 1990, Section 202 financing was available to developers of housing for both elderly and disabled, low-income households. This report focuses only on those properties that are for seniors, and therefore, the total number of units will be less than the number of units for the Section 202 program as a whole.

98. Other Section 8 is defined as any Section 8-assisted property that is not insured under the Section 202, Section 236 or Section 221(d)(3) BMIR programs. Some of these properties may not have a HUD-insured mortgage.

99. Housing Research Foundation, Public Housing for Seniors: Past Present and Future, Washington D.C.; 2002.

100. Housing Research Foundation, Public Housing for Seniors, 2002.

101. Testimony to the Commission by Thomas W. Slemmer, President, National Church Residences, Columbus, Ohio,  September 24, 2001.

102. Golant, Table 1.

103. Golant, see footnote 3.

104. Housing Programs of New York State 2002, New York State Department of Housing and Community Renewal, (2002).

105. Testimony to Commission by Dr. Jon Pynoos, Associate Professor of Gerontology, Ethel Percy Andrus Gerontology Center.   San Diego, California, Hearings,  November 7, 2001.

106. Many types of structures are built in the factory and designed for long-term residential use. In the case of manufactured and modular homes, units are built in a factory, transported to the site, and installed. In panelized and pre-cut homes, essentially flat subassemblies (factory-built panels or factory-cut building materials) are transported to the site and assembled. The different types of factory-built housing can be summarized as follows:

Manufactured Homes: Manufactured homes may be single- or multi-section and are transported to the site and installed.

Modular Homes: These factory-built homes are built to the State, local, or regional code where the home will be located. Modules are transported to the site and installed.

Panelized Homes: These are factory-built homes in which panels - a whole wall with windows, doors, wiring and outside siding - are transported to the site and assembled. The homes must meet State or local building codes where they are sited.

Pre-Cut Homes: This is the name for factory-built housing in which building materials are factory-cut to design specifications, transported to the site and assembled. Pre-cut homes include kit, log, and dome homes. These homes must meet local, State, or regional building codes.

Mobile Homes: This is the term used for factory-built homes produced prior to June 15, 1976, when the HUD Code went into effect. By 1970, these homes were built to voluntary industry standards that were eventually enforced by 45 of the 48 contiguous States.

107. The Lewin Group analyses for the Seniors Commission from the SIPP database.

108. NCSHA, conversation with Jim Thatcher.  According to a survey of the State housing agencies in 2000, 22 percent of the total production level of 60,000 units was developed as “seniors only” housing.

109. Huemann, et al, “The 1999 National Survey of Section 202 Elderly Housing, Public Policy Institute of the American Association of Retired Persons, Washington, DC, 2001.

110. HUD, “Evaluation of the Service Coordinator Program: August 1966”; Report to Congress: “Evaluation of the Hope for Elderly Dependence Demonstration Program and the New Congregate Services Program,” June 2000.

111. Jeffrey Sacks, Esq., Brown, Rudnick, Freed & Gesner, Boston, Massachusetts.

112. Rene Rodriquez, Executive Director, Miami Dade Housing Agency, Miami Hearings, January 14, 2002.

113. Recommendations to the Seniors Commission, National Rural Housing Coalition, October 2001.

114. Sue Harris-Green, Deputy Administrator for Multifamily Housing, Direct Loans, Rural Housing Services, Washington, DC, Baltimore Field Hearing, March 11, 2002. .

115. Subordination is a loan in a lower priority, for example a second mortgage is subordinate to a first mortgage.

116. HUD, “Housing Our Elders: A Report Card on the Housing Conditions and Needs of Older Americans,” November 1999.

117. Federally subsidized housing includes the following housing programs: Sections 202, 236, 221(d)(3) Below-Market Interest Rate, Section 8 New Construction and Moderate/Substantial Rehabilitation, and 515; conventional public housing, housing choice vouchers, and Low-Income Housing Tax Credits.

118. Some housing projects have the financial capability to use their operating budgets to pay for service coordinator positions.  The Commission believes that service coordinators should be included in the operating budgets of all assisted elderly housing developments. 

119. Janice C. Monks, Executive Director, American Association of Service Coordinators, Columbus, Ohio Field Hearing, September 24, 2001.

120. Elderly Housing Coalition comments to the Commission, March 15, 2002.

121. Jane Johnson, Director of Housing, Florida Association of Homes for the Aging, Miami, Florida, Field Hearing, January 14, 2002.

122. Edward Salsberg, Director, Center for Workforce Studies-SUNY Albany, Miami, Florida, Field Hearing, January 14, 2002.

123. Robyn I. Stone and Joshua M.  Wiener, “Who Will Care for Us? Addressing the Long-Term Care Workforce Crisis,” October 26, 2001.

124. Lynne M. Casper and Kenneth R. Bryson, “Co-resident Grandparents and Their Grandchildren: Grandparent Maintained Families,” March 1998.

125. 1997 American Housing Survey cited in HAC’s 2000 Report on the State of the Nation’s Rural Housing.  Washington, DC:  Housing Assistance Council, p. 7.

126. The Coordinating Council on Access and Mobility was established in 1986 by the U.S. Department of Health and Human Services and the U.S. Department of Transportation.  The Council promotes quality transportation services by encouraging the coordination of the program efforts of government and nonprofit human service agencies with public transit and paratransit providers.  The Council brings together Federal agencies that fund or purchase transportation services to improve the availability and quality of community transportation services.

127. See: Jon Burkhardt, “Coordinated Transportation Systems,” AARP Public Policy Institute, (2000).  http://research.aarp.org/consume/2000_16_transport_1.html.

128. Golant, Table 1.

129. A forward commitment is a financing tool for multi-unit, service-enriched housing that can make the difference in whether a project is built.  Generally, a forward commitment provides the borrower with a locked-in rate for the permanent loan in advance of the property being made available to tenants, and allows developers to know what their debt service will be in advance of construction.  Fannie Mae's forward commitment has financed market rate as well as affordable multifamily projects.  Freddie Mac has started a forward commitment program on a pilot basis. Freddie Mac's program offers financing to build or substantially rehabilitate garden or mid-rise apartments with either tax-exempt bond financing or low-income housing tax credits. 

130. Golant.

131. This refers to the Home Owners Equity Protection Act (HOEPA), and it is one title under the Truth-in-Lending Act.  The purpose of HOEPA is to trigger specific discloses by the lender to the borrower on a home equity loan when the interest rate and other closing costs cross a threshold where the ACT deems the loan to be of “high costs”.  It also prohibits or limits certain types of equity lending practices typically used by predatory lenders to drive up the cost of the loan to a borrower.

132. HUD Notice PIH 2000-41, Use of Housing Choice Vouchers in Assisted Living Facilities, defines assisted living facilities as those that are designed for residents who have the physical ability to live independently, but need assistance with some activities of daily living.  These can include residential care facilities, adult care facilities, congregate care facilities, or group homes.

133. L. Earl Armiger, for the National Association of Home Builders, President, Orchard Development Corporation and Elderly Housing Coalition Recommendations to the Commission, Baltimore Field Hearing, March 15, 2002.

134. Brian Burwell, “Medicaid Long-term Care Expenditures in FY 2000,” March 7, 2001.

135. Enid Kassner and Lee Shirey, “Medicaid Financial Eligibility for Older People: State Variations in Access to Home- and Community-Based Waiver and Nursing Home Services,” AARP Publication No. 2000-06, April 2000.

136. The AARP report that provides this information does not list all nine States that allow a shelter deduction.  It does, however, mention the use of this deduction in Idaho, Nebraska, Tennessee, and Utah.

137. Mollica and Jenkins, 2001.

138. Keith Campbell, President and Board Chair, AARP, Miami, Florida, Field Hearing, January 14, 2002.

139. D.U. Himmelstein, J.P. Lewontin, and S. Woolhandler, “Medical Care Employment in the United States, 1968 to 1993: The Importance of Health Sector Jobs for African Americans and Women.”  American Journal of Public Health, Vol. 86, No. 4, April 1996.

140. Richard J. Bringwatt, “Modernizing Medicare for People with Chronic Conditions.”  National Chronic Care Consortium, August  2001.

141. Sharon Bloom, Executive Director, National PACE Association, Miami, Florida, Field Hearing, January 14, 2002.

142. 1994 NLTCS, cited in Robyn I. Stone, “Long-Term Care for the Elderly with Disabilities: Current Policy, Emerging Trends, and Implications for the Twenty-First Century,” Milbank Memorial Fund,  2000.

143. National Academy on Aging 1997, cited in Stone 2000.

144. A Profile of Older Americans 2001. AOA http://www.aoa.gov/aoa/STATS/profile/2001/1.html.

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