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Alliance President Keynote Remarks, 2013 National Conference
February 17, 2014
Back in August, the 2013 National Conference on Ending Homelessness drew around 1,600 people from across the country, including federal and local officials, filmmakers, advocates, and people working on the front lines of the fight to end homelessness, to Washington, DC, for three days of sharing innovative practices, new research, and the latest developments in homelessness. These are the keynote remarks delivered by the Alliance's President and CEO Nan Roman on the first day of that conference, August 22, 2013.
2013 National Conference on Ending Homelessness
August 22, 2013
Welcome to Re-Framing for the Future: The National Conference on Ending Homelessness. It is fitting that the conference start with our thanks to all of you for the fantastic work you are doing to bring an end to homelessness, despite the seemingly overwhelming odds.
You are talented nonprofit organizations, committed to improvement. A high percentage of you are from federal, state and especially local government, showing the increasing leadership of the public sector. You are funders, mobilized through our great partner Funders Together to End Homelessness, who are serving as change agents in your communities. And you are homeless people, here to learn, but also to help with the on-the-ground knowledge of what works – and what does not.
We at the Alliance remain so proud and gratified that the homelessness sector continues to stand out for its innovation, its response to new knowledge and research, and its willingness to change. You are never satisfied that more cannot be done.
That is why you are here, today, to learn how to do things better, and smarter, and to share your better and smarter ideas with others. Please accept our gratitude for that and for your ongoing hard, determined and successful work.
Every year I get the opportunity, in preparing this keynote, to reflect on the most important developments in our field, and what it is that we should be thinking about for the future: what are the trends and where do they lead us? I am guided in this by our brilliant staff at the Alliance; by research and data; but also by what I learn throughout the year as I go around the country and observe what is going on in communities, and speak to and learn from so many of you.
This year there have been some important shifts. Among the things that have risen to the top are the tremendous opportunities presented by health care reform, and the full throttle movement to end veteran homelessness; and the ripple effects that developments in these two areas have caused in the rest of the homelessness world – and indeed in the broader human services and housing worlds.
Let me start with what I see as the important trends within homelessness. These trends have remained steady over the past few years.
First, is the shift to rapid re-housing, which I think will continue. Rapid re-housing should not be seen as a choice between giving homeless people a really great housing subsidy like Section 8, and giving them a meager rapid rehousing subsidy. It should be seen as a choice between giving people some money to access housing when they exit homelessness, or no money.
Almost no one who exits homelessness gets a Section 8-type subsidy unless they are chronically homeless, very disabled, and/or a veteran. That means that most people who exit homelessness leave homelessness with no subsidy. And so really, what rapid re-housing means is that people leave homelessness with some money to pay for housing, instead of leaving with no money. I call that a big improvement. That does not mean we should stop trying to get housing subsidy for everyone, and I will speak about that later. But it means that it is better to leave homelessness after a brief period with money for deposits than to spend two years homeless saving up that money, or leaving without it.
Rapid re-housing is a quick end to the homeless experience, but it does not mean that people do not need something more than a few months of rent. They often do, and the very high quality of crisis services, case management and service linkage that the excellent rapid re-housing providers deliver is a step up, not a step down, in what we can do for homeless people. Unlike before, they leave homelessness not just with a memory of services they received for the months while they were homeless, but with some money, and with services on hand that can help them with the hard work of making it in the community – in the spot where they are going to live in the long run.
Rapid re-housing implies something else as well: it implies the need for a community-wide systems approach to homelessness, and not a program-by-program approach. Again, this is not a new refrain.
Programs do awesome work – of course. It is programs – not systems – that help homeless people become housed people. But, if you will forgive the sports analogy, expecting individual programs in a community to end homelessness on their own is like expecting a baseball team to win the World Series with no general manager and no strategy, just a bunch of talented players each playing to their own strength. If everyone just plays to their own strength – no matter how formidable – we are not going to get there. We can see the proof of this in where we stand today after 25 years of program-by-program homeless assistance: over 40 percent of people who are homeless are unsheltered. It takes strategy and leadership and working together toward a common goal to make sure that we have the proper interventions and enough of them for everyone who becomes homeless.
You can call this work collective impact, or you can call it systems planning, or a 10 Year Plan, or the continuum of care, or whatever you want. It is not a new concept. In the homelessness world, we have had coordination, and we have told ourselves that it was the same as a system. It is not. Coordination just means that everyone knows what everyone else is doing.
We are going to have to move from a program-by-program approach to a systems approach. We do need to improve our programs, and programs do need to have their own goals. But to make progress on ending homelessness, programs in a community have to work together as a single unit. The community has to have a single set of goals, and measure its progress toward those goals as a unit. And someone needs to lead this effort and allocate resources to priorities in order to achieve the goal. Otherwise we are not going to make it.
This is being expressed at the moment by the coordinated assessment and entry work, which is tremendously important, but it is only the beginning. I would just note our ongoing and serious concern that unless your community is making sure that you are assessing people for something that you can actually deliver, you are just going to be creating fancier new waiting lists. But coordinated assessment and entry is an essential first step to a creating a homelessness system.
And in another theme from past years, an additional key element of this system has got to be the crisis system. Far from abandoning the front door of homelessness, we need to make it a whole lot better. If homelessness is going to be shorter, short term crisis housing or shelter is exactly where the action will be. We have often said that shelter is not the solution to homelessness: I have said it myself. But in fact, if we do a good job we can make the crisis system shelter the solution for homelessness. Most people who enter shelter do leave homelessness and do not come back; and if we had good shelter, that could be an even higher percentage. If we had a crisis system that could actually provide people with crisis services -- that had some tools for diversion, mediation with landlords or family members, rapid rehousing, service linkage, critical time intervention, and permanent supportive housing placement -- it really could be the place where homelessness was ended. Shelters need to be nicer. The crisis system needs the tools to solve the problem.
What we probably do not need is bigger shelters. Across the country there have been many large intake and assessment shelters built under the theory that they could do just what I have described. They have not, largely, succeeded. But whatever the configuration, whether centralized or de-centralized, the important thing is for the front door system to have a clear sense that the mission is to re-house quickly, and a strong set of tools at its disposal to accomplish that mission.
So rapid rehousing, the move from programs to systems, and the need to re-think the crisis system are three themes you have heard from us before, but which I believe remain very important trends for the future.
What are some of the new themes emerging in the sector?
I am hearing a lot of discussion in the wider field of human services and housing about changes coming down the pike. Many of these changes are being stimulated by the implementation of the Affordable Care Act (ACA), even in states that are not adopting, and they have to do with the way in which services will be delivered and financed.
With regard to ACA, there has been a lot of focus on getting involved in creating state plans, and in enrollment. And these remain very important, and will be discussed during the conference. But we need to be thinking beyond these to the impact ACA will have on how we deliver and bill services. Some of these impacts will be direct, as organizations find that they can work with health care entities to target resources to consumers who need services; coordinate care for their consumers; or provide direct services to consumers.
These impacts may also be indirect. Your regular funders may become reluctant or unable to fund services that they think the publicly funded health system should pay for. Or, your regular funders may be influenced by the new and more rigorous approach to service delivery that is emerging from health care systems. In either case, the ACA may change things for service providers.
In addition to ACA, another driver in our sector is the hard push by the Department of Veterans Affairs (VA) to end veteran homelessness by 2015, and the significant resources being devoted to this. VA, it should be remembered, approaches homelessness through its medical system. And so as it rapidly scales up to end homelessness, it mirrors some of the themes of ACA implementation. Some of these emerging, health-driven themes are: cost containment, with a special focus on high cost individuals; reimbursement only for interventions that are evidence based and clearly defined; requirements that those who deliver services have credentialed staff and in licensed facilities, or the equivalent; requirements that those who deliver services can manage data, including client records, interoperability, documentation of outcomes, billing for individuals services, etc.; and understanding that a key to success is partnership.
What does this mean to us in the homelessness arena?
One thing that is being reconsidered is residential care. There is a lot of questioning about when residential care should be used, because in the medical system, many residential care approaches are expensive. They also constrict consumer choice. It is going to be important to ensure that residential care is not conflated, in the homelessness context, with the need for affordable housing. Affordable housing is an essential component to health and well-being, and is a social determinant of health as defined by the Centers for Disease Control and others. There is, however, a need for affordable housing providers, including permanent supportive housing providers, to work hard to develop more data showing that non-facility housing is a cost effective health intervention. Further data is also needed to determine what services are best delivered in the context of housing.
Another trend in service delivery may be more focus on evidence, standardization, and fidelity in an intervention. So for example, VA has a set of standards for rapid rehousing that are extremely comprehensive, and also a tool for assessing fidelity to those standards. The Alliance itself is implementing a rapid re-housing certification process in Virginia. And of course there is emerging structure around the components of the Housing First model.
Having a stricter definition of interventions may also lead to a focus on the qualifications of the staff and the organizations that deliver the intervention. As a result, some of the larger nonprofit networks are looking at how this will affect credentials, certification, and data capacity of their staff and facilities. I want to thank Barbara Banaszynski from Volunteers of America for example, for sharing with me her always ahead-of-the-curve thinking on these issues. Stewards for Affordable Housing for the Future, a membership organization of innovative nonprofit housing developers, is creating a framework for delivery of services in affordable housing so as to maximize the possibility of reimbursement through the health care system. Enterprise and Leading Age – two hugely influential national organizations focused on community development, and housing and services for the aging, respectively, have convened a Housing Plus Services Learning Collaborative to define new ways, consistent with these trends, in which services can be delivered to people in housing. As opposed to residential care, linking services to stable housing seems to be an idea with a future.
These are some trends in how services may be delivered and by whom. What are some of the trends in how services will be funded? Certainly in the health care world there is a move away from grants and to fee for service or capitated rates. This is likely to have a carryover impact in the human services field. In a fee for service environment, organizations will need to be sure that they have a sufficient number of clients so that they can bill enough to support their staff: a significant change from the grant system. Capitated rates are another direction in which services will be financed. Here there may be real opportunities for homeless providers who have access to high cost individuals and have the potential to use that access to create savings. Also, with various partners in the mix, including medical and behavioral care systems, along with housing, coordination of care will become even more critical – especially for high need individuals. Again, here is an opportunity area for homeless service providers, but if you hope to get reimbursed by Medicaid or managed care, the staffing, data and facility issues will come into play again.
Summarizing, here are some of the trends to be thinking about for the future. The changes happening in health care may provide new funding sources. However, this may require more credentialed staff, different staff configurations, different licensing, and better data systems. The changes may also negatively affect your funding sources if it is felt that services could be funded through health care. Also, even funders that are not involved in health services may be influenced to change their funding standards and mechanisms to conform to new models. New partnerships are important. A way to keep an eye on trends, and to be positioned to move forward in the future is to get involved in the local groups and coalitions that are working on health care implementation. Things are different in different states, and these coalitions will help you understand what applies to your work. Through this effort, you will develop the new partnerships you need for the future.
These trends and changes are big and systemic, and it may be necessary to respond to them. But they are not the changes that will end homelessness. And we need to be aggressive in thinking about game-changing strategies, because we are not in a good position in that regard right now. Despite great progress in some areas – basically veterans and chronic homelessness – the number of homeless people has not gone down for several years. We cannot just keep holding steady. We have to move the needle. The status quo is not acceptable.
In that regard, there are some things going on around affordable housing.
About 18 months ago the Bipartisan Policy Center launched a Housing Commission on which I was honored to serve along with 20 other national leaders evenly split between democrats and republicans. The Bipartisan Policy Center (BPC) is a Washington think tank whose job is to forge bipartisan solutions to big national problems
In February, the Commission issued its recommendations. I want to tell you about the rental housing ones, which I think are quite significant. The Commission said that the federal government spends a lot on housing ($180 billion per year), most of it on home ownership through the tax code. The Commission recommended some re-balancing toward affordable rental because of the extreme need. It recommended that everyone under 30 percent of area median income who needs it should receive rental assistance, and that this should be delivered through an improved system. It recommended that everyone from 30 to 80 percent of area median income should have access to some short term housing assistance that can keep them stable in housing and prevent homelessness. It made some recommendations about increasing supply, including a 50 percent increase in the Low Income Housing Tax Credit with HOME funds to fill the financing gaps in those projects. This is significant, but not enough to meet the 7 million unit gap in the supply of affordable housing, although going to scale on rental assistance would also stimulate supply. Since the US is losing affordable housing every year, we need to preserve the affordable housing we have, including public housing which has a significant backlog of unmet capital needs. The Commission recommended funding for that.
This is an expensive set of rental recommendations -- about $33 billion a year. Where would the money come from? The Commission recommended that there might be an opportunity to shift some resources from home ownership to affordable rental housing in the context of comprehensive tax reform.
These were groundbreaking recommendations, coming from a bipartisan group. The value of these recommendations is not in how brilliant they are, but in their bipartisanship. The Commission is continuing its work, now focused on trying to move these recommendations forward.
There are other big things underway that would also be game changers, in the same vein. Our great partner Sheila Crowley from the National Low Income Housing Coalition will speak to you at later in the conference about progress on funding the National Housing Trust Fund, which would fill the 7 million unit gap in supply of affordable housing. There is a proposal from the Center of Budget and Policy Priorities for a renter tax credit. There are efforts underway to increase the Low Income Housing Tax Credit program. And of course there is the ACA.
I will freely admit that all of these housing efforts face an uphill battle. The sequester and budget cuts really hurt, and created a new, lower federal funding baseline, which is going to hurt even more in the years to come. Even though federal revenues are increasing as the economy improves, the zeal for cutting programs for poor people has not abated, and there is likely to be more pain in the future. But I think that between these bold new national proposals to go all the way in addressing the need for affordable housing, health care reform and some the opportunities presented by the ACA, veterans initiatives, and your hard to work to end homelessness, there is reason for optimism.
And I know that optimism has to be supported with hard work. The hard work that has to be done to advance these bold, great new ideas is advocacy. You are here in Washington. Every single one of you – with the sad exception of those of us who live in the District of Columbia – has a delegation of Senators and House members up on Capitol Hill. You should go see them. It is critical that you let your delegates know that homeless people have tremendous needs, but that the problem is solvable and that you are prepared and have the skills to end homelessness, if only they will do their part.
We are in a period of change, and I am not sure we even know yet how profound that might be. Your job is to do your brilliant best with what you have got. And it is to use your obvious capacity to highlight, through advocacy, what the situation is in your community, and what is needed to achieve both justice, and to maximize the potential of our nation. This is not a small thing.
There is a lot of work to do. You will get plenty of new ideas about how to do it from the conference. So go learn from each other, teach each other, and enjoy the conference!