Like so many of my Boomer brothers and sisters I ran the streets with, I never dreamed I'd make it anywhere near my "golden years" given the lifestyle I was leading. As I passed the half-century mark in 2009, I realized how damned lucky I had been in getting my act together at 40. I work now with folks every day who are my age and older, in terrible physical and mental health and struggling with health issues related to lifestyle and street living: depression, hopelessness, Post Traumatic Stress, substance abuse (Hepatitis a, b, c and now d, HIV/AIDS, lung/breathing problems resulting from smoking of cigarettes, cigars, cannabis, cocaine, pcp, heroin and "mixed jive," not to mention the thousands of rug fibers and hunks of assorted white stuff of unknown origin found on the floor in crack-fiend induced carpet crawls), hereditary conditions, exposure to the elements, and the brutish, unforgiving nature of the streets themselves.
Lack of insurance and money to fill prescriptions or purchase healthy foods or a healthy environment, little knowledge about preventative health, poor hygiene and mouth/teeth care, continuous exposure to unforgiving natural elements, all take their toll on the human body. I frankly don't know how many of them survive as well as they do and would hate to think of what my health would be like if I were still out there, living that life today.
We're going to cost the health care system oodles of cash as we geriatricize into oblivion, and we're going to suffer miserably along the way. We used to think we were invincible, invulnerable, infallible. Now many of us are lucky to think at all, and those of us who know better are scared beyond words at what we've done to ourselves. We also know we're trapped, by poverty, by history, by actions and the lack thereof.
Many of us have resigned ourselves to succumbing to whatever gets us first, and frankly many of us don't even want to know whats wrong with us, because we can't fix it and knowing about it will just add one more worry onto a pile that we can't climb over anyway.
Many of us played, and now we're paying. But we didn't realize the price was going to be so high, nor did any of us think about the fact that the cost was going to go way beyond our own pockets and deep into yours. I know it's of little consolation, but on behalf of my generation and those of us who were not paying attention - or who had dropped out of school by the time health class was offered - I'd like to extend my most humble apology for impacting you with my initial choices and subsequent consequences. It's not much but it's about all you're going to get from many of us because we're too busy trying to figure how we're going to make it through another day.....
The Complexities of Elder Homelessness,
a Shifting Political Landscape and Emerging
Community Responses
JUDITH G. GONYEA
School of Social Work, Boston University, Boston, Massachusetts, USA
KELLY MILLS-DICK
School of Social Work, University of Hawaii, Honolulu, Hawaii, USA
SARA S. BACHMAN
School of Social Work, Boston University, Boston, Massachusetts, USA
Despite their growing numbers, homeless older adults remain largely invisible in society and there has been a pervasive lack of public focus on elder homelessness. In this article, we seek to shine light on this forgotten population and deepen understanding of dif- ficult challenges they confront in regaining housing security. We also examine the shifting political climate regarding homelessness, particularly the enactment and subsequent reauthorizations of the McKinney–Vento Homeless Assistance Act, and how these shifts are influencing community responses to elder homelessness. Finally, future challenges and policy directions for breaking the cycle of elder homelessness in the U.S. are discussed.
INTRODUCTION
Recent statistics offer troubling evidence of a growing number of older
Americans who are either homeless or precariously housed. According to
U.S. Department of Housing and Urban Development’s 2009 annual report to Congress, over 250,000 homeless older adults were sheltered in emergency or transitional housing programs in the United States during 2008. In 2005, a study by the National Alliance to End Homelessness, based on local point- in-time studies, estimated that 744,313 people experienced homelessness in the United States (Cummingham & Henry, 2007). Using recent estimates of homeless elders as representing 10% to 15% of the total homeless popula- tion (Gibeau, 2001), this suggests that there are 74,431 to 111,646 homeless elders today.
Additionally, it is predicted that the number of homeless elders will con- tinue to rise as the baby boomer generation ages. Indeed, the baby boomer generation is experiencing the highest wage inequality of any recent genera- tion, and approximately 10% of late boomers (those born between the years of 1955 and 1964) are finding themselves in poverty at midlife (Hughes & O’Rand, 2004). This economic divide between the haves and the have-nots is predicted to lead to even greater disparities as the boomer cohort ages. As Hacker (2008) pointed out, primarily as a result of the transfer of economic risk from the broad structures of insurance (whether sponsored by govern- ment or the private sector) onto American families, Americans are witnessing a dramatic rise in the economic insecurity of America’s middle-class families, including their growing fears of slipping down the rungs of the economic ladder. The troubling signs of this phenomenon include significant increases in the rates of personal bankruptcy, consumer debt, and home foreclosures.
Despite their growing numbers, homeless older Americans remain largely invisible. This invisibility may be due, in part, to homeless elders’ fears and avoidance of shelters and soup kitchens, but it may also reflect society’s discomfort in acknowledging that aging family members—parents, uncles, aunts, and grandparents—may suffer from mental illness, addic- tions, and/or poverty and find themselves living in unsafe or unhealthy environments. Yet, there is also a pervasive lack of public focus on elder homelessness. Why is this? To some degree this lack of attention to elder homelessness may reflect the societal view that America’s older popula- tion is, by and large, faring quite well—particularly in relation to younger populations. The declining rates of poverty among the older population, in general primarily due to a federally mandated system of targeted benefits and programs, coupled with the stigmatization of this subgroup, may be contributing to the issue of homeless elderly being of limited concern to policy makers (Rosenheck, Bassuck, & Salomon, 1998). Rather, much of the public’s attention in the past 2 decades on the crisis of housing insecurity has focused on families with young children, one of the fastest growing groups of homeless people in the United States (Nunez & Fox, 1999), as well as on the increasing numbers of runaway or thrownaway adolescents and young adults (Ringwalt, Greene, Robertson, & McPheeters, 1998; Robertson & Toro,
1999). However, current and predicted increases in economic and housing instability, along with the projected rapid growth of the older population as a result of the baby boomers’ aging, suggest that America will continue to witness a rise in the number of homeless or precariously housed older adults in the upcoming decades.
In this article, we therefore seek to shine light on this forgotten pop- ulation of older adults who are either facing homelessness or are at risk of becoming homeless. Our goal is to deepen understanding of the multi- faceted causes of homelessness in later life, as well as the difficult challenges homeless older adults confront in trying to find pathways back to safe and permanent homes. Second, we examine the historical failure of the homeless service system to address the needs of older adults who experience home- lessness. Although homeless older adults face many of the same challenges as homeless younger adults, there are some unique differences. For seniors, the ravages of homelessness can accelerate and magnify the effects of aging, including increased physical frailty, chronic disease, impaired cognitive func- tioning, and loneliness and isolation. Third, we examine the shifting political climate regarding homelessness, particularly the enactment and subsequent reauthorizations of the McKinney–Vento Homeless Assistance Act, and how these shifts are influencing community responses to elder homelessness. Finally, we discuss future challenges and policy directions for breaking the cycle of elder homelessness in the United States.
THE MULTIFACETED CAUSES OF ELDER HOMELESSNESS Definitional Issues
Elder homelessness is not an easily defined concept; not only do differing
views exist about the breadth of the definition of homelessness, but there is also debate about what should be the lower age limit used to define elder homelessness. Some, including federal legislation, define homelessness strictly in terms of housing (Stewart B. McKinney Homeless Assistance Act,1987).
However, others incorporate sociological and psychological dimen- sions into the definition of homelessness, focusing on the issues of extreme disaffiliation and disconnection from supportive relationships and traditional systems of care (Bassuk, Rubin, & Lauriat, 1984). Although different ages have been used to demarcate the lower-age limit for elder homelessness (Cohen, Teresi, & Holmes, 1988; Crane, 1994; Kutz & Keigher, 1991), increas- ingly, people aged 50 and older are included in the category of homeless older adult. There is a growing consensus among policy makers, service providers, and researchers that, as a result of their harsh living conditions, the use of age 50 as the lower age limit of older homelessness is most mean- ingful, given chronically homeless adults aged 50 to 59 typically present with the same chronic health problems and levels of functional impairment as
persons aged 60 and older in the general U.S. population (National Coalition for the Homeless, 2009a).
It is also now widely accepted that the causes of homelessness are multifaceted. Researchers and scholars no longer focus on a single causal factor; rather, most identify both structural problems beyond the control of individuals and behavioral choices that put at risk individuals’ ability to maintain a stable lifestyle as contributing factors (Cohen, 1999, Crane & Warnes, 2001, Shinn et al., 2007).
Income and Housing
Poverty and lack of affordable housing are widely viewed as two critical structural factors contributing to seniors’ homelessness risk. Although the elderly have a lower poverty rate than other younger U.S. populations, they are more likely to have an income just above the poverty threshold (Gonyea
& Hooyman, 2005). Persistent poverty makes the pathway back to safe per- manent housing a difficult one; most homeless elders lack any safety net of income, pensions, or savings, and rely primarily on very limited benefits from Social Security or Supplemental Security Income (SSI). Although, com- pared to their younger homeless counterparts, they are more likely to have a steady income source (Hecht & Coyle, 2001); the reality is that most struggle to meet their most basic daily needs. Nationally, the average SSI monthly benefit payment to a person age 65 and older (the most common source of income) is approximately $400 (U.S. Social Security Administration, 2009). Further, the rise in joblessness and the loss of many semiskilled jobs within the United States has been particularly hard on older workers. Persons in their 50s, confronting job loss and prolonged unemployment, often find reentry into the labor force difficult, if not impossible; however, at the same time, they do not qualify for many old-age related benefits or employer or publicly sponsored health care coverage.
Lack of affordable housing can also push elders into homelessness. Persistent poverty makes the accumulation of funds (i.e., first and last month rent, security deposit) for a new rental an insurmountable obsta- cle. Market-rate housing is simply not a viable option for these seniors, yet publicly-subsidized housing options remain scarce. In many commu- nities, waiting lists for local housing authority apartments have become common for the elderly and younger adults with disabilities. For example, currently there are over 300,000 units of Section 202 Senior Housing nation- ally; however, for each unit that becomes available there are an estimated 10 seniors waiting (Kochera, 2006). The U.S. Department of Housing and Urban Development (HUD) rental assistance programs, Housing Choice (formerly known as Section 8 Vouchers) that allow lower-income individuals to rent in the private market and apply for a subsidy to their rent, either have long waiting lists or are closed to new applicants (Burt, Pearson, & Montgomery,
2006). In 2004, the average wait for Section 8 vouchers was 35 months (U.S. Conference of Mayors, 2005). For older adults, such waits increase the risk of homelessness and/or inappropriate or unnecessary placement in long-term care facilities.
Physical and Mental Health
Although homeless individuals of all ages are more likely to experience med- ical problems as compared to their same-aged housed counterparts, elderly homeless persons more often have serious chronic illnesses; conditions that, in some cases, may have been untreated or only sporadically treated over the years. A cross-sectional, community-based survey of 531 home- less adults in Pittsburgh and Philadelphia, for instance, revealed that older homeless persons (aged 50 or older) were 3.6 times more likely to report a chronic medical condition as compared to those homeless adults under age
50. Eighty-five percent of the surveyed homeless elders reported a chronic condition; with the three most commonly reported problems being hyper- tension, arthritis, or other musculosketal disorders (Garibaldi, Conde-Martel,
& O’Toole, 2005).
Living on the streets or staying in the noisy, close-living environment of a shelter can place individuals at greater risk for hypothermia, sleep deprivation, dehydration, and/or exposure to infectious diseases or infes- tations, all of which may further compromise already-weak immune systems and exacerbate existing chronic health problems (Bottomley, 2001). Medical conditions that require consistent treatment, such as diabetes, are very diffi- cult to control for those lacking stable housing. Maintaining good nutrition and personal hygiene and keeping up with medical appointments, as well as just doing basic first aid, are also often difficult to manage when homeless. Even in a shelter environment, there is little control over what or when to eat; medications or medical equipment are not easily stored and may be lost or stolen, and persons are typically required to leave the facility during the daytime hours, severely limiting the ability to rest or simply get off one’s feet.
Persons suffering from serious and persistent mental health problems are particularly vulnerable to homelessness. It has been estimated that as many as two-thirds of all people with serious mental illnesses have expe- rienced homelessness or have been at risk of homelessness at some point in their lives (Tessler & Dennis, 1989). According to the Substance Abuse and Mental Health Administration (2003), an estimated 20% to 25% of the homeless single adult population is suffering from a severe mental illness. Substance use problems are a further complicating factor for homeless adults who have serious mental illnesses. It is estimated that 50% of homeless adults with serious mental illnesses also have a co-occurring substance use dis- order (Substance Abuse and Mental Health Services Administration, 2003). In Garibaldi and his colleagues’ 2005 study, among homeless older adults,
74% self-reported one psychiatric condition and 30% reported two or more psychiatric disorders, with the most common conditions being depression, anxiety disorders and posttraumatic stress disorders. Additionally, 73% self- identified an abuse or dependence on alcohol or drugs. A recent study by California’s public mental health system found that 15% of those with serious mental illnesses had experienced some period of homelessness in the prior year (Folsom et al., 2005).
Cognitive impairment or dementia, whether due to Alzheimer’s dis- ease, alcoholism, head injury, or cardiovascular problems, is another mental health challenge experienced by a significant number of older homeless adults (Bottomley, 2001). Significant memory problems, cognitive impair- ment, depression, and alcohol and/or drug dependence can lead to impaired judgments including failure to pay rent or mortgages; filthy and unsafe liv- ing conditions; and irrational ideas about, or conflicts with, neighbors or property management, which sometimes results in eviction or abandon- ment of one’s home. Similarly, these impaired beliefs and behaviors can also make it extremely difficult to transition a homeless elder with signifi- cant cognitive impairments, mental health disorders, and/or addictions back into permanent housing (Bureau of Primary Health Care, 2003).
Social Support
Family and friends have often been thought to be an important protective factor in keeping a vulnerable older adult from either becoming or remain- ing homeless. Thus, attention has increasingly focused on how one’s social network— size, membership, and the level of support—affects homeless- ness risk (Nyamathi, Leake, Keenan, & Gelberg, 2000; Wu, & Serper, 1999). The National Coalition for the Homeless (2009b, p. 1) noted:
Mental illnesses may also prevent people from forming and maintaining stable relationships or cause people to misinterpret others’ guidance and react irrationally. This often results in pushing away caregivers, family, and friends who may be the force keeping that person from becoming homeless.
Cumulative Disadvantage, Trigger Events and Chronic Homelessness
As previously mentioned, the causes of homelessness are multifaceted; for most older homeless adults, it is not a single factor that led to their loss of a safe permanent home. For many elders, a trigger event or transition may precede their homelessness (Crane et al., 2005); these events include widowhood, divorce, domestic violence, eviction, or the declining health or death of the family member or friend who cared for them. For instance, someone who was previously coping, despite life-long struggles with mental illness or addictions, may find his or her life upended by the death of a spouse. Similarly, for someone in their late 50s, who was just getting by, the loss of a job, coupled with a rent increase, may start a downward spiral to becoming homeless. As Shinn and her colleagues (2007, p. 696) noted, homeless older adults, even those who had previously led “conventional lives,” typically faced “multiple, cascading risks.”
For most individuals, homelessness is a relatively short, one-time event. However, a small but significant proportion of individuals experience home- lessness repeatedly or for long periods of time. It is estimated that, nationally, approximately 10% to 20% of homeless adults of all ages are chronically homeless. This group of persons is most often made up of single, poor adults with disabilities. The federal government defines a chronically homeless per- son as an individual with a disabling condition (substance use disorder, serious illness, developmental disability or chronic physical illness or dis- ability) who has been homeless either continuously for 1 whole year, or four or more times in the past 3 years (U.S. Department of Housing and Urban Development, 2007). Chronically homeless individuals often cycle between emergency shelters, hospitals, jail, and treatment programs. In fact, research suggests that, on any given night, chronically homeless persons can account for up to 50% of those seeking emergency shelter (Substance Abuse and Administration, 2003). Yet, even those who become homeless for the first time in later life can quickly enter the ranks of the chronically home- less population due to the previously identified long waiting lists for public subsidized housing in most cities.
PUBLIC RESPONSES TO ELDER HOMELESSNESS Historical Neglect
Historically, older homeless adults have been overlooked by both the aging
service system and the homeless service system. Slightly more than a decade ago, Cohen (1999, p. 5) noted that “public policy focuses implicitly on younger homeless people (mothers with children, for example), or is con- cerned with social categories in which aging homeless people are subsumed without special notice (disabled persons and veterans, for instance).” Not designed to serve homeless adults, most community-based aging agencies remain ill-equipped to meet the needs of this population, particularly the comorbid mental health and alcohol and/or drug problems often experi- enced by chronically homeless older adults. Similarly, programs and services designed to aid individuals and families coping with homelessness have not focused on vulnerable elders and are ill-prepared for many of the health conditions associated with aging, including frailty, poor mobility, loss of vision and hearing, dental problems, and chronic pain.
This failure of the homelessness service system to address the needs of seniors is very evident in the emergency shelter system. As the Bureau of Primary Health Care (2003) indicated, the “the emergency shelter system can be an especially harsh environment for an elderly person” (p. ii). Enforcing strict hours, shelter programs typically place clients into the streets during the day. Further, because of high demand, individuals often must stand in long lines to secure a bed for the evening, a challenge for many older homeless adults. Lack of handicap accessibility and the geographic isolation of shelter programs can also limit their utility to homeless seniors. The requirement that shelter service users either be engaged in actively seeking or maintaining employment often is not a realistic goal for many homeless elders who have serious chronic health problems. Finally, many homeless older adults vigorously avoid shelters due to their fears of aggressive younger clients or staff that may be insensitive to their needs.
Growing Public Awareness
The McKinney–Vento Act
The McKinney–Vento Act is a comprehensive, multifaceted bill that has had far reaching effects. It was the first, and remains the only, federal legislation centrally focused on the problem of homelessness in America. A landmark act, it represents our nation’s critical first step to seeking solutions to homelessness. Importantly, the act established the Interagency Council on Homelessness, an independent body, within the executive branch of government, comprised of representatives from 15 federal agencies charged with the mission of designing a comprehensive approach to reduce, prevent, and end homelessness. The original act also created 15 programs (administered by nine federal agencies) providing a range of services to homeless persons, including emergency shelter, transitional housing, affordable permanent housing, and job training. The original text of the bill emphasized that “there is no single simple solution to the problem of homelessness because of the different subpopulations of the homeless, the different causes and reasons for homelessness, and the different needs of homeless individuals.” However, although the legislation underscored the diversity of homeless persons, as previously mentioned, the issue of elder homelessness was not highlighted as a significant social problem.
Since its enactment, the act has been amended several times. Yet, as Fleetwood (2010) noted, one of the most significant shifts or changes to the act occurred in the 1990s under the Clinton administration when HUD (a) adopted the continuum of care approach to homeless service delivery, and (b) created a Policy Academy model for the state-level integration of federal funds, breaking down silos to create an integrated system of care for homeless individuals. The outcome was that states were charged with creating long-term strategic plans for ending homelessness.
The National Coalition for the Homeless (2006, p. 2) also character- ized the 1990 amendments as “more far reaching, altering the majority of programs authorized by the original act. In addition to expanding eligible activities for several McKinney Act programs, a few new programs were created.” Two new programs that have particular relevance to older home- less adults were: (a) the creation of the Shelter Plus Care program, which provides assistance to homeless persons with physical disabilities, mental ill- ness, AIDS, and/or alcohol and drug addictions; and (b) the amendment and expansion of the Community Mental Health Service program to the Projects for Assistance in Transition from Homelessness program. This paradigm shift to an integrative continuum of care model is key to the development of more effective services for older adults who, as previously described, often find that homelessness can accelerate and amplify the effects of aging, including chronic disease, impaired cognitive functioning, and frailty.
Although numerous proposals have been debated to reauthorize the McKinney–Vento Act since the mid-1990s, controversies prevented the pas- sage of legislation until just recently. On May 20, 2009, President Obama signed into law the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act, the first significant reauthorization since 1992. HUD was given up to 18 months to develop regulations to implement the new McKinney–Vento Act. The act has several major changes, including the expansion of the HUD definition of homelessness. The old definition of homelessness was limited to individuals who are on the streets, stay- ing in a shelter, or in an institution that provides temporary residence for individuals intended to be institutionalized. The new definition includes those previously considered homeless, as well as (a) people who are los- ing their housing in 14 days and lack support networks or resources to obtain housing; (b) people who have moved from place to place and are likely to continue to do so because of barriers, such as access for people with disabilities; and (c) individuals who are victims of domestic violence or sexual assault. Much of the argument for the expansion centered on the fact that the majority of homeless children and youth were not cov- ered under the existing definition because it excluded people staying with others temporarily because they had nowhere else to go (doubling-up or couch-homelessness) and people staying in motels due to a lack of viable alternatives. However, these are also situations in which vulnerable elders find themselves; and these doubled-up and motel situations can be quite damaging to elders’ health, particularly those with chronic health conditions or reduced immune systems who need structure, routine and consistency for adherence to medical regimes.
Importantly, the HEARTH Act also has a greater focus on preventing homeless, permanent supportive housing, and rapid rehousing. A greater emphasis on permanent supportive housing is especially critical to reduc- ing elder homelessness. For many homeless or precariously housed elders, given their levels of physical and/or cognitive impairments, a brick-and- mortar approach—that is, simply providing a physical structure or home—is inadequate. For these vulnerable elders, it is increasingly recognized that service-enriched or supportive housing represents the best solution.
National and Local Nonprofit Leadership
