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OCR for page 134
Current and Emerging issues
in Housing Environments
for the Elderly
Raymond'J. Struyk
The dominant issue in the debate surrounding the housing
environment of the elderly is how to construct public assistance
to support those housing transitions that are necessary to allow
community-based housing to become an active and integral ele-
ment in the overall Tong-term care system.
Two attributes in particular should affect the way we think
about housing interventions for the elderly population. First, as
people reach retirement age, they experience numerous changes,
sometimes in rapid succession: incomes fall from preretirement
levels, children leave home, health problems and activity limi-
tations emerge, a spouse requires institutionalization or dies.
Such a variety of life events means that any public policy to
help with housing problems of such individuals must be flexibly
designed; it should range from rent supplements to counseling
homeowners about various housing options to the provision of
support services to compensate for the inability to perform key
activities of daily living.
Second, the elderly cannot be viewed as a monolithic group.
As has just been suggested, they have widely different housing-
related problems. What is at least as important is that individ-
uals in the elderly population differ in three fundamental ways
Raymond J. Struyk is with the Urban Institute.
134
OCR for page 135
ISSUES IN IIO USING FOR THE ELDERLY
135
that must be taken into account in designing public policy: (1)
health status (including activity limitations), (2) economic re-
sources, and (3) householding status whether they are home-
owners or renters. Again, the resultant emphasis is on policies
that are flexible enough to accommodate the elderly in these
. .
various circumstances.
The balance of this essay is in six main sections. It begins with
a general inventory of the housing problems of the elderly that
considers dwelling-specific items as well as the need for support-
ive services. The second section reviews current federal housing
assistance programs for the elderly; the third presents a frame-
work for thinking about housing policy that goes considerably
beyond the present programmatic structure. The fourth section
describes three specific federal housing interventions that could
meet the requirement of being an element in a long-term care
system. The next section gives some idea of the possible conse-
quences of adopting such interventions, and the final section
provides conclusions.
HOUSING AND HOUSING-RELATED NEEDS
This section, which draws heavily on an earlier paper (Struyk
and Katsura, 1985), inventories the current housing needs of the
elderly to provide an idea of the extent of the need for various
types of housing assistance. The inventory is not extrapolated
into the future because making such estimates is a highly com-
plicated task, the outcomes of which are dependent on broad
economic and housing market developments, trends in pension
payments, and changes in the incidence and severity of health
problems and activity limitations.
In considering the housing needs of the elderly, it is useful to
make a distinction between traditional housing "problems" and
the particular needs that arise from the health problems and
activity limitations that are frequently the lot of elder citizens.
The housing problems of the elderly (called dwelling-specific
problems hereafter) include deficiencies in the dwelling, the high
price of housing relative to income, and overcrowded conditions.
All of these are problems that can be measured in fairly
straightforward ways and whose definition does not generally
have a special dimension for the elder]Ly. Other, more general
aspects of the housing environment for example, conditions in
OCR for page 136
136
RA YMOND J. STRUCK
the neighborhood, the convenience and quality of local shopping
and medical services are also relevant. These latter aspects are
not as well measured in the available data, however, and are not
treated further here.)
Housing problems associated with activity limitations or so-
called dwelling-use problems are much less precisely defined.
Indeed, activity limitations, which are used here as a shorthand
label for the larger set of health-related problems, are better
thought of as an indicator of a potential housing problem. Limi-
tations on the activities of the elderly can mean that they are
unable to use their dwelling fully. For example, they may be
unable to use the kitchen and bathroom without assistance (pos-
sibly because the rooms are inconveniently located in relation to
living and steeping areas), clean and maintain their home prop-
erly, or go shopping without help. On the other hand, these
limitations may be effectively offset by the assistance provided
by other family members or neighbors or by modifications to the
dwelling itself. Unfortunately, the only general measures of
housing needs arising from activity limitations focus on the
limitations themselves and not on the services the household
must do without because of them.
Thus, to determine the number of elderly persons with hous-
ing-related problems, we must combine reasonably rigorous es-
timates of traditional dwelling-specific problems with less direct
estimates of dwelling-use problems. One major difficulty this
time because of data limitations is calculating the joint occur-
rence of dwelling-specific and supportive service needs. The ap-
parent needs for support services are sharply reduced by the
assistance (intervention) of family and friends.
Dwelling-specific Needs
Our focus in this section is on the incidence of physical defi-
ciencies and excessive housing expenditure burdens in 19792
(Table 11. Moreover, we limit the population considered to those
households that in 1979 were not participating in federal or state
housing programs some 14 million elder-headed households.
Among the elderly, a fairly clear ranking emerges, running
from those with the worst housing situation to those with the
best. Impoverished renters and impoverished owners with mort-
gages are at the low end of the ranking, and nonpoverty owners
OCR for page 137
ISSUES IN HOUSING FOR THE ELDERLY
TABLE 1 Incidence (percentage) of Housing Deficiencies
and Excess Expenditures by Population Group, 1979a
137
Deficient
Physically Excess and Excess
Group Deficientb Expendituresb Expenditures
Nonelderly
Total 7.6 15.2 2.1
Renters 13.2 33.4 5.3
Owners with mortgages 3.1 7.9 0.5
Owners without mortgages 7.9 1.7 0.3
In poverty 26.3 70.8 16.6
Renters 28.7 86.5 22.5
Owners with mortgages 17.1 73.2 10.1
Owners without mortgages 26.2 18.2 3.0
Elderly (65 +)
Total 11.5 18.4 2.4
Renters 17.2 55.3 7.8
Owners with mortgages 6.5 25.3 2.9
Owners without mortgages 10.1 4.5 0.4
In poverty 29.0 41.0 8.7
Renters 31.0 74.9 17.7
Owners with mortgages 33.6 74.9 21.0
Owners without mortgages 27.4 17.7 2.3
RentersC
Metropolitan 12.1 58.8 6.9
Nonmetropolitan urban 21.6 54.6 7.3
Nonmetropolitan rural 40.1 37.3 13.3
Black 46.0 57.8 20.9
Other 13.3 55.0 6.0
Owners with mortgagesC
Metropolitan 4.3 25.7 1.3
Nonmetropolitan urban 8.4 18.9 5.8
Nonmetropolitan rural 14.2 29.6 7.2
Black 24.7 44.3 12.5
Other 3.8 22.6 1.6
Owners without mortgagesC
Metropolitan 6.8 5.1 0.4
Nonmetropolitan urban 8.4 4.4 0.0
Nonmetropolitan rural 18.3 3.4 0.8
Black 36.5 7.2 2.0
Other 8.3 4.4 0.3
aOnly unassisted households are included in these figures; see Appendix for
definitions.
bThe definitions of these needs are consistent with those used by the U.S. Depart
ment of Housing and Urban Development (HUD). See Appendix.
CThese figures are only for households headed by elderly persons.
SOURCE: Struyk and Turner (1984), Table 3.
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138
MA YMOND J. STRUCK
with mortgages and without mortgages are at the higher end.
Differences by location exhibit a familiar pattern; the incidence
of deficiencies rises steadily as we examine successively more
rural locations. In addition, this pattern holds across all tenure
groups. The incidence of excessive expenditures is more varied
but generally tends to be Tower in rural areas.
The relative disadvantages of black households are strikingly
clear. Their units continue to exhibit extremely high levels of
deficiencies, and the incidence of excessive expenditures is also
higher for black than for other households, especially among
renters. The differences among black households are generally
small, however, in comparison to the divergence in dwelling
deficiency rates between the races. Finally, although it is not
shown in the table, it is worth noting that there is little differ-
ence in the rate of deficiencies among the elderly aged 65-74
and those 75 years of age and older (Struyk and Soldo, 1980,
Table 3-6~.
To summarize, in 1979 there were about 1.61 million elder-
headed households in dwellings that would be characterized as
physically deficient and about 2.58 million households spending
an excessive share of income on housings Because only about
340,000 of the households have these problems in common-
meaning that many are spending a large fraction of their in-
comes to live in decent housing a total of about 3.85 million, or
28 percent of all elder-headed households, have a dwelling-spe-
cific housing problem. The incidence among those below the
poverty line is much greater: of the 2.66 million elder-headed
households in this group, 61 percent have at least one of these
problems.
Dwelling-use Problems
Although it has Tong been recognized that those whose activi-
ties are limited by health problems or disabilities are less able
to function effectively in their homes without assistance, na-
tional housing policy has accepted this fact only to a limited
extent. In considering policy options for helping those persons
with such problems, clearly, we must know the size of the popu-
lation that needs assistance. A key point to note at the outset of
this discussion is that dwelling-use problems can be alleviated
OCR for page 139
ISSUES IN HOUSING FOR THE ELDERLY
139
by supportive services, by modifications made to the unit that
facilitate its use, or by both of these methods.
Following are two estimates of the number of households with
dwelling-use problems; these estimates are intended to bracket
the actual number of those needing help. The more generous
definition is one that counts as needing assistance all of those
who have a functional impairment as a result of disability or
health problems. Applying this type of criterion to data from the
1979 National Health-Interview Survey, we find that about 12
percent of persons age 65 and older have a need for some form
of supportive services in their homes; the figure is 7 percent of
those aged 65-74 and 21 percent of those aged 75 and older. If
we apply the same rate to elder-headed households, about 2
million households are in this category.4
The incidence of need defined in this way is greater for women
than for men (in both age groups), greater for blacks than for
other ethnic groups, and apparently (because it is possible that
many of those with Tow incomes in 1979 had spent their way
down to this level through expenditures for medical and support-
ive care) greater for those with Tower incomes.
A more conservative (and possibly more accurate) estimate of
the number needing supportive services can be obtained if we
look at the share of those who have a functional limitation and
who are receiving formal care services that is, services pro-
vided by an agency, whether they are paid for by the recipient
or not. This type of calculation has the advantage of deleting
those who receive essential services only from family members,
neighbors, and friends. Nationally, about 25 percent of the el-
derly who report a functional limitation are receiving formal
services. Applying this rate to the 2 million households noted in
the earlier paragraph yields about 500,000 households who re-
quire support services provided by a formal agency.
Yet this figure is probably too low for two reasons. First, it is
virtually certain that not all of those who need such services
are receiving them. Second, some persons are now in Tong-term
care institutions who would not be there if such services had
been available to them. The evidence for this last statement
appears in the analysis of the determinants of institutionaTiza-
tion. Those elderly persons who live alone are institutionalized
at higher rates than the elderly in multiperson households, even
OCR for page 140
140
RA YMOND J. STRUYK
after controlling for health status and activity limitations (Weis-
sert and ScanTon, 19831.
All in all, we might take as fairly accurate an estimate on the
order of 750,000 elder-headed households that need formal sup-
portive services. Additionally, half again that number now need
and receive informal services, either from sources within the
households or from outside. Public policy should be so structured
as to complement informal services rather than replace them.
It is also important to note that, when we examine the deter-
minants of the likelihood of a person receiving formal support-
ive services, the dominant factors are the extent of the person's
disability and the absence of informal services. After controlling
for these conditions, income by itself is not an important factor,
which suggests that, over some range, public programs and in-
formal assistance are reaching many of those in the greatest
need of supportive services (for details, see Soldo, 19831. Thus,
service recipiency seems to be largely determined by incapacity,
a lack of informal assistance, the availability of formal services,
and, in some cases, the ability to pay for them.
In general, then, the patterns of dwelling-specific and dwell-
ing-use needs are quite different. Whereas dwelling-specific
problems are strongly related to income and little associated
with age, dwelling-use problems are related to age and physical
impairments but not particularly to income.
Dwelling Moclifications
The need for some types of supportive services can be elimi-
nated by various changes to an elderly person's dwelling,
changes that can compensate for particular functional impair-
ments. Such modifications range from the installation of grab
bars and easy-to-grasp doorknobs and other hardware to spe-
cially equipped telephones to bathrooms and kitchens that have
been remodeled to accommodate wheelchair use. In other cases,
these changes can reduce the need for supportive services and
thus complement their provision. The best estimate of the prob-
able need for modified dwellings beyond those already occupied
by some 700,000 elder-headed households is on the order of 1
million units (Strnyk, 19821. As indicated earlier, these house-
holds are not in addition to the number of those needing some
type of support services. If we assume that the needed modifi
OCR for page 141
ISSUES IN HOUSING FOR THE ELDERLY
141
cations are concentrated among those with the greatest impair-
ments (who are also most likely to be receiving formal support-
ive services), then approximately 250,000 households that are
not also receiving formal supportive services need to occupy
units with some special features. (Unit modifications are dis-
cussed further in a later section.)
Overlap Between Dwelling Problems
Newman (1985) has used 1978 data taken from a supplement
to the annual housing survey to estimate that about 17 percent
of the elder-headed households with a person having an activity
limitation reside in a unit that is physically deficient. (Newman
uses the same definition of dwelling deficiencies used earlier in
this paper.) Note that this rate is substantially higher than the
10 percent rate for elder-headed households with no members
with such limitations, suggesting that households with an im-
paired member have greater difficulty maintaining or affording
decent housing.5 This rate implies that in 1979 there were some
340,000 households in the group with both dwelling deficiencies
and dwelling-use problems.
Similar calculations can be performed for the overlap between
those households with excessive housing expenditures and those
with a member with an activity limitation. This calculation
yields an estimate of 540,000 households with the combined
problems.6
Summary
The figures in Table 2 summarize the information compiled
on the number of elder-headed households with various housing-
related needs. As implied earlier in this section, these are order-
of-magnitude estimates designed to give a general picture of the
current situation. The first point is that those households with
dwelling-specific needs far outnumber those with dwelling-use
needs, which points to the necessity of continued action in this
area. An encouraging point is that probably less than a million
households are characterized as having both dwelling-specific
and dwelling-use needs. This figure is only about 6 percent of
all elder-headed households in 1981, suggesting that it is a group
for which assistance should be possible.
OCR for page 142
142
TABLE 2 Summary of Housing Needs of Elder-headed
Households, 1979
RA YMOND J. STRUYK
Type of Need
Households
Number (000s)
Percentages
Dwelling specific
Deficient dwelling
Excessive housing expenditures
Dwelling use
Supportive services
Generous estimate
Stringent estimate
Dwelling modifications
Including those needing supportive services-
stringent definition
Excluding those needing supportive services-
stringent definition
Overlap between dwelling-specific and dwelling-
use problems
Supportive services (generous definition) and:
Deficient dwelling
Excessive housing expenditures
Supportive services (stringent definition) and:
Deficient dwelling
Excessive housing expenditures
1,610
2,580
2,000
750
,000
250
340
540
128
140
11.5
18.4
14.3
5.4
1.8
2.4
3.8
0.9
1.0
Households not receiving housing assistance.
SOURCE: Struyk, 1985.
On the other hand, on the order of 5 percent to 14 percent of
elderly households do have dwelling-use needs (or up to 9 per-
cent of the population without dwelling-specific needs). These
households are prime candidates for the shifting of elderly per-
sons into institutions.
Finally, a cautionary note: these figures are for 1979. The
sharp increases in the number of elderly that will occur in the
years ahead, as well as the greater share of the older and more
frail in this population, is well known and should be kept in
mind when considering possible policy interventions.
CURRENT FEDERAL HOUSING POLICIES
How has the federal government organized its available re-
sources to assist the elderly with their housing? This section
OCR for page 143
ISSUES IN HOUSING FOR THE ELDERLY
143
presents an inventory of current federal programs. An overview
of these programs from the perspective of dwelling-use and
dwelling-specific problems provides a useful initial orientation.
Figure 1 is a simplified depiction of the arrangement of cur-
rent federal policies for meeting the housing-related needs of the
elderly. The central point is the essentially independent admin-
istration of programs dealing with housing problems and those
providing support services. The joint provision of services is
largely "unexplored territory," with the exceptions being the
fledgling congregate housing program and some local efforts in
which federal resources are effectively coordinated. Conspicuous
gaps in coverage are evident such as the absence of dwelling-
specific aid for homeowners (except for home purchasing assis-
tance provided by the Farmers Home Administration) and a lack
of programs to help with dwelling modifications related to activ-
ity limitations. Likewise, the targeting of resources to Tower
income groups is mixed; it is probably good in the housing area
and much weaker in the area of support services.7 In short, the
present system is a patchwork and one that only infrequently
provides the right aid to persons who need both housing assis-
tance and supportive services.
Current federal housing programs that assist the elderly can
be divided into broad categories: (1) those that facilitate the
operation of the private market and (2) those that provide some
housing assistance, sometimes accompanied by support services
but generally without them. The private market-facilitating pro-
grams that are relevant to this discussion are a set of insurance
programs operated by the Federal Housing Administration
(FHA). By agreeing to insure certain mortgages, the FHA re-
duces the riskiness of the loan to the lender, a consequence that
encourages both more lending and lending at interest rates Tower
than otherwise would have been charged. Insurance also makes
the mortgages marketable to secondary facilities (e.g., Govern-
ment National Mortgage Association, Federal National Mort-
gage Association), which in turn increases their attractiveness
to loan originators. FHA traditionally has insured market-rate
housing projects designed for elderly occupancy and also nursing
homes and intermediate care facilities. Legislation enacted in
1983 also permits FHA to insure congregate housing facilities,
board and care facilities, and "life care centers," which offer
services beyond those provided in congregate facilities. (On the
OCR for page 144
144
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OCR for page 158
158
RAYMOND J. STRUCK
these figures indicate that about ~ percent of elder-headed and
6 percent of nonelder-headed households make one of these three
types of housing adjustment each year. These rates can be put
into perspective by noting that about 3.3 percent of elderly
homeowners and 13 percent of nonelderly homeowners adjust
their housing circumstances by changing residence each year.
As a result, the rates of in-place adjustments for the elderly are
at least double those achieved by relocating.~3
A better idea of the national incidence of dwelling modifica-
tions is available from data gathered by a special supplement to
the 1978 annual housing survey (AHS). These figures, which are
shown in Table 5, indicate that only about 10 percent of elderly
households with at least one member with self-reported health
or mobility problems had made a modification to their unit at
the time of the survey. These rates appear to be considerably
TABLE 5 Dwellings Occupied by Elder-headed Households with at
Least One Member with Health or Mobility Problems
Modification
Number of Dwellings Percentage of
(in thousands) Dwellings
Extra handrails or grab bars548 6.6
Sink, faucet, or cabinet
adjustments103 1.2
Wall socket or light switch
adaptations103 1.2
Elevators or lift chairs69 0.8
Specially equipped telephone69 0.8
Ramps60 0.7
Extra-wide doors or hallways60 0.7
Door handles instead of knobs26 0.3
Bathroom designed for
wheelchair use26 0.3
Flashing lights26 0.3
Raised lettering or braille9 0.1
Push bars on doors9 0.1
Other features163 1.9
Total number of dwellings with
at least one modification886 10.3
Total number of dwellings8,600a
Figures do not add to total because not all dwellings have modifications and some
report more than one modification.
SOURCE: Struyk and Zais (1982), Table 2.
OCR for page 159
ISSUES IN HOUSING FOR THE ELDERLY
159
lower than those cited earlier for the seven-city sample; because
the AHS data are from a national representative sample of
dwellings, the Tower rates presumably are more generally valid.
The available research strongly suggests that the receipt of
assistance from inside or outside the home, including such serv-
ices as meals programs, significantly reduces the likelihood that
a household will undertake a dwelling modification. Such
changes do not seem to be very sensitive to the household's
economic position. The likelihood does increase, however, when
the person with activity limitations or the person who must use
assistance (e.g., a cane or wheelchair) in getting around is the
spouse in a husband-wife household (Strnyk and Katsura, 1985~.
Although this information is helpful in understanding why
_ _ ~ ~ ~ · . ~ · if- 1 · · ~ 1 ~ 1 1 1 __ 1_ _ _ _1
households make unit mocl~cat~ons, lit tells us norn~ng about
the effectiveness of such changes in delaying institutionaliza-
tion. Some research on this topic using the 1982 Tong-term care
and annual housing survey data sets is just now getting under
way. Until more information on effectiveness is forthcoming, it
is very difficult to argue for any type of broad-based public
intervention to provide dwelling modifications.
All of the information generated to date, however, points to
the fact that a decision to make such changes to a dwelling is
complex, and it is critically dependent on the types of supportive
services available to the impaired person. Under these condi-
tions, the provision of modifications may make little difference
over a wide range of cases and, hence, may not be cost effective.
It is to be hoped that the work now beginning will help to isolate
those instances in which such modifications will be the most
effective strategy for delaying institutionaTization.
Group Homes
The terms "house sharing" or "group home" usually refer to a
single structure in which a number of unrelated people live.
Many group homes are single-famiTy homes that have been con-
verted to provide private rooms as well as common space for
residents. In these small group home arrangements, outside
health or social services can be provided to individuals who need
them, although they are seldom provided to all persons in the
structure.
Arrangements of this type have been organized by individuals
OCR for page 160
160
HA YMOND J. STRUYK
(sometimes an elderly person who wants to share his or her
home in a particularly expansive way) and by local agencies.
Our attention is on those that have been developed by local
agencies. The central premise of such arrangements is that the
occupants help each other and together take care of common
tasks such as meal preparation. The occupants thereby substi-
tute their own labor for that of others, which could Tower consid-
erably the cost of living in a relatively "service-rich" environ-
ment. (See Morgan, in this volume, for a more detailed discussion
of the possibilities for mutual support without cash transactions.)
There is little systematic information about small group
homes, largely because the development of these homes has been
so dominantly one of [Local initiative. One survey in 1982 of 21
shared residences found the "typical" resident to be a woman in
her early seventies who had resided in the group household for
at least a year. The majority of residents had at least weekly
contact with their families. As might be imagined, monthly
charges varied widely as did the service package provided by
the residence. All resident households used community services
such as a senior center or visiting nurse. According to a study
by the Shared Housing Resource Center reported in Gold (1985,
pp. 49-50), two-thirds of the organizations expected the resi-
dents to participate at least minimally in housekeeping chores.
Another survey of such living arrangements (van Dyke and
Bresiow of the Jewish Council for Aging of Greater Washington,
reported in National Policy Center on Housing and Living Ar-
rangements for Older Americans, 1983, pp. 26-27) found that
residents tended to be somewhat old and in declining health; the
shared living arrangement was clearly viewed by occupants as
the only real alternative to a nursing home. Perhaps the most
significant aspect of these arrangements is their diversity, as
recently documented in 15 case studies by Streib et al. (1984,
chap. 61.
With so little material of even a descriptive nature about
shared living, the absence of any real evaluation on the impact
of such arrangements on institutionalization is not surprising.
In this case, three distinct types of issues should be addressed
in any demonstrations and accompanying evaluations that might
be mounted.~4 First, the effectiveness of such arrangements in
forestalling institutionalization should be documented. Second,
the potential for shared housing to allow the elderly to assist
OCR for page 161
ISSUES IN HOUSING FOR THE ELDERLY
161
each other actively, thereby extending their own period of pro-
ductive activity and Towering the cost of this alternative com-
pared with others, should also be studied. Third, it will be im-
portant to understand the types of people who do well in this
environment. The limited information we do have is clear about
the fact that such arrangements do not work for everyone; it
would be helpful to have more accurate profiles of those who
seem especially suited to shared housing.
The Impact of Such Arrangements
What would be the effect of the widespread adoption of the
kind of living arrangements just described, assuming that they
were found to be effective in delaying the institutionalization of
the frail elderly? To begin with, it seems quite evident that the
life satisfaction of those who would have been placed in institu-
tions otherwise will be significantly improved. Although the
value of such improvements is difficult to quantify, it is never-
theless clearly important.
The possible savings to society in the resources that must be
used could be substantial. Let us assume that 20 percent fewer
persons would be institutionalized in the future because of the
existence of congregate and other housing arrangements. We
will also use Heumann's (1985) estimate that equivalent serv-
ices for those needing less than nursing home care can be pro-
vided in a congregate setting for about one-third less cost than
in the long-term care facilities. Together, these figures imply a
reduction in long-term care costs of about 7 percent. The overall
resource savings would presumably be greater because the inci-
dence of couples continuing to live together would rise, thereby
cutting down the need for two separate living arrangements (one
of which would have been in an institution).~5 Such effects might
raise the savings from these alternatives to the equivalent of
or 9 percent of Tong-term care costs.
This is clearly the upper limit of such savings, however, be-
cause we have tacitly assumed that only those persons that
would have been institutionalized would be served in congregate
facilities. From Heumann's study (1985, Table 10),- we know that
the services portion of the congregate package constitutes about
half of the total cost. If we assume that a household would have
been paying for the shelter component in any event (or would
OCR for page 162
162
RAYMOND J. STRUCK
have received a subsidy to help pay for it), then for a system of
congregate facilities and Tong-term care facilities to operate with
the same resources as the present arrangement would require
that no more than half of the households in congregate facilities
be without a member who would otherwise have been in an
institution. Of course, if the households would have purchased
some of the supportive services in other environments, then a
higher share of congregate housing occupants could be those
who would have been in community housing. If congregate
"slots" were targeted in such a way that one-third of the occu-
pant households were living in such facilities "inappropriately,"
then the savings figures cited above would be cut in half.
The foregoing suggests two things. First, the savings potential
is large in the billions of dollars-from the use of congregate
and other arrangements that provide appropriate levels of sup-
portive services as a substitute for those provided in Tong-term
care facilities. Second, the realization of such savings depends
critically on the effectiveness of such arrangements in prevent-
ing institutionalization and on the degree to which services can
be targeted toward those genuinely at risk of being
institutionalized.
CONCLUSIONS
This paper has argued that the central issue in federal hous-
ing policies for the elderly is the development of public assis-
tance that will help them make necessary housing transitions
in such a way as to allow community-based housing to be an
active and integral element in the overall Tong-term care sys-
tem. Current housing policy for the elderly only gives passing
attention to this issue. Consequently, the programs now in op-
eration are poorly designed to address broad housing needs.
There is no shortage of suggested alternatives for using hous-
ing-oriented programs to assist the elderly to remain in the
community rather than being institutionalized. Indeed, local
governments and some states are moving forward on a number
of options. There has, however, been little evaluation of the ef-
fectiveness of these interventions in reducing institutionaliza-
tion and little assessment of the extent to which they substitute
formal for informal care.
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It seems clear that the first step must be for federal policy to
be reoriented toward the nexus of dwelling-specific and dwelling-
use problems, as they have been defined in this essay. We are
not, however, in a position to argue for any particular program-
matic package to implement this policy. Rather, the next phase
must be one of intense experimentation and evaluation. The role
of the Department of Housing and Urban Development in car-
rying out the essential evaluations will be paramount. If we
proceed with alacrity, it may be possible to be in a position by
1990 to make forceful recommendations for the adoption of op-
erational programs in this area.
APPENDIX
Definitions
Dwelling Deficiency
See Table A-1. Specifics of the definition were dictated by the
data available in the annual housing survey. This definition is
the same as that employed by HUD.
Excessive Housing Expenditures
Here we follow HUD's lead so that our results will be consistent
with other tabulations. Excessive burden is defined separately
for renters and homeowners. For renters, a gross rent (the con-
tract rent plus utilities paid by the tenant) above 30 percent of
gross household income is considered excessive. For owner-occu-
pants, out-of-pocket expenditures for housing (excluding expen-
ditures for maintenance and improvements) above 40 percent of
family income is considered excessive. The higher standard for
homeowners is based on the tax advantages accruing to home-
owners and on the capital gains-producing investment embodied
in their housing expenditures. (See Feins and White, 1979, for
more discussion on this point.)
Need for Supportive Services
Two definitions are used, based on data in the 1979 National
Health Interview Survey. The "generous" definition, developed
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RAYMOND J. STRUYK
TABLE A-1 Deficiencies that Cause a Housing Unit to be Judged
Physically Inadequate (using the HUD/Simonson Definition),
Based on Annual Housing Survey Items and a Revised Definition
(1981)
Type of
Deficiency Description
Plumbing 1. Lacks or shares some or all plumbing facilities. The unit
must have hot and cold piped water, a flush toilet, and a
bathtub or shower-all inside the structure and for the
exclusive use of the unit.
2. Lacks adequate provision for sewage disposal. The unit must
be connected with a public sewer, septic tank, cesspool, or
chemical toilet. (Units with this deficiency are almost
invariably defined as having a plumbing deficiency as well.)
Kitchen 3. Lacks or shares some or all kitchen facilities. The unit must
have an installed sink with piped water, a range or
cookstove, and a mechanical refrigerator-all inside the
structure and for the exclusive use of the unit.
Physical 4. Has three or more of five structural problems: leaking roof;
structure open cracks or holes in interior walls or ceiling; holes in the
interior floors; either peeling paint or broken plaster over 1
square foot of an interior wall; evidence of mice or rats in the
last 90 days.
Common areas 5. Has three or more of four common area problems: no light
fixtures (or no working light fixtures) in common hallway;
loose, broken, or missing stairs; broken or missing stair
railings; no elevator in building (for units two or more floors
from main building entrance in buildings four or more
stories high).
6. Has unrented room heaters that burn oil or gas. If the unit is
heated mainly by room heaters burning gas, oil, or kerosene,
the heaters must have a flue or vent.
Heating
Electrical 7
Lacks electricity.
8. Has three out of three signs of electrical inadequacy: One or
more rooms without a working wall outlet; fuses blown or
circuit breakers tripped three or more times during the last
90 days; exposed wiring in house.
SOURCE: Simonson (1981), pp. 84-85.
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by Soldo (1983) includes any person with at least one of the
following characteristics:
· needed or received help with at least one of the seven activ-
ities of daily living (ADL);
· needed or received help with at least one of the four instru-
mental activities of daily living (lADL);
· was not able to perform one or more of the ADL functions;
· stayed in bed all or most of the time; or
· needed help with urinary or bowel devices.
The "stringent" definition includes only those persons in the
above group who receive formal home care services.
NOTES
1. The annual housing survey is the primary source of national housing data. For
analyses of the neighborhood data included in the survey, see Bielby (1979) and
Marans (1979).
2. Since 1979 we know, in general, from annual housing survey data that the
share of households with "excessive" housing expenditures has increased, whereas
the share living in dwellings with deficiencies has decreased slightly.
3. Less detailed estimates with 1981 data by Irby (1984) and using somewhat
different definitions for deficiencies show about 1.2 million elderly households in
deficient units and 2.55 million households with excessive expenditures.
4. This procedure seems to be reasonable, given that Newman (1985), using a
similar definition of impairment, found about 13 percent of elderly households had
at least one member with such a condition.
5. Together with the information on the determinants for the receipt of support
services, the higher rate also implies that the services received do not have much
effect on dwelling conditions.
6. In doing this calculation, the rate was applied only to those elder-headed house-
holds that were not participating in a housing program, the general assumption
being that, if they were part of a housing program, they would not have excessive
expenditures for housing.
7. Services provided under the Older Americans Act are not means tested. Those
funded by the social services block grant program have varying income limits that
are set by the states; almost universally, however, these limits are less stringent
than those in the housing programs.
8. These figures correspond generally to those prepared by the Congressional
Budget Office; see Levine (1985, p. 11).
9. Of course, one could approach the issue from the other direction, that is, start-
ing with households that are receiving supportive services and then examining their
housing circumstances. The housing-oriented approach has been chosen here be-
cause it is more in keeping with the overall perspective of the paper.
10. The Section 202 program is one in which specially designed housing is devel-
oped by nonprofit sponsors for occupancy by elderly households and households with
a handicapped member. Federal subsidies are provided in the form of direct loans
that carry interest rates below the market level and, in recent years, through rental
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RA YMOND J. STRUYK
assistance payments, available under the Section 8 program, for all occupants who
are eligible to receive them.
11. For a discussion of a congregate housing voucher program for low-income
households, see Struyk (1984b).
12. Heumann (1985) in the first careful analysis calculates that, for equivalent
services, congregate facilities are about one-third less expensive overall than long-
term care facilities.
13. Repairs and improvements are associated with the types of adjustments we
have just reviewed and with longer term strategies of housing upkeep and invest-
ment. A central hypothesis considered here is that there is a cohort of elderly
homeowners who, because of economic or health circumstances, decide implicitly to
draw on the equity in their homes through a program of lower maintenance. Simi-
larly, we are interested in which households persistently are investing in their
homes. The last two rows of figures in Table 4 show that 20 percent of the elderly in
the sample undertook little or no repair activity over 2 years and that they were
somewhat more likely to do this than their nonelderly counterparts; the differences
between the two groups are not large, however. Similarly, the elderly as a group are
undertaking repairs, and improvements-even large improvements-to their homes
at quite high rates. Still, they undertake fewer such repairs and investments, and
each year they spend less, than their more youthful counterparts. The overall pat-
tern is one in which properties are indeed largely being maintained, and disinvest-
ing households are a definite minority and comparable in size with the proportion
of such households in the nonelderly population.
14. The implied call for a demonstration may seem odd, given the existence of
ongoing projects. It might be that one could evaluate the present programs, but as a
group, they may be so heterogeneous as to preclude anything but a series of case
studies. Although case studies may be an essential first step in designing a demon-
stration with an evaluation, they probably could not serve as the basis for an
evaluation by themselves.
15. For a discussion and projections of future long-term care costs to the federal
government, see Palmer and Torrey (1984).
16. It is assumed that supportive services constitute half of all congregate costs
and that congregate costs are about 67 percent of long-term care costs. It follows that
services in congregate facilities are equivalent to 33 percent of long-term care costs.
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Representative terms from entire chapter:
congregate housing
