GAO

United States General Accounting Office

Report to Congressional Requesters

July 2000 HOMELESSNESS

Barriers to Using

Mainstream Programs

GAO/RCED-00-184

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Contents

Letter 3

Appendixes 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

Related GAO Products 55

Abbreviations

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
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United States General Accounting Office

Washington, D.C. 20548

Resources, Community, and

Economic Development Division

B-283390 Letr

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 selfsufficiency. 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
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convened a panel of eight nationally recognized experts on homelessness;

the views of panel members are included in appendix VIII.

Results in Brief 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 lowincome 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
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approaches to serving homeless people in such areas as mental health,

substance abuse treatment, primary health care, housing, and job training.

Background 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.

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.
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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 lowincome 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.

Characteristics of

Homelessness and

Federal Programs Can

Impede the 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

3

Homelessness: Coordination and Evaluation of Programs Are Essential (GAO/RCED-99-49,

Feb. 26, 1999).
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federal mainstream programs can create barriers to providing a

coordinated set of services that addresses the multiple needs of homeless

people.

Homelessness Itself Creates

Obstacles in Accessing and

Using Federal 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
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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 lowincome 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.
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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

4

The Community Health Center program is a federal grant program that helps fund health

centers serving medically underserved populations.
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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.

Underlying Structure and

Operations of Federal

Programs Can Result 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

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.
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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
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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:

• 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.

• 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.

• 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
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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.

Alleviating Barriers to

Mainstream Programs

Requires Addressing

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:

• 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.

• 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.

• 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.

• 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.

• 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.)
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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,

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.
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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.

Agency Comments 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.)
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Scope and

Methodology

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
B-283390

Page 17 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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
B-283390

Page 18 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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
Page 19 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs
Page 20 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix I

Food Stamp Program ApApenednxidexiIs

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.

Background 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 lowincome 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.
Appendix I

Food Stamp Program

Page 21 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Homeless People May

Face Barriers in

Receiving and Applying

for Food 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.1 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

1

Food Stamp Program: Various Factors Have Led to Declining Participation (GAO/RCED-99-

185, Jul. 2, 1999).
Appendix I

Food Stamp Program

Page 22 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.

Homeless People May

Face Barriers in Using

the Food Stamp

Program 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.
Page 23 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix II

Public Housing and Section 8 Tenant-Based

Assistance ApendxiI

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 tenantbased assistance.

Background 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.

Homeless People Face

Numerous Barriers to

Accessing Public

Housing

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
Appendix II

Public Housing and Section 8 Tenant-Based

Assistance

Page 24 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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
Appendix II

Public Housing and Section 8 Tenant-Based

Assistance

Page 25 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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 May

Face Barriers to Using

Section 8 Vouchers

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:

• Homeless people are more likely than other low-income people to lack a

telephone, reliable transportation, and other means necessary to search

for housing.

• The homeless population includes an especially large number of people

with physical or mental health problems, which can interfere with the

search for housing.

• 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.
Page 26 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix III

Employment and Training Services ApendxiI

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.

Background 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.

Barriers to Accessing

Job Training

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,
Appendix III

Employment and Training Services

Page 27 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.

Potential Concerns

About Using WIA Job

Training Vouchers

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-toserve 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
Appendix III

Employment and Training Services

Page 28 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.

Potential Concerns

About WIA’s

Performance

Accountability System

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.
Page 29 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix IV

Supplemental Security Income ApendxiIV

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.

Background 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.

SSI Application

Process Can Create

Barriers for Homeless

People

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.
Appendix IV

Supplemental Security Income

Page 30 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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:

• 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.

• 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.

• 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
Appendix IV

Supplemental Security Income

Page 31 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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 followup. 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.
Appendix IV

Supplemental Security Income

Page 32 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Since 1991, SSA and the Department of Veterans Affairs (VA) have been

conducting the SSA-VA Joint Outreach Initiative for Homeless Veterans.1

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.

1

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).
Page 33 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix V

Community Health Centers ApendxiV

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.

Background 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.1 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.

1

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.
Appendix V

Community Health Centers

Page 34 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Conditions of

Homelessness Can

Cause Barriers in

Accessing Community

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

• be unaware of the health care services available to them through

community health centers or where these centers are located;

• lack transportation to get to a community health center, particularly if it

is not located in the central city;

• 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

• 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
Appendix V

Community Health Centers

Page 35 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.

Care Provided by

Community Health

Centers Does Not

Always Meet the 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
Appendix V

Community Health Centers

Page 36 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.
Page 37 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix VI

Medicaid ApendxiVI

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.

Background 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.

Conditions of

Homelessness Can

Create Barriers to

Accessing Medicaid

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:

• 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.

• 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
Appendix VI

Medicaid

Page 38 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

are often transient, it may be difficult to find them if follow-up

information is needed to complete an application.

• 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.

• 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.
Appendix VI

Medicaid

Page 39 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Medicaid Managed

Care May Create

Additional Barriers for

Homeless 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 feefor-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 highcost 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
Appendix VI

Medicaid

Page 40 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.
Page 41 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix VII

Substance Abuse Prevention and Treatment

Block Grant Program ApendxiVI

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.1

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.

Background 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.

1

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

prevention activities.
Appendix VII

Substance Abuse Prevention and Treatment

Block Grant Program

Page 42 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Mainstream Substance

Abuse Programs Are

Not Always

Appropriate or

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

• 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;

• 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;

• do not typically conduct the proactive street outreach that is needed to

bring many homeless people into treatment;

• often rely on outpatient treatment rather than the residential treatment

that experts say many homeless people need for effective recovery;

• 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

• are often ill-equipped or unwilling to integrate mental health treatment

into the substance abuse treatment, which homeless people often

require.
Appendix VII

Substance Abuse Prevention and Treatment

Block Grant Program

Page 43 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Extent to Which Block

Grant Resources Serve

Homeless People Is

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.2 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

2

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.
Appendix VII

Substance Abuse Prevention and Treatment

Block Grant Program

Page 44 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.
Page 45 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix VIII

Views of GAO’s Expert Panel on

Homelessness ApendxiVI

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.

Members of GAO’s

Expert Panel

The following individuals were members of GAO’s expert panel on

homelessness:

• Martha Fleetwood, Executive Director, HomeBase;

• Maria Foscarinis, Executive Director, National Law Center on

Homelessness and Poverty;

• Mary Ann Gleason, Executive Director, National Coalition for the

Homeless;

• 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;

• Fred Karnas, Deputy Assistant Secretary for Special Needs Populations,

Department of Housing and Urban Development;

• Walter Leginski, Senior Advisor on Homelessness, Department of Health

and Human Services;

• Nan Roman, Executive Director, National Alliance to End

Homelessness; and

• Carol Wilkins, Director, Health, Housing, and Integrated Services

Network, Corporation for Supportive Housing.

Views of the Panelists 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
Appendix VIII

Views of GAO’s Expert Panel on

Homelessness

Page 46 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

of resources is a fundamental barrier that prevents mainstream programs

from better assisting homeless people.

Need for Better Integration

and Coordination of

Mainstream Programs

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:

• 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.

• 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.

• 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.1

• Revitalizing the Interagency Council on the Homeless with greater

authority and resources.2 Panelists said the Council needs to have the

1

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.

2

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.
Appendix VIII

Views of GAO’s Expert Panel on

Homelessness

Page 47 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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.

• 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.

Need for Simpler and

Unified Application

Processes

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:

• 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.

• Developing a database that would provide comprehensive information

on all federal mainstream programs and benefits available to lowincome 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.

• 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.
Appendix VIII

Views of GAO’s Expert Panel on

Homelessness

Page 48 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Need to Provide Greater

Outreach

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:

• 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.

• 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.

• 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.

Need for an Appropriate

System of Incentives

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:
Appendix VIII

Views of GAO’s Expert Panel on

Homelessness

Page 49 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

• Ensuring that capitation rates for homeless people, under Medicaid

managed care, reflect the true cost of providing medical care to this

population.3 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.

• Possibly providing higher reimbursement rates for tenants in public and

assisted housing who have the fewest resources, such as homeless

people.

• 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.

• 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.

Need for More

Accountability for Serving

Homeless People

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:

• Tracking the numbers and outcomes of homeless people served through

federally funded programs is an essential first step toward developing a

system of accountability.

• 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.

• 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

3

A “capitation rate” is the fixed monthly amount given to a health plan for each enrollee

under a system of managed care.
Appendix VIII

Views of GAO’s Expert Panel on

Homelessness

Page 50 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

population will be served with funds they receive from the Substance

Abuse Prevention and Treatment Block Grant program.

• 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.
Page 51 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

Appendix IX

Comments from the Department of Health and

Human Services ApendxiIX

Note: GAO comments

supplementing those in the

report text appear at the

end of this appendix.
Appendix IX

Comments from the Department of Health

and Human Services

Page 52 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

See comment 1.
Appendix IX

Comments from the Department of Health

and Human Services

Page 53 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs
Appendix IX

Comments from the Department of Health

and Human Services

Page 54 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

GAO’s Comments 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.
Page 55 GAO/RCED-00-184 Homeless Face Barriers to Mainstream Programs

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).

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