Homelessness: Barriers to Using Mainstream Programs (Letter Report,
07/06/2000, GAO/RCED-00-184).

Pursuant to a congressional request, GAO provided information on the
ability of homeless people to obtain assistance through mainstram
federal programs, focusing on: (1) why homeless people cannot always
access or effectively use federal mainstream programs; and (2) how the
federal government can improve homeless people's access to, and use of,
these programs.

GAO noted that: (1) homeless people are often unable to access and use
federal mainstream programs because of the inherent conditions of
homelessness as well as the structure and operations of the programs
themselves; (2) while all low-income populations face barriers to
applying for, retaining, and using the services provided by mainstream
programs, these barriers are compounded by the inherent conditions of
homelessness, such as transience, instability, and a lack of basic
resources; (3) furthermore, the underlying structure and operations of
federal mainstream programs are often not conducive to ensuring that the
special needs of homeless people are met; (4) for example, federal
programs do not always include service providers with expertise and
experience in addressing the needs of homeless people; (5) these
providers may not be organized or equipped to serve homeless people, may
not be knowledgeable about their special needs, or may not have the
sensitivity or experience to treat homeless clients with respect; (6) in
addition, the federal government's system for providing assistance to
low-income people is highly fragmented, which, among other things, can
make it difficult to develop an integrated approach to helping homeless
people, who often have multiple needs; (7) alleviating these barriers
would require the federal government to address a number of
long-standing and complex issues; (8) the expert panel GAO convened
discussed a variety of strategies the federal government could pursue to
improve homeless people's access to, and use of, mainstream federal
programs; (9) these included: (a) improving the integration and
coordination of federal programs; (b) making the process of applying for
federal assistance easier; (c) improving outreach to homeless people;
(d) ensuring an appropriate system of incentives for serving homeless
people; and (e) holding mainstream programs more accountable for serving
homeless people; (10) most of these issues are not new, and federal
agencies have tried to address them for years with varied degrees of
success; (11) at the same time, however, panel members noted that
federal agencies could do more to incorporate into mainstream programs
the various lessons learned from McKinney Act programs and demonstration
projects targeted to homeless people; and (12) these demonstration
projects have developed effective approaches to serving homeless people.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  RCED-00-184
     TITLE:  Homelessness: Barriers to Using Mainstream Programs
      DATE:  07/06/2000
   SUBJECT:  Homelessness
	     Federal aid programs
	     Interagency relations
	     State-administered programs
	     Disadvantaged persons
IDENTIFIER:  Food Stamp Program
	     Medicaid Program
	     Supplemental Security Income Program
	     SAMHSA Substance Abuse Prevention and Treatment Block
	     Grant Program
	     SSI

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GAO/RCED-00-184

Appendix I: Food Stamp Program

20

Appendix II: Public Housing and Section 8 Tenant-Based
Assistance

23

Appendix III: Employment and Training Services

26

Appendix IV: Supplemental Security Income

29

Appendix V: Community Health Centers

33

Appendix VI: Medicaid

37

Appendix VII: Substance Abuse Prevention and Treatment
Block Grant Program

41

Appendix VIII: Views of GAO's Expert Panel on Homelessness

45

Appendix IX: Comments from the Department of Health
and Human Services

51

55

DDS Disability Determination Service

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

HRSA Health Resources and Services Administration

HUD Department of Housing and Urban Development

GAO General Accounting Office

SAMHSA Substance Abuse and Mental Health Services Administration

SSA Social Security Administration

SSI Supplemental Security Income

TANF Temporary Assistance for Needy Families

USDA U.S. Department of Agriculture

VA Department of Veterans Affairs

WIA Workforce Investment Act

Resources, Community, and
Economic Development Division

B-283390

July 6, 2000

Congressional Requesters

Low-income people, including those who are homeless, can receive a wide
range of assistance--such as housing, food, health care, transportation, and
job training--through an array of federal programs, such as the Food Stamp
Program and Medicaid. These programs, often referred to as mainstream
programs, are generally designed to help low-income individuals either
achieve or retain their economic independence and self-sufficiency. However,
in the late 1980s, the Congress recognized that existing programs were not
effectively meeting the needs of homeless people. Consequently, to develop a
comprehensive federal response to homelessness, the Congress passed the
Stewart B. McKinney Homeless Assistance Act in 1987. The act established
programs providing emergency food and shelter, those offering longer-term
housing and supportive services, and those designed to demonstrate effective
approaches for providing homeless people with other services, such as
physical and mental health care, education, and job training. Originally,
many of the programs authorized under this act were intended to provide
targeted, emergency relief to the homeless population and were appropriated
at about $350 million in 1987. A decade later, this amount had increased to
about $1.2 billion annually, and much of the assistance these programs now
provide often mirrors the assistance available through the mainstream
programs. Even with this expansion, however, experts generally agree that
the McKinney Act programs, by themselves, cannot adequately meet the needs
of homeless people and that mainstream programs must be made more accessible
to this population.

Concerned about the ability of homeless people to obtain assistance through
federal mainstream programs, you asked us to determine (1) why homeless
people cannot always access or effectively use federal mainstream programs
and (2) how the federal government can improve homeless people's access to,
and use of, these programs. To address the first objective, we interviewed,
and reviewed documents obtained from, federal officials, representatives of
national advocacy and policy organizations, providers of services to
homeless people, and individuals who were currently or formerly homeless. We
focused in depth on barriers to seven key mainstream programs. Information
on these programs can be found in appendixes I through VII. To address the
second objective, we convened a panel of eight nationally recognized experts
on homelessness; the views of panel members are included in appendix VIII.

Homeless people are often unable to access and use federal mainstream
programs because of the inherent conditions of homelessness as well as the
structure and operations of the programs themselves. While all low-income
populations face barriers to applying for, retaining, and using the services
provided by mainstream programs, these barriers are compounded by the
inherent conditions of homelessness, such as transience, instability, and a
lack of basic resources. For example, complying with mainstream programs'
paperwork requirements and regularly communicating with agencies and service
providers can be more difficult for a person who does not have a permanent
address or a phone number. Furthermore, the underlying structure and
operations of federal mainstream programs are often not conducive to
ensuring that the special needs of homeless people are met. For example,
federal programs do not always include service providers with expertise and
experience in addressing the needs of homeless people. These providers may
not be organized or equipped to serve homeless people, may not be
knowledgeable about their special needs, or may not have the sensitivity or
experience to treat homeless clients with respect. In addition, the federal
government's system for providing assistance to low-income people is highly
fragmented, which, among other things, can make it difficult to develop an
integrated approach to helping homeless people, who often have multiple
needs.

Alleviating these barriers would require the federal government to address a
number of long-standing and complex issues. The expert panel we convened
discussed a variety of strategies the federal government could pursue to
improve homeless people's access to, and use of, mainstream federal
programs. These included (1) improving the integration and coordination of
federal programs, (2) making the process of applying for federal assistance
easier, (3) improving outreach to homeless people, (4) ensuring an
appropriate system of incentives for serving homeless people, and (5)
holding mainstream programs more accountable for serving homeless people.
Most of these issues are not new, and federal agencies have tried to address
them for years with varied degrees of success. At the same time, however,
panel members noted that federal agencies could do more to incorporate into
mainstream programs the various lessons learned from McKinney Act programs
and demonstration projects targeted to homeless people. These demonstration
projects have developed effective approaches to serving homeless people in
such areas as mental health, substance abuse treatment, primary health care,
housing, and job training.

Homelessness in America is a significant and complex problem. The exact
number of homeless people is unknown, but research by the Urban Institute,
conducted in 1987 and still widely cited today, estimated that over a 1-week
period, approximately 500,000 to 600,000 people lived on the streets or in
emergency shelters.1 According to a survey conducted for the federal
Interagency Council on the Homeless in 1996, in the year prior to the
survey, 60 percent of homeless people (excluding children in homeless
families) who used homeless assistance programs had an alcohol and/or drug
problem, and 45 percent had a mental health problem.2 While nearly all
homeless people are extremely poor, it is generally the combination of this
poverty with other vulnerabilities--such as lack of education or job skills,
severe mental illness, substance abuse, or lack of family and social
supports--that results in homelessness. The homeless population is far from
homogenous. For many homeless people, particularly those in homeless
families, homelessness is a short-term or episodic event; these individuals
may require little more than emergency shelter to get them through a
difficult situation. For other homeless people, particularly those with
severe substance abuse or mental health disorders, homelessness is a chronic
condition; these individuals may require intensive and ongoing supportive
services in addition to housing. As a result, the types of mainstream
assistance that different homeless people and families require vary greatly.

Homeless people can be served by two types of federal programs: (1) those
targeted to the homeless population, such as the programs authorized under
the McKinney Act, and (2) those designed to assist all eligible low-income
people. As we reported in 1999, 50 key federal programs administered by
eight federal agencies provided services to homeless people.3 Of these 50
programs, 16 were specifically targeted to homeless people and 34 were
mainstream programs designed for low-income people in general. In fiscal
year 1997, the federal government obligated about $1.2 billion for targeted
programs and about $215 billion for mainstream programs.

Services available through federal mainstream programs are delivered to
eligible individuals in a variety of ways. Some federal programs, such as
Supplemental Security Income (SSI), are largely administered by the federal
government, while others, such as the Food Stamp Program, are administered
by the states under broad federal guidelines. Still other programs, such as
the Substance Abuse Prevention and Treatment Block Grant, are administered
by the federal government as grants to states and communities and provide
considerable discretion to grantees in using these funds. In addition, many
of the services, such as health care and job training, that are funded by
federal mainstream programs are ultimately provided to eligible individuals
by "service providers," who are typically local, nonprofit organizations. As
a result, the extent to which the federal government can influence program
implementation and service to the homeless population varies significantly
according to the structure of the mainstream program.

Ability of Homeless People to Use Mainstream Programs

The characteristics of homelessness--transience, instability, and a lack of
basic resources--mean that homeless people often find it more difficult than
other low-income people to apply for, retain, and use the services provided
by federal mainstream programs. At the same time, the underlying structure
and operations of federal mainstream programs are often not conducive to
ensuring that homeless people are well served. This is because federal
programs may not always include service providers with expertise and
experience in addressing the needs of homeless people and because these
programs may lack incentives that encourage mainstream service providers to
serve this population. Also, the fragmented nature of federal mainstream
programs can create barriers to providing a coordinated set of services that
addresses the multiple needs of homeless people.

Mainstream Programs

While all low-income people face various obstacles in accessing and using
federal mainstream programs, the special circumstances of homeless people
greatly compound these obstacles, as well as create unique obstacles.
Homelessness is characterized by a lack of resources and stable housing, and
homeless people suffer disproportionately from a variety of personal
problems, such as poor health, mental illness, and substance abuse
disorders. The combination of these conditions can exacerbate obstacles to
(1) getting information about mainstream programs and fulfilling their
administrative and documentation requirements, (2) communicating and meeting
with mainstream service providers, and (3) effectively using the services
provided by mainstream programs.

Information, Administrative, and Documentation Obstacles

Homeless people may lack information about federal programs and services
that can assist them. While a lack of information about services can be an
obstacle to all low-income people, homeless people are less likely to have
access to as many sources of information as people who are housed, in part
because they are less likely to be connected with a community. As a result,
homeless people may be unaware of their eligibility for a program or how to
apply for it. In addition, mental illness, substance abuse, and other
personal problems common among the homeless population can interfere with
obtaining information about mainstream programs.

The application process for mainstream programs presents additional
obstacles. The process can be lengthy and complicated and can involve
considerable paperwork. For example, to receive SSI, which provides cash
benefits to eligible blind, disabled, and aged individuals, an applicant
must complete a 19-page application form, be interviewed by a claims
representative at a Social Security Administration district office, provide
the names and addresses of doctors and hospitals that have their medical
records, and document income and resources. It takes an average of nearly 3
months between the time an individual applies for assistance and receives an
initial decision. However, if the application is denied and the applicant
files an appeal, a final decision may take over a year. This complex process
and long wait can be difficult for all applicants but present special
problems for homeless people, whose personal conditions and lack of stable
housing can make it particularly difficult to negotiate a complicated
process. Moreover, many homeless people have literacy or language problems
or developmental disabilities, which can inhibit their ability to read and
fill out application forms.

Providing the required documentation is essential to obtaining federal
assistance but can be particularly problematic for homeless applicants. Many
mainstream programs require applicants to provide documents proving their
identity, citizenship, income, and financial resources, among other things.
However, homeless people often do not have these documents because they do
not have a safe and secure place to store important papers. For example, in
1998, the National Law Center on Homelessness and Poverty found that working
homeless people are not always able to receive the Earned Income Tax Credit
because they are unable to obtain and keep the tax forms needed to document
their earned income. Similarly, because homeless people often receive
medical care at various locations, including emergency rooms and clinics at
scattered sites, they may have difficulty providing the location of their
complete medical records to document their disability, as required for SSI
and other programs.

Communication and Transportation Obstacles

Communication difficulties can hinder homeless people in applying for
assistance from mainstream programs. The application process for many
programs can involve multiple contacts--in person, on the telephone, or by
mail--between the applicant and one or more program offices. Failure to
respond to a request for information from a program or to meet certain
deadlines can delay an applicant's receipt of benefits. Like many other
low-income people, homeless people may lack a telephone, but they are also
more likely to lack a reliable mailing address. As a result, communicating
with program offices can be difficult. For example, applicants for public
housing are typically put on a waiting list until housing becomes available,
which can be several months or years. When a homeless applicant reaches the
top of the list, the housing authority maintaining the list may be unable to
contact the applicant to offer housing. As a result, the homeless applicant
may either be deleted from the list or moved to the bottom of it.

Communication problems can continue once a homeless person enrolls in a
federal program. For example, without a dependable mailing address, a
homeless family may have difficulty receiving, on a reliable and consistent
basis, the cash benefits available through the Temporary Assistance for
Needy Families program. Communication difficulties can also create obstacles
to receiving consistent medical care, including care provided through
federally supported programs such as Medicare, Medicaid, and the Community
Health Center program.4 A homeless person without a telephone or mailing
address may have difficulty making and keeping scheduled appointments and
arranging for appropriate follow-up care.

For many low-income people, the contacts necessary with program offices and
service providers are also made difficult by a lack of transportation. This
problem is common among homeless people, who are less likely to own a car
and whose minimal resources may make public transportation unaffordable.
Without adequate transportation, it is more difficult to apply for benefits
or attend the interviews required as part of the application processes.
Transportation difficulties can also hinder the ability of homeless people
to use the services they need, such as medical care, job training programs,
and outpatient programs for substance abuse treatment.

Obstacles Posed by the Lack of Stable Housing

Without stable housing, homeless people face certain practical constraints
on their ability to effectively use many federal mainstream programs. For
example, homeless people generally have no place to store or refrigerate
food purchased with food stamps, and the program does not allow them to use
food stamps to purchase hot prepared foods from grocery stores. As a result,
they may be less able to maintain a nutritious, healthy diet. Recognizing
this problem, the Congress amended the Food Stamp Act in 1990 to allow
homeless people to redeem their food stamps at certain authorized
restaurants for hot meals; however, few restaurants are enrolled in this
program.

In addition, the use of managed care by state Medicaid programs may increase
barriers to health care for Medicaid beneficiaries who lack stable housing.
Managed care can have the advantage of giving homeless people a single and
consistent "medical home" where they can receive services. At the same time,
managed care organizations often operate under a tightly controlled set of
rules that may not always be compatible with the circumstances of someone
without a fixed place to live. For example, managed care organizations
usually require that care be provided at specific locations, which may not
be feasible for someone who is homeless and transient.

The lack of stable housing can also create obstacles to receiving effective
substance abuse treatment, which may be funded in part through the federal
Substance Abuse Prevention and Treatment Block Grant program. Substance
abuse treatment programs often provide outpatient rather than residential
treatment. However, many experts on homelessness and substance abuse
treatment believe that outpatient treatment is unlikely to be effective for
many homeless people because they do not have the stable and substance-free
living environment needed for successful recovery. Moreover, many outpatient
mainstream treatment programs have requirements that may not always be
feasible or realistic for someone who is homeless, such as requiring daily
contact with a case manager or requiring the individual to be sober upon
admittance to the program.

in Barriers for Homeless People

The underlying structure and operations of federal mainstream programs are
often not conducive to ensuring that the special needs of homeless people
are met. Specifically, these programs (1) may not include service providers
with experience and expertise in serving homeless people; (2) may
inadvertently create disincentives for serving homeless people; and (3) are
highly fragmented, which, among other things, can make it difficult to
provide homeless people with coordinated care.

Mainstream Service Providers May Not Have Experience and Expertise in
Serving Homeless People

According to many service providers, advocates,5 and homeless people we
spoke with, mainstream programs often do not include service providers with
experience and expertise in serving homeless people. These providers may not
be organized or equipped to serve homeless people, may not be knowledgeable
about their special needs, and may not have the sensitivity or experience to
treat homeless clients with respect. For example, many providers delivering
Medicaid services for states are not adept at dealing with homeless
patients' special needs and characteristics, such as their inability to
store medicines or their lack of adequate shelter, nutrition, and hygiene.
Many Medicaid providers are also generally not organized to integrate
medical care with other needs, such as substance abuse treatment, nutrition,
and housing, which is often required to effectively treat homeless patients.

Similarly, recent changes to the federal government's system for providing
job training may affect the supply of job training providers with expertise
serving homeless people. The Workforce Investment Act of 1998 allows
communities to use contracts to fund specific providers but directs the
majority of resources toward job training "vouchers," which are provided to
individuals needing assistance. Some advocates and service providers have
expressed concerns that the emphasis on individual vouchers could result in
less funding for providers that specialize in training hard-to-serve
individuals, such as homeless people.

Mainstream Programs May Not Provide Adequate Incentives for Serving Homeless
People

Federal mainstream programs may not provide adequate incentives for service
providers to serve the homeless population. Homeless people often have
multiple needs, more severe problems, and fewer resources than other
segments of the low-income population. Therefore, they can be a
comparatively more expensive and difficult population to serve. States,
localities, and service providers who receive federal funds but face
resource constraints may therefore be deterred from making the special
efforts that are needed to reach out to and serve the homeless population.
For example, although overall federal grant funding to community health
centers has not decreased, the proportion of health center revenues that
these grants represent has declined steadily over the past several years,
and the advent of Medicaid managed care has reduced some centers' Medicaid
revenues. As a result, according to health center representatives and other
providers we spoke with, community health centers are constrained in their
ability to allocate resources toward outreach and services for homeless
people.

In addition, the federal government's performance-based approach to
measuring program outcomes, while beneficial in many respects, can
inadvertently create disincentives to states, local areas, or individual
providers to serve the most challenging populations, such as homeless
people. This is because programs that focus on hard-to-serve populations,
such as homeless people, may not have outcomes that are as successful as
programs that focus on more mainstream and easier-to-serve populations. For
example, the Workforce Investment Act holds states, communities, and service
providers accountable for performance measures, such as success rates in
placing people in jobs and improving earnings. However, to be effective,
states and communities will need to adjust performance standards on the
basis of the characteristics of different populations. According to some
advocates and service providers for homeless people, across-the-board
performance standards may act as a disincentive for job training programs to
serve homeless people. Such standards, they say, may serve to penalize
programs serving populations with multiple barriers to success, such as
homeless people. A Department of Labor official told us that although the
act does not require that performance measures be adjusted to reflect the
characteristics of different populations, it does allow the states and local
areas, if they choose, to do so.

Fragmentation of Federal Programs Can Cause Barriers

As we and others have reported in the past, the federal government's system
for providing services and benefits to low-income people is highly
fragmented. In part, this is because these programs have developed
incrementally as the Congress created programs over a period of time to
address the specific needs of low-income individuals and families. Some
fragmentation of these programs may be inevitable because many serve
different missions, or fragmentation may be constructive because it allows
the states and localities to design their own programs in response to local
needs and preferences. At the same time, the fragmentation of federal
assistance programs can create difficulties for low-income people in
accessing services, and it particularly affects the homeless population in
several ways. For example:

ï¿½ Each federal assistance program usually has its own eligibility criteria,
application, documentation requirements, and time frames; moreover,
applicants may need to travel to many locations and interact with many
caseworkers to receive assistance. While all people needing assistance may
find it confusing and time-consuming to navigate this complex system of
programs, the obstacles inherent in homelessness only compound these
difficulties.

ï¿½ The fragmentation of federal programs can make it difficult for homeless
people to receive an integrated system of care. Numerous studies have
demonstrated that the multiple and complex needs of homeless people--which
may include medical care, mental health care, substance abuse treatment,
housing, income support, and employment services--should not be addressed in
isolation but rather through programs that are integrated and coordinated.

ï¿½ Fragmentation at the federal level also creates fragmentation at the local
and provider levels, according to service providers, advocates, and
government officials we spoke with. States, localities, and service
providers administering multiple federal programs have to contend with
different program regulations, operating cycles, and limits on the use of
funds for the various programs. This hinders their efforts to effectively
coordinate mainstream programs at the state and local levels. Often, to
overcome the problems caused by fragmentation in the mainstream programs and
to develop services that meet the multiple needs of homeless people, program
administrators must cobble together funding from a variety of different
federal sources.

Complex Underlying Issues

Many experts on homelessness believe that the federal government will have
to address a number of long-standing and complex issues in order to reduce
the barriers that homeless people face in accessing and using mainstream
programs. To help us identify the actions and strategies that federal
agencies could implement to alleviate these barriers, we convened a panel of
nationally recognized experts on homelessness. These panelists identified a
number of changes or strategies that would help mainstream programs better
serve the homeless population:

ï¿½ The federal government needs to better integrate and coordinate federal
programs, both to facilitate integration and coordination at the community
level and to improve the care that is provided to homeless people with
multiple needs.

ï¿½ The process of applying for federal assistance should be made easier
through, for example, efforts that allow people who need assistance,
including homeless people, to apply for several programs simultaneously.

ï¿½ Mainstream programs need to conduct greater outreach to homeless people,
such as sending program staff to shelters, soup kitchens, and other
locations where homeless people congregate.

ï¿½ A better system of incentives is needed to help ensure that mainstream
programs adequately serve homeless people by, for example, making certain
that the high cost of serving this population does not become a disincentive
for providing them with adequate services.

ï¿½ Mainstream programs need to be more accountable for adequately serving
homeless people by, for example, encouraging programs to track the numbers
and outcomes of the homeless people they serve. (See app. VIII for more
detailed information on the panelists' views.)

The issues the panel members identified are not new to the federal agencies
responsible for administering mainstream programs. These agencies have been
trying to address some of these challenges for many years, with varying
degrees of success. For example, with regard to improving coordination and
simplifying the application processes, the Department of Health and Human
Services (HHS) developed an information system design in the 1980s that
facilitated state efforts to combine the eligibility determination process
for Medicaid, the Food Stamp Program, and Aid to Families With Dependent
Children.6 In addition, several states are planning or implementing their
own automated systems to coordinate the delivery of services provided by
multiple federal programs. However, these projects have faced several
serious challenges, owing, in part, to the complexity of the system of aid
for low-income people and the difficulties inherent in managing any large
information technology project. Similarly, in terms of increasing
accountability, the Government Performance and Results Act of 1993 requires
federal agencies to collect performance data and use these data to hold
programs accountable for their performance. However, as we reported in 1999,
the extent to which federal agencies are using this process to hold
mainstream service providers more accountable for serving homeless people is
not yet clear. This issue of program accountability is further complicated
by the fact that many federally funded services are now provided through
block grants, which give the states and localities wide discretion in
administering programs. A purpose of the Federal Financial Assistance
Management Improvement Act of 1999 is to improve the effectiveness and
performance of federal grant programs. Federal agencies are working with the
Office of Management and Budget to develop uniform administrative rules and
common application and reporting systems, replace paper with electronic
processing in the administration of grant programs, and identify ways to
streamline and simplify grant programs.

Federal agencies have developed a large body of knowledge about serving
homeless people effectively through the McKinney Act programs and various
demonstration and research projects targeted to homeless people. These
programs and demonstration projects clearly show there are strategies
mainstream programs can adopt to better serve the homeless population in
such areas as mental health, substance abuse treatment, primary health care,
housing, and job training. In 1994, we recommended that the Secretaries of
Housing and Urban Development (HUD), HHS, Veterans Affairs, Labor, and
Education incorporate the successful strategies for working with homeless
people from the McKinney Act demonstration and research projects into their
mainstream programs. While the federal agencies have taken some steps to
implement our recommendation, members of our expert panel emphasized that
these efforts have not been adequate. They said that federal agencies need
to do more to incorporate the "best practices" for serving the homeless
population that have been learned from past demonstration and research
projects into mainstream programs.

We provided a draft of this report to the departments of Agriculture, HHS,
HUD, and Labor, as well as the Social Security Administration, for review
and comment. These agencies advised us that they agreed with the information
presented in the report, and USDA, HHS, and the Social Security
Administration provided us with some technical comments that we have
incorporated, as appropriate.

In addition, HHS provided us with general comments that stated that the
report's categorization of the problems and barriers experienced by homeless
people in accessing mainstream programs is useful. HHS also stated that it
appreciated the report's observations regarding the heterogeneity of the
homeless population and the implication that a complex variety of mainstream
programs must be considered. However, HHS disagreed with the report's
implication that outcomes for programs serving homeless people may not be as
successful as outcomes for programs that serve other special populations,
such as the gravely disabled or chronically ill. We agree with HHS that
outcomes for programs serving homeless people can be as successful as
programs serving other special populations. However, our report simply
highlights that homeless people, like any population that faces special
challenges, may be more difficult to serve than mainstream populations that
do not face special challenges. As a result, performance measurement systems
that compare the outcomes of hard-to-serve populations with those of other
populations may put programs that focus on hard-to-serve populations at a
relative disadvantage. (See app. IX for the complete text of HHS' comments.)

To determine why homeless people cannot always access or effectively use
federal mainstream programs, we interviewed, and reviewed documents obtained
from, officials at the departments of Agriculture, Health and Human
Services, Housing and Urban Development, and Labor, as well as the Social
Security Administration. In addition, we obtained information from
representatives of national advocacy and policy organizations, including
those that deal with issues of homelessness, housing, primary health care,
mental health, substance abuse, nutrition, access to legal services,
veterans' affairs, and youth welfare. We also met with representatives of
organizations that provide services to homeless people, such as homeless
shelters and transitional housing programs. In addition, we conducted four
group interviews of 30 people who were either currently homeless or formerly
homeless. While we sought to identify the barriers faced by homeless people
across all federal mainstream programs, we focused in depth on seven key
mainstream programs--the Community Health Center program, the Food Stamp
Program, Medicaid, public and assisted housing, the Substance Abuse
Prevention and Treatment Block Grant, Supplemental Security Income, and the
job training activities provided under the Workforce Investment Act.

To determine how the federal government can improve homeless people's access
to and use of federal mainstream programs, we convened a panel consisting of
eight nationally recognized experts on homelessness. These individuals
included officials from federal agencies and directors of advocacy and
policy organizations concerned with the issue of homelessness. (The names
and organizational affiliations of the panel members are listed in app.
VIII.) We selected the panelists on the basis of recommendations we received
during our audit work. At a day-long meeting at our offices in Washington,
D.C., panel members developed recommendations for actions and strategies
that the federal government could take to alleviate the barriers homeless
people face in accessing and using federal mainstream programs. The meeting
was recorded and transcribed to ensure that we had accurately captured the
panel members' statements.

We performed our work between July 1999 and July 2000 in accordance with
generally accepted government auditing standards.

This is the fourth and final report on issues concerning homelessness that
we have prepared at your request. (See Related GAO Products.) We are sending
copies of this report to the appropriate congressional committees; the
Honorable Dan Glickman, Secretary of Agriculture; the Honorable Donna E.
Shalala, Secretary of Health and Human Services; the Honorable Andrew M.
Cuomo, Secretary of Housing and Urban Development; the Honorable Alexis M.
Herman, Secretary of Labor; the Honorable Kenneth S. Apfel, Commissioner of
Social Security; and other interested parties. Copies will also be made
available to others on request.

If you have any questions about this report, please call me or Anu Mittal at
(202) 512-7631. Other key contributors to this report were Jason Bromberg,
Lynn Musser, and John Shumann.

Stanley J. Czerwinski
Associate Director, Housing
and Community Development Issues

List of Requesters

The Honorable Phil Gramm
Chairman, Committee on Banking, Housing and Urban Affairs
United States Senate

The Honorable Pete V. Domenici
Chairman, Committee on the Budget
United States Senate

The Honorable James M. Jeffords
Chairman, Committee Health, Education,
Labor and Pensions
United States Senate

The Honorable Arlen Specter
Chairman, Committee on Veterans' Affairs
United States Senate

The Honorable Christopher S. Bond
Chairman, Subcommittee on VA, HUD and
Independent Agencies
Committee on Appropriations
United States Senate

The Honorable Wayne Allard
Chairman, Subcommittee on Housing and Transportation
Committee on Banking, Housing and Urban Affairs
United States Senate

The Honorable Bill Frist
Chairman, Subcommittee on Public Health
Committee on Health, Education, Labor and Pensions
United States Senate

Food Stamp Program

This appendix provides information about the barriers that homeless people
face in accessing and using the Food Stamp Program. This program, which is
administered by the U.S. Department of Agriculture (USDA), provides
low-income individuals with paper coupons or an electronic card that can be
redeemed for food items at authorized food stores. Misinformation about the
program, administrative difficulties, and a lack of outreach may create
obstacles to homeless people in accessing food stamp benefits. In addition,
because homeless people often lack facilities for refrigeration, storage,
and food preparation, they may face obstacles in using the Food Stamp
Program effectively.

In fiscal year 1999, the Food Stamp Program provided 18.2 million people
with an average of $72 in food stamps each month. The Food Stamp Program is
a federal-state partnership, with USDA's Food and Nutrition Service paying
the full cost of food stamp benefits and approximately half the states'
administrative expenses. States are responsible for administering the
program, including determining applicants' eligibility and calculating and
issuing benefits.

Homeless people, like all low-income individuals, may apply for the Food
Stamp Program at state or county welfare offices. The application form
varies from state to state and is between 7 and 20 pages long. Applicants
who meet income and resource requirements receive food stamp benefits within
30 days of submitting their application. Most homeless people, because of
their very limited resources and income, qualify for expedited service and
can receive food stamps within 7 days of applying. As a result of the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996,
able-bodied adults without dependents are required to meet certain work
requirements in order to maintain their eligibility for food stamp benefits.

USDA does not collect data on the number of homeless people who are
participating in the Food Stamp Program. Although the Food Stamp Program is
an entitlement program that is available to nearly all low-income people, a
1996 survey conducted for the federal Interagency Council on the Homeless
found that only 37 percent of the homeless people surveyed were receiving
these benefits.

Stamps

While some service providers for homeless people told us that it is
relatively easy to apply for the Food Stamp Program, others said that their
homeless clients face numerous obstacles in accessing the program. One of
the primary obstacles cited by the service providers and advocates we spoke
with was misinformation about the program's eligibility requirements. For
example, some homeless people incorrectly believe that they need a permanent
address to receive food stamps. Moreover, the implementation of Temporary
Assistance for Needy Families (TANF) has led to confusion among some food
stamp applicants and eligibility workers about the eligibility requirements
for the program. In 1999, we reported that some people were under the false
impression that applicants must qualify for TANF in order to qualify for the
Food Stamp Program.7 According to some providers and homeless people we
spoke with, this misinformation can deter homeless people from applying for
benefits.

The process of applying for the Food Stamp Program can also create certain
obstacles for homeless people. Transportation to the local welfare office,
which can be difficult for all low-income people, can serve as a particular
obstacle for homeless people, who often do not have private transportation,
and who may find public transportation inaccessible or unaffordable.
Furthermore, the application form can be difficult for some homeless people
to complete, particularly those who suffer from a mental illness. Moreover,
once they are receiving benefits, food stamp recipients who cannot
reasonably predict their income from month to month--which is the case for
many homeless people--are required to recertify their eligibility every 1 to
2 months. This recertification process is similar to the initial application
process and can be particularly burdensome for someone with an unstable
housing situation, who may not have access to a mailing address, phone, or
reliable transportation. In addition, according to some service providers
and homeless people, caseworkers at local welfare offices, who administer
the Food Stamp Program, can be rude or disrespectful, and may not make the
special efforts required to assist someone who is homeless.

Outreach efforts can help ensure that eligible homeless people are enrolled
in the Food Stamp Program. These outreach efforts can include such things as
sending caseworkers to local homeless shelters and helping individuals
complete their food stamp applications. In 1993 and 1994, USDA's Client
Enrollment Assistance Demonstration Projects provided $2.8 million to 26
local social service agencies to provide outreach for hard-to-serve
populations, including homeless people. A final evaluation of these
demonstration projects concluded that outreach can successfully increase the
enrollment of hard-to-serve people in the Food Stamp Program if it is
conducted by well-trained staff and tailored to match the characteristics of
particular communities and populations.

However, according to a USDA official, because the Food Stamp Program is
administered by the states, the decision to conduct outreach is left up to
the states. USDA encourages the states to conduct outreach by offering
technical assistance, distributing information about best practices for
outreach, and providing informal encouragement. USDA also provides matching
funds for states to conduct outreach to hard-to-serve populations, such as
homeless people. However, in fiscal year 1999, only nine states took
advantage of this funding.

Effectively

Homeless people may face certain obstacles in using the Food Stamp Program
effectively because they lack facilities for refrigeration, storage, and
food preparation. This can restrict the kinds and quantity of food they can
purchase with their food stamps. For example, homeless people may need to
purchase food items that are sold in single-serving containers and are
nonperishable, which can restrict their choice of nutritious foods.
Moreover, food stamps can be used to purchase cold single-serving foods
(such as a sandwich or a quart of milk) but cannot be used to purchase hot
foods prepared in a supermarket. Some service providers we spoke with
suggested that USDA could expand its definition of "eligible foods" so
homeless people could purchase hot foods prepared by the delicatessen
departments of supermarkets and grocery stores. Recognizing the special
circumstances of homeless people, the Congress amended the Food Stamp Act in
1990 to allow homeless people to redeem their food stamps at certain
authorized restaurants for hot meals; however, few restaurants are enrolled
in this program.

Public Housing and Section 8 Tenant-Based Assistance

This appendix provides information about the barriers that homeless people
face in accessing public housing and Section 8 tenant-based assistance,
which are overseen and funded by the Department of Housing and Urban
Development (HUD). The repeal of federal preferences given to homeless
people for public housing, changes in eligibility criteria, communication
problems, and the difficulties homeless people may have finding a suitable
unit using a Section 8 voucher can serve to impede homeless people's access
to and use of public housing and Section 8 tenant-based assistance.

HUD's two largest rental assistance housing programs--public housing and
Section 8 tenant-based assistance--house more than 6 million people. Public
housing is owned and operated by a local housing authority that provides
housing units to low-income people. Section 8 assistance is privately owned
housing that is federally subsidized. Section 8 assistance can be either
project-based, which is linked to particular housing units, or tenant-based,
which provides recipients with a voucher they can use at a housing unit of
their choice.

All forms of assisted housing have certain eligibility criteria based on
income status. In addition, federal housing assistance programs are
generally available only to families with children, the elderly, and persons
with qualifying mental or physical disabilities. As a result, single
nonelderly adults without a qualifying disability--who constitute a
significant proportion of the homeless population--occupy very few units of
public housing and generally do not receive Section 8 assistance. In
addition to its mainstream programs, HUD has housing programs specifically
targeted to homeless people, such as the Supportive Housing Program and the
Shelter Plus Care program.

The fundamental barrier that homeless people face in accessing public
housing is its scarcity. The demand for public housing greatly exceeds the
supply, and waiting lists for public housing (as well as other forms of
assisted housing) are often very long. However, while the scarcity of public
housing affects all low-income people needing housing assistance, recent
changes in legislation have made it harder for homeless people, in
particular, to access the limited available public housing, according to
many advocates and service providers. Before 1996, the federal government
required public housing authorities to give certain preferences to
households experiencing housing-related hardships, such as homelessness. In
an effort to give public housing authorities more flexibility in their
admissions and occupancy policies, the Congress suspended these federal
preferences in 1996 and permanently repealed them through the Quality
Housing and Work Responsibility Act of 1998. A HUD study issued in July 1999
found that, in response to this legislative change, nearly 60 percent of all
public housing authorities had eliminated federal preferences, including the
preference given to homeless people. The study did not gauge the effect
these changes have had on the populations affected. However, according to
housing and homelessness advocates and service providers, the loss of
federal preferences for homeless people will almost certainly have a major
effect on the ability of homeless people to access public housing. Homeless
people will no longer automatically move up the waiting list in most areas,
they say, resulting in fewer public housing units occupied by people who
were formerly homeless.

Other changes made to the admissions and occupancy rules for public housing
may also have reduced the ability of homeless people to secure units in
public housing. The Quality Housing and Work Responsibility Act also allows
public housing authorities to admit a greater proportion of relatively
higher-income families into public housing. These provisions were designed
to reduce the concentration of poverty in public housing. However, some
advocates and service providers told us that this change will reduce the
proportion of public housing units rented to people with very low income,
including homeless people. In addition, other provisions of the law made it
easier for housing authorities to exclude applicants with criminal
convictions or a history of alcohol or drug abuse. While these provisions
are aimed at making public housing safer, they may also further reduce
access to public housing units for homeless people, many of whom have
multiple personal problems.

Homeless people may face additional barriers to public housing because of
communication difficulties. Although the initial process of applying for
public housing is generally not difficult, communication problems between a
housing authority and a homeless applicant can serve as a barrier once an
initial application has been made. For example, applicants who have been
deemed eligible for public housing are typically placed on a waiting list,
which can be several years long in some locations. When a unit becomes
available, an applicant is typically notified by telephone or mail and is
required to respond within a certain period of time. Advocates and service
providers told us that homeless people sometimes lose their spot in public
housing because they do not have a reliable mailing address or telephone
number at which they can be contacted. In addition, when housing authorities
update their waiting lists, they require applicants to respond in writing
that they are still interested in a unit. Homeless people who lack a fixed
address may get dropped from the waiting list because they did not receive
the notice mailed to them. According to the housing and homelessness experts
we spoke with, housing authorities vary greatly in the degree to which they
make special accommodations to help applicants who are homeless overcome
these obstacles.

Homeless people face many of the same eligibility and communication barriers
to accessing Section 8 tenant-based assistance that they do to accessing
public housing, since both programs are administered by public housing
authorities and share the same basic application process. However, they may
face additional challenges in using Section 8 vouchers once they receive
them, because landlords are not required to accept a voucher and because the
rent provided through the Section 8 program may not equal the rent a
landlord can get on the private market. An October 1994 study prepared for
HUD found that the rate of success in finding suitable rental units where
the landlords would honor Section 8 vouchers was not significantly different
for homeless and other participants. However, as rents rise and the supply
of affordable housing drops in many parts of the country, there are concerns
that homeless people will have an increasingly difficult time finding a
suitable unit for the following reasons:

ï¿½ Homeless people are more likely than other low-income people to lack a
telephone, reliable transportation, and other means necessary to search for
housing.

ï¿½ The homeless population includes an especially large number of people with
physical or mental health problems, which can interfere with the search for
housing.

ï¿½ Private landlords may not rent to homeless people who have Section 8
vouchers because they perceive homelessness to be an undesirable trait for
potential tenants, according to advocates and service providers.

Employment and Training Services

This appendix provides information about the potential barriers homeless
people face in accessing employment and training activities provided under
the Workforce Investment Act of 1998 (WIA), which is to be fully implemented
by July 1, 2000. Some advocates and service providers have raised concerns
about the effects of WIA's use of job training vouchers and performance
management on providing appropriate and effective employment and training
services for homeless people.

WIA is the legislation that provides the framework for the federal
government's employment and training activities. It requires states and
localities to establish workforce investment boards that develop employment
and training systems and allocate the systems' resources within their
community. Each local board develops a "one-stop" system that allows a job
seeker or an employer to access an array of employment and training services
in one place. The states are to fully implement WIA's job training
provisions by July 1, 2000. The Congress appropriated about $5.37 billion
for fiscal year 2000 for activities authorized under title I of the act,
which authorizes the new workforce investment system.

Employment services are essential for many homeless people to achieve
economic self-sufficiency and move out of homelessness. According to a
national survey conducted for the federal Interagency Council on the
Homeless in 1996, 44 percent of homeless individuals surveyed were employed
for pay in the 30 days prior to the survey, although only 13 percent had, at
the time, a regular job that had lasted 3 months or more. While data are not
yet available on the numbers of homeless people served by the activities
funded under WIA, under its predecessor, the Job Training Partnership Act,
about 2 percent of the 151,580 individuals served in program year 1998 by
the act's adult programs were homeless.

Homeless people can be a particularly challenging population for providers
of employment services. Homeless people often face serious personal
barriers, such as alcoholism or a deficiency in basic skills, that need to
be addressed before they are ready for employment or employment training. In
addition, the transience, instability, and lack of basic resources
characteristic of homelessness create certain practical obstacles to
accessing job training programs. Not having a telephone or a reliable
mailing address can impede access to these programs. Furthermore, homeless
shelters may require that residents be in and out by certain times, which
may not coincide with the requirements of a training program. In addition, a
lack of child care can be a major barrier to entering a job training
program; homeless women, in particular, often do not have a place to leave
their children during the day.

Recognizing the difficulty that homeless people may face in obtaining
employment services, the Congress authorized the Job Training for the
Homeless Demonstration Program as part of the Stewart B. McKinney Homeless
Assistance Act. Conducted by the Department of Labor from 1988 to 1995, this
program sought to develop effective ways of providing job training services
for homeless people. The demonstration found that mainstream employment and
training programs can be effective for homeless people if program providers
adopt certain strategies. These strategies included such things as making
special accommodations to help overcome obstacles related to the lack of a
stable residence, providing special training to staff on the needs of
homeless people, creating linkages with homeless service agencies, and
providing homeless clients with access to a wide array of services beyond
employment services.

Because special strategies are needed to serve homeless people effectively,
some advocates and service providers are concerned that certain provisions
of WIA may hinder the ability of the homeless population to receive
appropriate job training services. Under WIA's predecessor, the Job Training
Partnership Act, most services were delivered through contracts with job
training providers. Under WIA, however, most job training for adults is
provided through Individual Training Accounts, also referred to as vouchers.
Individuals who are unable to get or keep a job on their own may be referred
to intensive case management services and undergo an assessment. If
eligible, individuals may then be given a voucher that is used to "buy"
training services from their choice of qualified providers. Some advocates
and service providers for hard-to-serve populations have expressed concern
that (1) the dollar value of the vouchers may not be sufficient to meet the
training needs of homeless individuals who require more intensive services,
(2) the network of "qualified providers" may not include enough providers
with expertise in meeting the needs of hard-to-serve populations, and (3)
homeless people may find the vouchers difficult to use and may not be in a
position to choose the training programs most suitable for them.

A Department of Labor official responded to these concerns by noting that
while WIA emphasizes the use of vouchers, it also allows the use of
contracts to serve special populations with multiple barriers to employment,
including the homeless population. The official said that the degree to
which these contracts are used to serve homeless people and other special
populations will be largely determined by the decisions and efforts made by
the state and local workforce investment boards.

Some advocates and service providers are also concerned that WIA's
performance accountability system may serve as a disincentive to states,
local areas, or individual providers to serve homeless people. The act
requires states and local areas to set performance goals and track the
performance of job training programs by measuring job placement rates and
the earnings of program participants, among other things. While this
performance-based approach is beneficial in many respects, it can
inadvertently discourage programs and service providers from serving the
most challenging populations, such as homeless people, whose outcomes are
not likely to be as successful as those of other program participants.
According to some advocates and service providers for homeless people,
across-the-board performance standards may serve as a disincentive for job
training programs to serve homeless people. Such standards, they say, may
serve to penalize community-based organizations and others who serve
populations with multiple barriers to success, such as homeless people. A
Department of Labor official told us that although the act does not require
that performance measures be adjusted to reflect the characteristics of
different populations, it does allow the states and local areas, if they
choose, to do so.

Supplemental Security Income

This appendix provides information about the barriers that homeless people
may face in accessing and using the Supplemental Security Income (SSI)
program. SSI is administered by the Social Security Administration (SSA) and
provides cash benefits to blind, disabled, and aged individuals whose income
and resources are below certain specified levels. The complexity and
duration of the SSI application process can create obstacles that are
particularly difficult for people who are homeless.

The SSI program is authorized under title XVI of the Social Security Act. In
January 1999, 6.3 million people received a monthly average of $341 in SSI
benefits. To qualify for disability benefits, applicants must meet medical
and functional disability criteria as well as financial eligibility
requirements.

SSA does not collect data on the number of homeless people who receive SSI.
However, a 1996 survey conducted for the federal Interagency Council on the
Homeless found that 11 percent of homeless people were receiving SSI. The
Congress changed the eligibility criteria for SSI so that starting in 1997
people who were previously eligible for SSI because of a diagnosis of
alcohol and/or drug addiction were no longer eligible for benefits.
According to advocates and service providers for homeless people, this
change may have reduced the number of homeless people who are eligible for
SSI.

The SSI application process is complex and requires extensive documentation,
which can create a number of barriers for homeless people. The SSI
application form is about 19 pages long and includes detailed questions
about living arrangements, resources, income, and medical history.
Applicants must also provide a variety of documents to support the
information on the application form. Completed applications are sent to the
state's Disability Determination Service (DDS), which decides whether the
applicant has an eligible disability as defined by SSA regulations. DDS
officials may need to contact SSI applicants throughout the disability
determination process to obtain additional information. DDS officials may
also ask applicants to undergo a consultative medical examination paid for
by SSA to help determine an applicant's disability status.

While all SSI applicants may find this application process challenging,
service providers and advocates said it is particularly difficult for
homeless people for the following reasons:

ï¿½ Successfully completing the SSI application process may require multiple
communications with the SSA office. However, homeless applicants are not
always able to communicate regularly with employees at SSA because they may
not have a permanent mailing address, a telephone, or transportation.

ï¿½ Homeless people often seek medical care in emergency rooms and a variety
of other facilities, so they often do not have a single medical provider who
can provide their complete medical record. Homeless applicants are often
unable to remember the names and addresses of physicians and hospitals that
have provided care, which makes it more difficult for DDS to compile a
medical record.

ï¿½ Most homeless applicants apply for SSI on the basis of a mental
disability, and a mental disability can be significantly harder to diagnose
and document than a physical disability. In addition, many homeless people
have a substance abuse disorder, further complicating the SSI process.

In addition, the documentation requirements for SSI can be particularly
onerous for homeless people, who often do not have a place to store
important papers or other possessions. All SSI applicants are required to
provide a wide array of legal and financial documents. For example, an
applicant must provide a Social Security card or record of a Social Security
number, a birth certificate or other proof of age, payroll slips, bank
records, insurance policies, car registration, and other information related
to income and resources. Applicants applying on the basis of a disability
must also provide documentation regarding their health status. According to
service providers and advocates that we spoke with, homeless people often do
not have these documents and information.

In addition to the complexity of the process, its length can create
significant obstacles and hardships for people who are homeless, according
to service providers and advocates for homeless people. SSI benefits may be
the only income that some homeless people have, and the long wait for
benefits makes it particularly difficult for them to afford basic
necessities, such as housing, food, and clothing. According to SSA data, the
average waiting time for an initial SSI disability decision in fiscal year
1997 was 80 days after the application was filed. However, 68 percent of the
applications were initially denied. If an application is denied, applicants
can appeal the decision to DDS, then to an SSA administrative law judge,
then to SSA's Appeals Council, and finally to the federal court system.
Appeals are not uncommon for the SSI program; for example, in fiscal year
1997, more than one-quarter of the decisions to grant SSI were made by an
administrative law judge. During that year, the process of appealing a
denial through DDS and then to an administrative law judge took an average
of 374 days from the time the appeal was filed. Under its fiscal year 2001
Performance Plan, SSA says it hopes to simplify SSI policies and issue
disability decisions more quickly.

Because of the complexity and duration of the SSI application process, it is
extremely difficult for most homeless people to successfully complete this
process without assistance, according to service providers, advocates, and
homeless people we spoke with. SSA does offer assistance to applicants who
have difficulty producing information or records. However, homeless people
who receive assistance in completing their SSI application typically receive
such assistance through service providers or legal aid agencies, which help
applicants fill out the required forms, maintain contact with SSA and DDS,
and help obtain and provide medical documentation.

An SSA Outreach Demonstration Program in fiscal years 1990 through 1992
found that it can be difficult for homeless people to navigate the SSI
application process by themselves; an advocate or caseworker is an essential
part of the process for these applicants. Under this program, SSA awarded
funds to 82 project sites to conduct outreach to special populations,
including homeless people. Specifically, local nonprofit and human service
agencies were given funds to educate individuals about the SSI program and
assist them throughout the application process. This assistance included
identifying eligible individuals who were not enrolled in SSI, providing
application assistance, gathering medical evidence to support these
individuals' applications, and tracking applicants for follow-up. SSI's
evaluation report for the demonstration program found that these local
service providers were able to effectively identify hard-to-serve eligible
individuals, including homeless people, and help them complete the SSI
application process. The evaluation recommended that SSA establish a strong
organizational commitment to promote outreach. However, according to SSA,
because of budget constraints, the agency does not currently have a national
program to conduct outreach. SSA does direct its field offices to maintain
contact with facilities such as homeless shelters but does not have any
documentation of local outreach efforts.

Since 1991, SSA and the Department of Veterans Affairs (VA) have been
conducting the SSA-VA Joint Outreach Initiative for Homeless Veterans.8
Through this pilot project, SSA and VA staff work collaboratively at VA
health care facilities to identify homeless veterans who are eligible for
SSI and assist them in receiving their benefits as quickly as possible. A
1994 evaluation of the project found that it increased the rate of homeless
veterans applying for and receiving SSI and decreased the duration of the
application and decision process. However, this project serves only a
limited number of homeless veterans; it is currently operating at four VA
health care facilities nationwide and in fiscal year 1997 assisted 372
veterans with their applications, resulting in 56 awards of SSI benefits.

Community Health Centers

This appendix provides information about the barriers homeless people may
face in accessing and using health centers supported by the federal
Community Health Center program. This program, which is administered by the
Department of Health and Human Services' (HHS) Health Resources and Services
Administration (HRSA), helps fund primary and preventive health care
services in medically underserved areas. Homeless people face many of the
same barriers to accessing services from community health centers that they
face in accessing health services in general. In addition, financial
constraints limit the amount of outreach to homeless people that community
health centers undertake. Finally, these health centers do not always have
the expertise or experience needed to adequately address all of the unique
characteristics and needs of homeless people.

The Community Health Center program provided approximately $835 million in
fiscal year 2000 to help fund approximately 650 community-based public and
private nonprofit organizations that develop and operate community health
centers nationwide.9 In addition to providing medical services, community
health centers provide other services that facilitate health care, such as
health education, transportation, and linkages with other social services.
According to a 1996 study by the HHS Office of Inspector General that
surveyed 50 community health centers, about 2 percent of the centers'
clients were homeless and about 3 percent of the centers' annual budgets
went toward serving homeless people.

HHS also administers the Health Care for the Homeless program, which was
created under the McKinney Act and awards grants to local public or private
nonprofit organizations--including community health centers--to provide
health care services that are targeted to the homeless population. About 10
percent of the approximately 650 federally-funded community health centers
also receive an HHS grant to provide services under the Health Care for the
Homeless program. This appendix focuses only on community health centers
that do not have a Health Care for the Homeless component.

Health Centers

Although the mission of the Community Health Center program is to serve
those populations that may lack adequate access to medical care, homeless
people face many of the same barriers to accessing services from community
health centers that they face in accessing health care services in general.
Specifically, homeless people may

ï¿½ be unaware of the health care services available to them through community
health centers or where these centers are located;

ï¿½ lack transportation to get to a community health center, particularly if
it is not located in the central city;

ï¿½ have difficulty making and keeping scheduled appointments because they
have competing priorities for survival, such as finding food or shelter, or
because they do not have easy access to a telephone; and

ï¿½ not seek care because they fear or distrust large institutions, which is
particularly the case for individuals who are mentally ill.

Because of these barriers, experts generally agree that special outreach
efforts are required to ensure that homeless people receive access to
adequate health care. These outreach activities can include disseminating
health care information to homeless people and their service providers,
providing direct services at homeless shelters or special clinics, and using
mobile health units to serve homeless people living on the street. The
Office of Inspector General study found that while 64 percent of the 50
community health centers surveyed provided outreach services for homeless
people, the outreach did not always adequately ensure that homeless people
had sufficient access to care.

Limitations in outreach efforts by mainstream community health centers do
not generally stem from a lack of desire to serve the homeless population
but rather from a lack of resources, according to service providers,
advocates, and health center directors with whom we spoke. Community health
centers face financial constraints that result, in part, from changes in
their sources of revenue and in the overall health care environment.
Although overall federal grant funding to health centers has not decreased,
the proportion of health center revenues that these grants represent
declined from more than 50 percent in 1980 to 23 percent by 1998. In
addition, the growth of Medicaid managed care programs has reduced some
centers' cost-based reimbursement from Medicaid, which is an important
source of their revenues. Furthermore, community health centers are serving
an increasing number of uninsured patients. As a result of these factors,
many community health centers are unable to spend as much as they would like
on services such as outreach, transportation, and education, which help
ensure access to health care for homeless people. The tight fiscal
environment in which many community health centers operate also serves as a
disincentive to making greater efforts to reach homeless people, who are a
high-cost population to serve and are often uninsured.

Needs of Homeless People

Community health centers typically have extensive experience in addressing
the needs of underserved populations and providing culturally sensitive care
to them. At the same time, according to some health care providers and
advocates for homeless people, mainstream community health centers do not
always have the expertise or experience needed to adequately address all of
the unique characteristics and needs of homeless people. For example,
because these centers serve relatively broad populations, they may not be
organized to make some of the special accommodations homeless people may
require. Community health centers typically work on a system of scheduled
appointments, but homeless people may not be able to reliably make and keep
such appointments. In addition, homeless people may have difficulty storing
and refrigerating medications. Mainstream community health centers also do
not usually have many of the special services that health clinics targeted
to homeless people often have, such as a medical respite facility or laundry
machines for patients' use.

Furthermore, while community health centers often link patients with
welfare, substance abuse treatment, and other related services, their focus
is largely on providing medical care. Since the health care needs of
homeless people are often inextricably related to their need for other
services--such as housing, food, clothing, and mental health and substance
abuse treatment--a mainstream community health center, unlike a targeted
program, may not have the capacity to address these various needs and
services in an integrated fashion.

Because community health centers are largely autonomous, HRSA's efforts to
improve homeless people's access to these health centers may be limited in
their effectiveness. However, some providers and advocates we spoke with
said they believe that HRSA could do more to encourage and facilitate health
care for homeless people in mainstream community health centers. In
addition, the 1996 Inspector General's report suggested several improvements
HRSA could make, such as encouraging more collaboration and communication
between the community health centers and nearby homeless shelters. The
Health Care for the Homeless program, which is also administered by HRSA,
has taken several actions in the past few years to help ensure that homeless
people are adequately served by those community health centers that do not
have a Health Care for the Homeless component. These actions have included
publishing and disseminating a book on organizing health services for
homeless people; efforts to improve communications among community health
centers, homeless shelters, and advocacy groups; and the development of
"best practice" clinical guidelines for serving homeless people in
mainstream health care programs.

Medicaid

This appendix provides information about the barriers that homeless people
face in accessing and using health care services provided by Medicaid, a
joint federal-state program that finances health care coverage for
low-income individuals. Homeless people may have difficulty accessing
Medicaid because problems with communication, documentation, and other
factors associated with the inherent conditions of homelessness can impede
the application process. In addition, there are some concerns about the use
of Medicaid managed care and its effect on the care of homeless people
enrolled in the program.

In fiscal year 1998, the Medicaid program spent about $177 billion to
finance health coverage for over 40 million Americans. HHS' Health Care
Financing Administration (HCFA) has oversight responsibility for Medicaid.
Within broad federal guidelines, the states determine their specific
eligibility criteria and the type of services they will provide. However,
eligibility is mandatory for certain groups, including low-income families
with children and most recipients of SSI. HCFA does not have comprehensive
data on the number of homeless people enrolled in Medicaid. However, a 1996
survey of homeless people conducted for the federal Interagency Council on
the Homeless reported that about 30 percent of homeless people surveyed were
receiving Medicaid. Many homeless people are not eligible for Medicaid
because they are childless adults who do not have a qualifying disability.

Homeless people face a number of barriers accessing Medicaid because of the
conditions associated with homelessness, according to service providers,
advocates, federal officials, and homeless individuals who we spoke with.
Among these barriers are the following:

ï¿½ Some homeless people are unaware of the existence of the Medicaid program
or do not know how to apply for it. Welfare reform may have exacerbated this
problem because some homeless people incorrectly believe that they can
qualify for Medicaid only if they qualify for TANF.

ï¿½ The process of applying for Medicaid, which varies by state, can be
complex and time-consuming, and can be particularly difficult for someone
who is homeless. For example, a homeless person may not have a telephone or
reliable mailing address, making it more difficult to schedule appointments
and respond to follow-up inquiries with the local office that administers
Medicaid. In addition, because homeless people are often transient, it may
be difficult to find them if follow-up information is needed to complete an
application.

ï¿½ Because homeless people often do not have a place to store papers, they
may have difficulty providing the documentation that Medicaid may require to
establish their eligibility based on income, resources, and medical history.

ï¿½ States require individuals already on Medicaid to recertify their
eligibility for the program every 6 to 12 months. A homeless person without
a reliable mailing address is at greater risk of being inadvertently dropped
from the program for not having responded to the mailed notice of
recertification.

The barriers that we identified for Medicaid are consistent with the
findings of a 1992 study conducted by the HHS Office of Inspector General.
The study surveyed 298 directors of substance abuse or mental health
treatment programs, state Medicaid staff, Social Security staff in district
offices, and providers of services to homeless people. Many of the providers
surveyed indicated that a significant number of the homeless people they
served were not enrolled in Medicaid even though they were eligible for the
program. These providers cited the complexity and length of the application
process, the transience of the homeless population, and the difficulty of
providing the necessary documentation as the major barriers that prevent
homeless people from accessing Medicaid.

According to service providers and others we spoke with, outreach activities
can be effective in reducing these barriers. These activities may include
having agency staff visit homeless shelters to assist clients with the
application and enrollment process, accompanying clients to appointments,
helping them fill out forms correctly, and assisting them in gathering the
necessary documentation. However, HCFA officials told us that because
Medicaid is state-administered, the states vary considerably in the degree
to which they conduct outreach to homeless people and accommodate their
special needs. Although HCFA currently has various initiatives under way to
improve Medicaid enrollment among certain populations, including some
requirements for states to conduct outreach, these initiatives are not
targeted specifically to homeless people.

People

Increasingly, states are providing Medicaid coverage through managed care
organizations. While managed care may have certain benefits for homeless
people, it also raises concerns that it can create additional barriers to
health care for this population.

Under a system of Medicaid managed care, states contract with managed care
plans and pay them a fixed monthly, or capitated, fee per Medicaid enrollee
to provide most medical services. In some states, Medicaid beneficiaries can
choose whether to enroll in a managed care plan or a fee-for-service plan,
while in other states enrollment in a managed care plan is mandatory.
According to HCFA and other health care experts, enrollment in such a plan
provides certain advantages for homeless people. For example, a managed care
plan can provide homeless people with greater continuity of care by giving
them a "medical home" where they can go to receive all of the services they
need. In addition, unlike fee-for-service plans, managed care plans allow
the state's Medicaid agency to hold a single organization accountable for
providing care.

However, homeless service providers, HCFA officials, and others also share
concerns that the tightly controlled set of rules under which managed care
operates may not be compatible with the circumstances of homeless people.
For example, managed care organizations usually require that care be
provided at specific locations that are either operated or affiliated with
the managed care organization. This may not be feasible in the case of a
homeless person, who may be transient and not easily able to go to a
specific location for medical care. Furthermore, some health care providers
told us that homeless people who are enrolled in Medicaid often are not even
aware that they have been enrolled in a managed care plan and have little
information about the plan and where they should go to obtain services.

Some service providers and advocates also have concerns that Medicaid
payment policies may create disincentives for managed care organizations to
provide homeless clients with the special services or adaptations they
require. Because managed care organizations typically pay their providers a
capitated rate based on the average cost per person of providing care,
providers do not necessarily receive additional amounts for serving
high-cost populations, such as the homeless. This can discourage mainstream
providers from spending the additional money needed to effectively serve
homeless people and conduct special outreach to this population. In
addition, according to some service providers and advocates, a system of
fixed capitated payment rates may prevent the participation of providers who
have more experience and expertise in treating homeless people, such as
those involved in the Health Care for the Homeless program, since the
capitation rate may not be sufficient to cover the increased costs these
providers face in serving specialized populations.

HHS has been addressing the issue of homelessness and Medicaid managed care
in several ways. HRSA funded two booklets to provide the states with
guidance on developing and implementing Medicaid managed care programs that
include homeless people. HRSA is also funding the development of model
language that the states and others can use in their contracts with managed
care organizations to help ensure that Medicaid managed care programs meet
the needs of underserved populations, including homeless people. In
addition, at the request of the Congress, HCFA began a study in 1997 to
identify the safeguards needed to ensure that the health care needs of
persons with special needs enrolled in Medicaid managed care are adequately
met. Homeless people were one of six groups that the study focused on, and
the draft report makes a number of recommendations to the states. According
to HCFA officials and some advocates, because Medicaid is a
state-administered program, the degree to which Medicaid managed care serves
homeless people may depend in large part on whether and how states act on
these proposed recommendations.

Substance Abuse Prevention and Treatment Block Grant Program

This appendix provides information about barriers that homeless people may
face in accessing substance abuse treatment services funded through the
federal Substance Abuse Prevention and Treatment Block Grant program. This
program, which is administered by HHS' Substance Abuse and Mental Health
Services Administration (SAMHSA), is the primary tool through which the
federal government funds substance abuse treatment.10 Homeless people may
have limited access to effective substance abuse treatment programs because
mainstream substance abuse treatment programs are not always appropriate or
effective for homeless people and because states vary in the extent to which
they devote their resources--including those received through the block
grant--to serving the homeless population.

The Substance Abuse Prevention and Treatment Block Grant program was
appropriated $1.6 billion in fiscal year 2000. These funds support the
states and territories in planning, implementing, and evaluating activities
to prevent and treat substance abuse. The states and territories receive
grant awards according to a legislative formula, and the states have
significant flexibility in how they allocate their block grant funds.
Federal funding for public substance abuse treatment facilities, as a
percentage of all funding used at the state level for substance abuse
treatment, ranges from 11 percent to 84 percent, depending on the state.

While estimates vary on the prevalence of substance abuse in the homeless
population, in a 1996 survey conducted for the federal Interagency Council
on the Homeless, 60 percent of homeless individuals surveyed reported having
had an alcohol and/or drug problem in the year prior to the survey.
Fifty-two percent of those with a substance abuse problem during that time
also had a co-occurring mental health problem. Substance abuse treatment
experts generally agree that homeless people are among the most challenging
populations to treat for substance abuse disorders--both because their
addiction is often especially severe and because it is very difficult to
effectively treat someone who lacks stable housing.

Effective for Homeless People

Mainstream substance abuse treatment programs may not be appropriate or
effective for many homeless people because the programs often do not take
into account the unique needs and circumstances of homeless people,
according to experts on homelessness and substance abuse. In particular,
mainstream substance abuse treatment programs

ï¿½ often have long waiting lists, which can cause hardships for homeless
people because their situations are often especially dire and because they
may be difficult to contact when a treatment slot becomes available;

ï¿½ may have requirements that are not feasible or realistic for some homeless
people, such as requirements for sobriety upon admission or daily telephone
contact with a case manager;

ï¿½ do not typically conduct the proactive street outreach that is needed to
bring many homeless people into treatment;

ï¿½ often rely on outpatient treatment rather than the residential treatment
that experts say many homeless people need for effective recovery;

ï¿½ tend to focus exclusively on an individual's addictive disorder, rather
than addressing the multitude of needs, such as housing, health care, and
income support, that also must be addressed for a homeless person to recover
successfully; and

ï¿½ are often ill-equipped or unwilling to integrate mental health treatment
into the substance abuse treatment, which homeless people often require.

Unclear

Many advocates and service providers believe that the states often do not
allocate enough resources towards substance abuse treatment options that are
appropriate and effective for homeless people. While SAMHSA does not have
definitive data on how federal block grant funds are used for homeless
people, a SAMHSA official said the best information currently available is
the Treatment Episode Data Set, which showed that in 1998 homeless people
represented about 8 percent of all admissions into treatment programs
receiving public funding (local, state, or federal). According to a 1998
National Coalition for the Homeless study of substance abuse services, the
13 states reviewed spent very little of their state and federal substance
abuse treatment funds on services targeted to homeless people. A 1992 study
by the HHS Office of Inspector General surveyed programs that received state
funding through the federal Alcohol, Drug Abuse and Mental Health Services
block grant.11 Three-quarters of the 129 substance abuse treatment programs
surveyed said they did not do outreach to, or make special services
available to, the homeless population, even though most agreed that such
special services were needed to serve homeless people effectively.

Unlike the Mental Health Performance Partnership Block Grant, which funds
care for serious mental illness, the substance abuse block grant does not
require the states to submit plans describing how they will provide outreach
and services to homeless people. However, in its fiscal year 2001 block
grant application, SAMHSA has requested that states provide data, on a
voluntary basis, on the homelessness status of clients served through
treatment programs. In addition, SAMHSA recently asked the National
Association of State Alcohol and Drug Abuse Directors to collect data from
the states to better understand how the states use block grant funds to
serve the homeless population.

Some advocates and providers believe that more could be done to ensure that
homeless people are served effectively by the resources of the substance
abuse block grant. For example, they told us that states could be required
to include plans for addressing the needs of homeless people in their block
grant applications, and the states could be required to track the numbers
and outcomes of homeless people enrolled in treatment programs. In addition,
some advocates and service providers for the homeless believe that the
Congress should improve access to substance abuse treatment services for
homeless people through either (1) an earmark within the existing block
grant requiring that some portion of funding address the needs of homeless
people or (2) the creation of a substance abuse treatment program targeted
to homeless people. They noted that while there is a federal funding program
targeted to homeless people with severe mental illness--the Projects for
Assistance in Transition From Homelessness program--there is no similar
funding program targeted specifically to the treatment of homeless people
with substance abuse disorders.

As with any block grant, the Substance Abuse Prevention and Treatment Block
Grant gives the states significant latitude in how they use this funding. In
addition, the program does not require specific services for homeless
people. Consequently, SAMHSA may have limited effectiveness in directing how
block grant funds are used to meet the needs of homeless people. SAMHSA
officials told us they work with state project officers to try to ensure
that block grant funds and other resources are used to meet the needs of all
populations, including homeless people. SAMHSA also recently started a
strategic planning workgroup on homelessness issues to develop both short-
and long-term strategies for better addressing the needs of homeless people.
In particular, a SAMHSA official said the agency hopes to improve its
dissemination of information to the states and communities on model
treatment programs for homeless people, which could help encourage the
states to use block grant dollars to serve homeless people more effectively.

Views of GAO's Expert Panel on Homelessness

This appendix provides the views of the expert panel that GAO convened on
homelessness. The panel consisted of eight nationally recognized experts
who, during a day-long meeting, discussed the issues the federal government
should address in order to improve homeless people's access to and use of
mainstream programs. All the ideas presented in this appendix may not
represent the view of every member of the panel. Moreover, these ideas
should not be considered to be the views of GAO.

The following individuals were members of GAO's expert panel on
homelessness:

ï¿½ Martha Fleetwood, Executive Director, HomeBase;

ï¿½ Maria Foscarinis, Executive Director, National Law Center on Homelessness
and Poverty;

ï¿½ Mary Ann Gleason, Executive Director, National Coalition for the Homeless;

ï¿½ Jean Hochron, Chief, Health Care for the Homeless Branch, Bureau of
Primary Health Care, Health Resources and Services Administration,
Department of Health and Human Services;

ï¿½ Fred Karnas, Deputy Assistant Secretary for Special Needs Populations,
Department of Housing and Urban Development;

ï¿½ Walter Leginski, Senior Advisor on Homelessness, Department of Health and
Human Services;

ï¿½ Nan Roman, Executive Director, National Alliance to End Homelessness; and

ï¿½ Carol Wilkins, Director, Health, Housing, and Integrated Services Network,
Corporation for Supportive Housing.

The panel members discussed a number of issues the federal government needs
to address in order to improve homeless people's access to and use of
mainstream programs. Specifically, panelists discussed actions and
strategies the federal government could undertake related to (1) improving
the integration and coordination of federal programs, (2) simplifying the
process of applying for federal assistance, (3) improving outreach to
homeless people, (4) ensuring an appropriate system of incentives for
serving homeless people, and (5) holding mainstream programs more
accountable for serving homeless people. Although the panel members were
asked to limit their discussions to those ideas that would not require
substantial increases in resources, many panelists emphasized that the lack
of resources is a fundamental barrier that prevents mainstream programs from
better assisting homeless people.

Panelists said that there is a need to reduce the fragmentation of programs
at the federal level. This would not only improve access to mainstream
programs for homeless people, they said, but would also facilitate the
coordination of programs at the state and community levels and support the
integration of care for homeless people who have multiple needs. More
specifically, panel members discussed the following:

ï¿½ Reducing federal funding restrictions in order to facilitate providing
integrated care for people with multiple needs at the community level. For
example, allowing communities to more easily combine mental health block
grant funds with substance abuse block grant funds could make it easier for
providers to serve individuals with co-occurring mental health and substance
abuse problems. One panelist said that the states, localities, and service
providers need clearer guidelines from the federal government on how to
combine funds from different funding streams to serve individuals with
multiple needs.

ï¿½ Synchronizing federal funding cycles and consolidating funding of similar
federal programs to make it easier for communities to coordinate their own
programs and planning efforts.

ï¿½ Incorporating the best practices on coordination and integration that have
been developed from the McKinney Act's targeted programs for the homeless
and from several federally funded demonstration projects. For example,
federal agencies could benefit from adopting many of the strategies
developed in the Access to Community Care and Effective Services and
Supports demonstration project for integrating systems of care for homeless
people.12

ï¿½ Revitalizing the Interagency Council on the Homeless with greater
authority and resources.13 Panelists said the Council needs to have the
authority to effect changes at a policy level, not just at a program level,
and the power to coordinate programs across agencies, rather than serve
simply as a vehicle for discussion.

ï¿½ Having the congressional committees and subcommittees with jurisdiction
over the programs that affect homeless people take the lead on improving the
coordination and integration of federal programs. The panelists urged
congressional committees to consider the federal assistance system as a
whole when drafting legislation, rather than creating individual programs
that are not integrated with each other.

Members of our expert panel said that simplifying the application processes
for federal programs would facilitate homeless people's ability to access
these programs. They said increased efforts could be made that would allow
individuals seeking assistance to apply to several programs simultaneously.
Panelists said that better use of technology could help achieve these goals.
More specifically, panel members discussed the following:

ï¿½ Using a core application form that gathers the basic information required
for most federal programs, so as to reduce the need for applicants to
provide the same information to multiple programs. Supplemental forms could
gather the more detailed information required for certain programs. Improved
linkages between the databases of different federal programs would be needed
to make using a core application form feasible.

ï¿½ Developing a database that would provide comprehensive information on all
federal mainstream programs and benefits available to low-income people,
including those who are homeless. This would help service providers give
people needing assistance immediate and complete information on all of the
different kinds of federal assistance for which they are eligible.

ï¿½ Granting presumptive eligibility on the basis of homelessness for some
federal programs, and granting provisional eligibility on the basis of
homelessness while permanent eligibility is being established for other
programs. In addition, one panelist noted that homeless people may need
longer grace periods to comply with the requirements of the application
processes.

Panel members said that greater outreach to homeless people is needed to
ensure that they have access to federal programs. Panelists cited several
activities that could be conducted to better reach homeless people. However,
the panelists noted that outreach is more important for those programs that
have the resource capacity to meet an increased demand, such as the
entitlement programs, than it is for programs that have scarce resources to
begin with. Panelists discussed outreach activities that included the
following:

ï¿½ Sending mainstream program staff to places where homeless people
congregate, such as shelters and soup kitchens, so that they can encourage
eligible individuals to apply for programs and assist them with the
application process. Agencies could also make more use of satellite offices
in areas where homeless people and other underserved populations live.

ï¿½ More widely disseminating information about federal programs through more
visual and creative methods. For example, videotapes produced by federal
agencies could be used to train service providers about program rules and
eligibility and to inform homeless people waiting in program offices about
services available to them.

ï¿½ Developing flexible pools of funds that providers of services to homeless
people can use to engage homeless individuals, particularly those living on
the street, and encourage them to reconnect with the community and take
advantage of services available to them.

Our panelists stated that there is a need to create a system of incentives
that encourage federal mainstream service providers to better serve homeless
people. According to the panelists, federal programs must find ways of
ensuring that the high cost of serving the homeless population does not
serve as a disincentive to providers to serving this population. In
addition, panelists said, performance-based incentives--which reward
successful outcomes--need to be structured in a manner that does not
penalize mainstream service providers who assist hard-to-serve populations,
such as homeless people. Among the issues panel members discussed were the
following:

ï¿½ Ensuring that capitation rates for homeless people, under Medicaid managed
care, reflect the true cost of providing medical care to this population.14
One panelist said that the federal government needs to conduct additional
research on the health condition and medical costs of homeless people to
help the states incorporate these costs into their capitation rates.

ï¿½ Possibly providing higher reimbursement rates for tenants in public and
assisted housing who have the fewest resources, such as homeless people.

ï¿½ Setting aside earmarked (targeted) funds, or other kinds of financial
incentives, to help ensure that the states and communities use block grant
dollars to serve homeless people adequately.

ï¿½ Encouraging localities to adjust performance measures for job training
programs of the Workforce Investment Act so that they do not create
disincentives for serving homeless people. Panelists said job training
providers that serve homeless people should not be held accountable for
achieving the same outcomes as those providers who serve less challenging
mainstream populations.

The need for greater accountability was a recurring theme raised by panel
members. They emphasized that the federal agencies, the states, communities,
and service providers administering and operating federally funded
mainstream programs need to be more accountable for adequately serving
homeless people. Some of the ideas discussed by the panel members to achieve
greater accountability included the following:

ï¿½ Tracking the numbers and outcomes of homeless people served through
federally funded programs is an essential first step toward developing a
system of accountability.

ï¿½ Developing a set of minimum standards for how block grant funds should
address the needs of the homeless population that would help ensure that
states and communities are held accountable for serving homeless people
while still preserving the flexibility inherent in a block grant.

ï¿½ Requiring recipients of some federal funds to address in their planning
documents how they will serve the homeless population. For example, states
could be required to develop plans for how the homeless population will be
served with funds they receive from the Substance Abuse Prevention and
Treatment Block Grant program.

ï¿½ Creating a White House-level office on homelessness, analogous to the
Office of National Drug Control Policy, to help focus responsibility and
ensure accountability for the federal government's response to homelessness
in one central and visible office.

Comments from the Department of Health and Human Services

1. We agree with HHS that outcomes for programs serving homeless people may
be as successful as programs serving other special populations and that
homeless people are not necessarily more exceptional than other special
populations, such as the gravely disabled or chronically ill. However, our
report simply highlights that homeless people--as with any population that
faces special challenges--can be more difficult to serve than mainstream
populations that do not face special challenges. As a result, performance
measurement systems that compare the outcomes of hard-to-serve populations
with those of other populations may put programs that focus on hard-to-serve
populations at a relative disadvantage.

Related GAO Products

Homelessness: Grant Applicants' Characteristics and Views on the Supportive
Housing Program (GAO/RCED-99-239, Aug. 12, 1999).

Homelessness: State and Local Efforts to Integrate and Evaluate Homeless
Assistance Programs (GAO/RCED-99-178, June 29, 1999).

Homelessness: Coordination and Evaluation of Programs Are Essential
(GAO/RCED-99-49, Feb. 26, 1999).

(385814)
  

1. Martha R. Burt and Barbara E. Cohen, America's Homeless: Numbers,
Characteristics, and Programs that Serve Them (Washington, D.C.: The Urban
Institute Press, July 1989).

2. The "1996 National Survey of Homeless Assistance Providers and Clients"
was designed and funded by 12 federal agencies under the auspices of the
Interagency Council on the Homeless, a working group of the White House
Domestic Policy Council. The U.S. Bureau of the Census collected the data,
which the Urban Institute analyzed.

3. Homelessness: Coordination and Evaluation of Programs Are Essential
(GAO/RCED-99-49 , Feb. 26, 1999).

4. The Community Health Center program is a federal grant program that helps
fund health centers serving medically underserved populations.

5. The advocacy organizations we contacted for this report included both
those that focus on issues of homelessness, such as the National Coalition
for the Homeless and the National Alliance to End Homelessness, and those
that advocate for broader populations, such as the National Low Income
Housing Coalition and the Food Research and Action Center.

6. Aid to Families With Dependent Children, which provided eligible families
with monthly cash assistance, was replaced by the Temporary Assistance for
Needy Families block grant for the states.

7. Food Stamp Program: Various Factors Have Led to Declining Participation
(GAO/RCED-99-185 , Jul. 2, 1999).

8. For more information on homeless veterans, see Homeless Veterans: VA
Expands Partnerships, but Homeless Program Effectiveness Is Unclear
(GAO/HEHS-99-53, Apr. 1, 1999).

9. The Health Centers Consolidation Act of 1996 (P.L. 104-299, 110 Stat.
3626) combined programs for community health centers, migrant health
centers, health care for the homeless, and primary care for residents of
public housing into one. The consolidated appropriation for these programs
was over $1 billion in fiscal year 2000, of which funding for community
health centers represented about 82 percent.

10. This appendix focuses on the treatment activities funded by the block
grant and not on the prevention activities.

11. Federal funding to the states for mental health services and for
substance abuse prevention and treatment services were combined in a single
block grant until 1992.

12. Access to Community Care and Effective Services and Supports was a
demonstration project that evaluated the effectiveness of integrated systems
of care for homeless people with mental illness. It was sponsored by the
Department of Health and Human Services and conducted from 1994 to 1999; the
final results of the project are still being analyzed.

13. The Interagency Council on the Homeless was established by the McKinney
Act as an independent council, with its own funding and staff, to promote
the coordination of homeless assistance programs across federal agencies. In
1994, the Congress stopped appropriating funds for the Council, and it
became a voluntary working group under the President's Domestic Policy
Council.

14. A "capitation rate" is the fixed monthly amount given to a health plan
for each enrollee under a system of managed care.
*** End of document. ***