ACT UP testimony on housing needs of people with HIV in Philadelphia

Testimony by Max Ray-Riek
Member, ACT UP Philadelphia

Philadelphia is completing its first HOPWA needs assessment in 20 years. The quantitative portion of the assessment is not complete, but the qualitative portion has been released, and points to some very important themes that will be crucial to get right if we want to fight the many epidemics threatening Philadelphia’s public health, including HIV but also homelessness, drug and alcohol addiction, and mental illness.

In order to move forward, we need to build on the needs assessment to craft a comprehensive, city-wide plan for improving the public health of Philadelphia through ending homelessness, and the HOPWA needs assessment provides some clear next steps.

Solution Step 1: We need to coordinate care and services across multiple city departments and private agencies, through a centralized housing case management service. This needs to include centralizing data and maintaining a single master wait list in which people are automatically applied to any program for which they are eligible.

Federal best practices strongly recommend the housing hub model I am describing, but Philadelphia has challenges to overcome to get there.

Right now, the Office of Homelessness Support and the Department of Housing and Community Development and the Health Department (through AACO) and the Office of Behavioral Health Services all have separate and silo-ed roles in providing housing services for people with HIV. Add to the mix the Philadelphia Housing Authority and you have a problem that manifests itself in three major ways.

Problem 1: Individuals with HIV are slowed down in accessing care because they aren’t on all of the different lists they are eligible for. Case management is a very stressful job with a very high turnover rate. Very few case managers have the level of experience needed to navigate a large and confusing bureaucracy like the one we’ve created. Having well-trained, expert case managers with access to a single point of entry for all housing services across all city departments would make a huge impact in the ability of case managers to support clients.

Problem 2: We use funds inefficiently. Each bureaucracy has its own priorities and its own requirements for housing. Some of that we are stuck with because of federal and state stipulations. But in an integrated system, we could assess the need and better connect people to tiered support, from intensive case management up front to help someone dealing with chronic homelessness and multiple physical and behavioral health issues, to emergency homelessness prevention grants, to ongoing shallow rent support to help a home stay affordable. HOPWA funding is very flexible by design, and yet we tend to use it primarily for long-term rent subsidies without the level of case management that might help people move effectively through addiction towards employment. If we had a better sense of the community’s needs, and HOPWA funds were coordinated with PHA, Section 8, and other rental subsidy sources, we might be able to free up HOPWA funds for more creative uses.

Problem 3: We don’t have a strong advocate. Besides ACT UP whose members have (in the great tradition of AIDS activism) become experts on housing funding and policy, our champions are spread across city agencies and private providers, each of whom has to fight so hard for their tiny slice of the pie that they can’t speak up about the big picture of homelessness and chronic illness in Philadelphia. If there were a single coordinated list, the department overseeing that list would have a clear picture of the immediate need and overall trends in homelessness in Philadelphia and would be able to speak clearly to the Mayor, the Governor, and our federal representatives about what is needed. Right now, if you have a question about HOPWA funding, AACO (which is part of the Health Department) points you to DHCD who points you right back to AACO and you’re left wondering… does anyone really take responsibility for ending homelessness for people with HIV in Philadelphia?

All it would take to improve housing case management, use our existing funds more wisely, and empower a strong advocate for housing in Philadelphia is for Mayor Kenney to bring ALL agencies dealing with housing into a single, cross-department unit able to share data, coordinate funding, and manage all housing case managers, providing a single point of entry into a flexible, well-managed system for preventing and treating homelessness.

Solution Step 2: Leverage the newly coordinated and flexible city-wide housing unit to provide a true housing first approach. One of the gravest findings of the qualitative needs assessment (besides the struggles with case management, inefficiency, and lack of advocacy) was the fact that people with drug and alcohol addiction cycle in and out of HOPWA housing without getting into a more stable, healthier situation. 

Except for the relatively small number of official Housing First beds managed by Pathways to Housing, most AACO housing requires sobriety – but not long-term sobriety, even a few weeks sober or in treatment counts. The needs assessment turned up a pattern of people getting sober, moving into housing, relapsing, losing housing, ending up on the streets or in shelters, getting prioritized for housing again, getting sober, moving into housing, relapsing, etc.

This is NOT a Housing First model, and more importantly it does NOT demonstrate that people in active addiction are not ready for housing. Despite a pervasive belief among HOPWA providers, what this demonstrates is that Housing First is a specific philosophy and program that requires intensive case management, affordable housing available outside of the area where people were previously using, very close relationships with landlords, and plenty of flexible funding to help with some of the bumps in the road.

Housing First is essentially a commitment to using housing as a tool to help people get more stable and healthy, as long as that takes. It is needed in Philadelphia and it is NOT what we are doing, with a few exceptions.

In order to solve the problem of people cycling in and out of housing and in and out of sobriety, of risking their lives in a spiral of using, losing housing, and cycling into despair and reckless use that threatens lives and health, we must transition HOPWA to the philosophy and program that housing is not a reward for stability but a tool to support health.

To do that will require funding, but there is the potential for a promising funding source if we can advocate quickly and strongly at the state and federal level.

Pennsylvania is beginning the process of applying for a Medicaid waiver to allow housing case management to be reimbursable by Medicaid – and under Medicaid expansion that would mean that the federal government will reimburse PA for 90% of those costs.

We need to advocate that people with HIV be eligible for this waiver, so that all HOPWA housing case management is reimbursable.

We need to win that and then expand housing case management to include lots of support to make sure people get housing, keep their housing, stabilize, and hopefully get to a place where they need less of a subsidy or even no subsidy at all.

Know that in New York, by providing housing they have been able to realize such impressive cost savings that they are investing state Medicaid dollars directly into housing subsidies.

Now I know that everything about Medicaid is up in the air right now, but with the opioid epidemic sweeping through red and blue states alike, and with great strides that Republican governors have made with Housing First policies, and with the massive public outcry to save Medicaid expansion and prevent block grants, we can’t take our eyes off the prize and must advocate for people with HIV to be eligible for Medicaid reimbursing housing case management in Pennsylvania.

Solution Step 3: We need more funding. The HOPWA program used to grow every year, but since the recession it has been flat-lined and cuts have been threatened. Under President Trump I am not sure we can count on any HOPWA funding.

Philadelphia must invest in housing. We must invest in affordable housing and stabilizing housing prices. We must invest in keeping people in their homes and keeping those homes in good repair. And we must invest in providing safe, stable housing for chronically homeless and chronically unstably housed Philadelphians.

The Philadelphia Coalition for Affordable Communities is working with Councilmember Bobby Henon to introduce legislation to discourage rapid housing cost increases while providing more money to Philadelphia’s Affordable Housing Trust Fund. Pennsylvania’s Affordable Housing Trust Fund is also expanding.

The city needs a plan for that funding that prioritizes the public health by focusing on housing stability for people with chronic illness, and especially communicable chronic illness.

In summary, the HOPWA needs assessment is exposing that we are using HOPWA funds inefficiently, that housing case management is needlessly complicated by having too many wait lists managed by too many entities, that we are failing to provide housing and case management that helps people with addictions move towards stability, and that we do not have a strong advocate in the city.

To begin solving these problems, we need to quickly make a plan to:

  • Coordinate all housing providers and agencies, including the Housing Authority, and maintain a single wait list that automatically links people to the care they are eligible for and allows us to use funds flexibly and transparently to meet the demonstrated need, including:
    • Prioritizing people with communicable chronic illnesses across agencies including Section 8 and PHA
    • Making sure that people who are moving out of shelters and homelessness through the AACO-managed housing program has access to priority with PHA in the same way that people supported through OHS do
    • Using shallow rent vouchers as a tool to help prevent homelessness
  • Invest in intensive housing case management that helps people with addiction move towards stability, using housing as a tool. We need to advocate for that investment to be reimbursed by Medicaid for all people with HIV.
  • Advocate for increased funding for housing in Philadelphia and a clear plan for how to use the Affordable Housing Trust Fund to improve the public health by prioritizing housing for people with communicable chronic illness.