# Health, Homelessness, and Poverty: Keynote Address 2013

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• 00:01

BONNIE: So welcome to our second annual forum on health,homelessness and poverty.I thank you so much for being here.The idea of the event is to bring togetherresearchers in academia and practitionersfrom the community who are doing the real work of mitigatingand working towards alleviating the problems of homelessnessand health.

• 00:21

BONNIE [continued]: So to that end, I welcome you.Leaf Richler is going to be welcoming our speaker on behalfof the School of Public Policy.I'd like to thank a few people before we get started.The Policy Studies organization is a supporterof both the World Medical and Health Policy Journal

• 00:42

BONNIE [continued]: where we will publish some of these articlesto further the conversation beyond the confinesof this room.We also would like to thank the School of Public Policy,the Center for the Study of International Medical Policyand Practices, and the Center for Non Profit Managementat George Mason, all of whom have contributed to helping

• 01:03

BONNIE [continued]: bring this event together.Without further ado, I'll welcome Dr. Richler.

• 01:09

DR. RICHLER: Thank you, Bonnie.And thank you for asking me to welcome you all.I'm doing it on behalf of our Dean, Marc Roselle, whounfortunately at this moment is at a meeting in Fairfaxon the main campus.That's one of the hazards of havingseparation between campuses.It takes quite a while to get between the two,especially during the daytime when there's

• 01:31

DR. RICHLER [continued]: traffic on Route 66-- or 60.What is that route?60, whatever it is.I've repressed it.The school welcomes you.We feel that this is just exactly the kind of programwe like to be a part of.It fits in neatly with the interests of our faculty

• 01:53

DR. RICHLER [continued]: and a large number of our students.The school is about 25 years old now.It is a graduate school.We have about 800 master's degree studentsand probably around 30 to 50 PhD students, and a full timefaculty of around 50 students.You're in our very new building, which

• 02:16

DR. RICHLER [continued]: we think is about the best academic buildingon the planet.I can't think of one that's better fitted it outfor academia than this one is.So welcome and take a look around.Now, Mark Johnson is the speaker today.I think most of you know a great deal about him.

• 02:38

DR. RICHLER [continued]: He's had a very fine career in government.He's one of those government peoplewho makes one, me anyway, angry whenI think about the shutdown of a few weeksago, because he is doing, and hasdone for years, excellent work in the area of homelessness.

• 02:59

DR. RICHLER [continued]: He is the Deputy Assistant Secretary at HUD.He is very interagency oriented.I noticed one thing in his biography, whichI found very interesting, he worked--I think it was over a period of a year,with a Veterans Administration, and reduced homelessnessveterans by 10% in that year.

• 03:19

DR. RICHLER [continued]: That's quite an achievement.So, congratulations on that.Why don't you take your position up here.And Mark said he'd like to take questions very soon.So I'll let you play that by ear.

• 03:33

JOHNSON: Great.

• 03:34

DR. RICHLER: Welcome.

• 03:35

JOHNSON: Thanks for the very kind introduction.Good afternoon.It's a pleasure to be here.For me, this topic of health, homelessness and povertyreally relates to my background.As was suggested, I've been involvedin this area for quite a while, for actually justover 30 years.

• 03:56

JOHNSON [continued]: And I began right out of grad schoolworking for the Department of Agricultureon anti-poverty efforts.And one of my rotations as a fellowwas to the White House on a presidential commissionon hunger.And the thing I learned most there was notanything about hunger, but about homelessness.And I had writer's block one day,and I left the White House area, and I'm

• 04:16

JOHNSON [continued]: walking around the ellipse, and I see this guysleeping on a heating grate.This is 1983.And back then, there were very, very few homeless peoplein most cities.And there were actually three guys sitting there.So I sat down and I said, what you guys doing here.It's like 20 degrees.It's in the middle of winter, and there's a homeless shelterthat just opened up.

• 04:37

JOHNSON [continued]: And the man that was responding to me, his name's Saif, and hesaid, that shelter's really dangerous.And I checked into it.Frankly, it was.There were no rules back then.And he felt safer living on the streetsthan he did in a shelter.And so I kept engaging him for about two years.He did not want to come off the streets.

• 04:57

JOHNSON [continued]: And he became increasingly more mentally ill.He was afraid the State Department wasgoing to be taking him away.And then one day, he just disappeared.And so that was my first introductionto the notion of homelessness.And went back to the Department of Agricultureand started working on that topic.Fast forward 30 years, until today.

• 05:18

JOHNSON [continued]: the Department of Housing and Urban Developmentis very close to a train station at La'Enfant Plaza.And that's how I get to work and leave to go home every night.And as I do that, there is a guy namedStan near there, who's in a wheelchair, African American.Severe back problems-- he's in a wheelchair because of that.He has AIDS.

• 05:39

JOHNSON [continued]: He has a whole host of problems, but he's alwaysgot a big smile on his face.And started engaging him to figure out why are youout here like all the time.And he's been waiting for a voucher.He's been waiting for the health care.So I start working with the local housing authorityand with the VA, trying to figure outif we can get him housing.

• 05:60

JOHNSON [continued]: Because he's panhandling day after day,sitting in his wheelchair.He can hardly move around.He finally gets in.And so I'm thrilled.Got him a house, right?And the very next day, there he is panhandling again.So, I said Stan, what's going on.He goes, well, I don't have any money,so I don't have any food.

• 06:20

JOHNSON [continued]: So I gotta panhandle.What do you mean you don't have any money?Well, I put in for my disability seven years agoand they're still assessing my claim.And so he's still out there.Today, I'll see him again.Because our systems, while they're better thanthey were back in 1983, when there were no federal resourceson homelessness.

• 06:40

JOHNSON [continued]: There was nothing on housing.There was nothing on health care.There was nothing on mental health,or frankly, anything else.We have a lot of resources now, and they'reworking, frankly, a lot better.But we have a long ways to go in actually collaboratingbetween agencies to get stuff done for people.I also wanted to just give you a brief overview,

• 07:02

JOHNSON [continued]: and I realize many of you are experts in homelessness,but I want to give the sort of 30,000 footlook on homelessness.So that we're all sort of on the same pageas we go into this forum, by using some numbersthat we collect through the annual point in time count.There are, at this point, about 600,000 persons thatare homeless, that is on the streets

• 07:22

JOHNSON [continued]: or in a homeless facility at a point in time in January.And as you know, we require that each community doa point in time count, and we find,and I trust communities do, and the ones I've talk to,tend to find them helpful, to really knowthe size and the nature of a problem, you gotta know it.And I think as researchers, you appreciate that.

• 07:44

JOHNSON [continued]: So it's a gross kind of effort to geton one night how many people thereare in this country in every city and every county,how many are homeless.It is a good indicator about the size, and frankly the nature,because there are number of questionsasked about the characteristics of homeless persons.For instance, we know that about two thirdsof all homeless persons in this country

• 08:04

JOHNSON [continued]: are single individuals, that means a third are familieswith children.We have about 100,000 persons who we considerto be chronically homeless.That is, they're out there for a long timeand they have at least one disability.We have about 1 in 10 homeless persons, about 60,000 whoare homeless veterans.Which I think all of us would agree is a shame.

• 08:26

JOHNSON [continued]: They have to risked their lives for us.They come home and there is no home for them.So that is a continuing focus of this administration.I'm going to get into that more in just a few minutes.We know, and it's well under reported,there are at least 10,000 people whoare homeless who have HIV/AIDS.We also know that homelessness is very concentrated.

• 08:47

JOHNSON [continued]: We know from the point in time countsthat a lot of homelessness, while homelessnessis in suburban, urban, and rural areas, that five statesaccount for half of all homelessness.And these are coastal states.So California, Texas, Florida, New York, and Georgia.A significant percentage of all homeless persons

• 09:08

JOHNSON [continued]: live in very large cities.So it's a very concentrated problem.Although it is everywhere, there are certainlyconcentrations in certain states and in larger cities.We also track homelessness over timebecause we certainly appreciate through the research of DennisCulhane that there's a lot of dynamicslongitudinally that you could never

• 09:28

JOHNSON [continued]: pick up on through a point in time effort.And so we know that while there maybe 600,000 persons at a point in time,that is on any given January, thereare about 2 million people that arehomeless through the course of one year.So that really informs us a lot, that peopleare flowing in and out of homelessnessa great deal, which then informs the interventions we

• 09:51

JOHNSON [continued]: ought to be using.Because if lots of people are leaving on their ownin short order, we don't need to becommitting large sets of resourceson permanent supportive housing.So setting-- with that backdrop, of challengesof 2 million people homeless during the course of a year,I do want to emphasize now what we've

• 10:12

JOHNSON [continued]: been trying to do at the federal level for now five years,and that is trying to end homelessnessin a very strategic way.So I've worked in every administration since Reagan.And every president, including Reagan,had something positive to do on homelessness.Their plans were hopeful, but frankly, not very focused.

• 10:34

JOHNSON [continued]: So plans of the past would be plans suchas I want to break the cycle of homelessness,or I want to end the tragedy of homelessness.But it wasn't actually measuring and ending homeless.Until this, this is the first of administrationthat is committed to doing that.I'm a career guy, I'm not a political person,so I'm freely saying what I really think here.

• 10:55

JOHNSON [continued]: So I really impressed that we nowhave an administration who is sayingwe don't want to just break the cycle,or have a little sound bite that sounds like we'retrying to do something, we're actually trying to end it.And it's taken, frankly, a lot of work.In 2009, the president issued Opening Doors,a plan to prevent and end homelessness

• 11:17

JOHNSON [continued]: with very specific goals, and it includes19 different federal agencies.So everything from Housing and UrbanDevelopment, which does the housing part.And that makes a lot of sense, to Health and Human Servicesand a range of agencies within HHSthat confront homelessness, to other agencies that you mightnot think about, like the US Department of Agriculture,which confronts rural homelessness,

• 11:39

JOHNSON [continued]: but frankly, even more importantly,has mainstream entitlement programs like food stamps.And even to the Department of Defense,when they close down bases, thereis a law, the Realignment Act, thatrequires that every one of those propertiesbe reviewed, frankly, by me, at HUD,to assess if we could use those bases to househomeless persons.

• 11:59

JOHNSON [continued]: So there are 19 different agencies, each of whichhave some role in ending homelessnessand is part of this federal plan.The overall goals of the plan areto first of all end chronic and veteran homelessness by 2015.And end family and youth homelessness by 2020.And that was intentional.

• 12:20

JOHNSON [continued]: We didn't want to bite off the whole apple at once.We knew, frankly, we couldn't possiblyaccomplish that with so many peoplebeing homeless and limited resources, given the recessionthat we were in the middle of when we juststarted rolling this plan out.The implementation really was tryingto focus on using best practices, evidence based

• 12:41

JOHNSON [continued]: approaches to strategically use interventionsfor different populations, as opposedto just a generic approach to confronting homelessness.So we have learned a great deal from researchover the years on homelessness.One of my first areas of working on homelessnessat the Department of Agriculture back in the mid-80s

• 13:01

JOHNSON [continued]: was working with our contractor at that time, MartyByrd on the first national survey of homelessnessto get a sense of the size and nature of it back then.And that was our baseline to figure out wherewe were going to be going.For many years, we thought that transitional housing,for instance, was going to be a key solution to endinghomelessness.

• 13:23

JOHNSON [continued]: And more and more, by practice, and frankly, by research,we are seeing that while it probablyis an effective tool for youth homelessness,for domestic violence, and perhaps one or two other subpopulations, overall it is not a largely effective or costeffective intervention for homelessness in general.

• 13:45

JOHNSON [continued]: A recent effort looking at a number of different citiesfound that transitional housing costs about $22,000 a year.And yet the outcomes are fairly mediocre, about 45%of the families helped fell back into homelessness.Another intervention, which is frankly a bit counter-intuitiveto me, and to many people, called rapid re-housing, • 14:06 JOHNSON [continued]: has some really, really promising results.That program has a cost of about$4000 a person,and yet the outcomes are far, far betterthan transitional housing.About 85% of people that went through rapid re-housing, whichis get them into an apartment, provide utility assistance,give them a little bit of case management,

• 14:27

JOHNSON [continued]: but not a whole lot else, other than the expectationthat in 6, or 9 or 12 months, they'vegot to be paying for that apartment on their own,has been wildly successful.So even a year after we stopped the assistance,85% of those families were still in those housing situations.So much less cost, much greater outcomes.

• 14:48

JOHNSON [continued]: And in times like these, when we have horrific budgetchallenges, we need to find strategic interventionslike that to be solving this problem.We also are evaluating the long term impact of programslike rapid re-housing, and I don'tknow what that's going to be.We're doing a longitudinal study to tracka number of interventions over a 36 month period

• 15:10

JOHNSON [continued]: to get a sense of, for instance, people in rapid re-housing,great after the first year if you're still housed,but do you actually get more income by getting employment?Do you actually start lifting yourselfabove the poverty line?We don't know that yet.We know we can stabley house people even a yearafter the intervention stops.We don't know what the long term impact is for that.

• 15:32

JOHNSON [continued]: We will know a lot more.We're going to get some initial results this next summeron a number of interventions, including rapid re-housing.We did find, also, in the research-- Dennis Culhane foundthis first, that there is a small componentof the homeless population, as you well know,the chronically homeless, who absorba huge amount of resources.

• 15:52

JOHNSON [continued]: About 50% of the resources go to about 15% of the people,because these folks on the streetsare not just on the streets.They're constantly going into emergency care centers,they're going to detox, they're goingto mental hospitals, costing 40, 60,Seattle found $80,000 a person, for one year,and at the end of that year, where are they? • 16:14 JOHNSON [continued]: They're back on the streets.So we have spent a lot of focus in this administrationand the previous administration, Bush 2,on trying to end chronic homelessness,because of that huge cost to the person, living outsidefor extended periods of time, but alsofor the public reason of spendingexorbitant amounts of money with having no good outcomes • 16:34 JOHNSON [continued]: whatsoever.We're able to do this really because we'rerelying on research to inform us on what we should be doing.For example, people were quite skeptical on Housing First,this notion of getting somebody on the streetsand moving them directly into their own apartmentimmediately. • 16:54 JOHNSON [continued]: Not going to shelters, then not going to transitional housingto prepare them to go to permanent housing.Just put them in housing.Stan Sebares, a former outreach worker, whois sort of the founder-- at least I consider him that,of Housing First, said when I did outreach,and I'd say to people, so you need stabilization,what is it that you need, and they'd say, you idiot, • 17:15 JOHNSON [continued]: I need housing.I need to get a house to live in.And that was transformative for him, and frankly,for the whole country.That people don't have to become housing ready.We need to get them into housing,so they can start focusing on the rest of their life.And the data has really informed us on that.Sam did a study of his own projects. • 17:37 JOHNSON [continued]: I then did a study on Sam's projects and other HousingFirst projects just to reaffirm what he was doing.And sure enough, 85%, actually 84%,of folks that were in Housing First,like chronically homeless personswith severe mental illness, a year after that, were housed.It's not to say they were sitting in their apartmentthe whole time. • 17:57 JOHNSON [continued]: A lot of them fell out, they went to emergency rooms,they went to hospitals, they went to jail.But because they had services connected to them,they did get back into that housingand were becoming stablely housed.The data really do show that people living off the streets,moving into permanent housing, can stay there,can really thrive.So that's a huge savings in lots of different ways. • 18:21 JOHNSON [continued]: It's first and foremost important for that individual,who really has had horrific experiences.I remember talking to a woman that Sam introduced meto living in Central Park, trading sex for drugs.She really needed drugs.And then one night, the guy said I'm notgoing to give you the drugs, held a gun to her head and saidbut I want the sex anyway.And she realized I got to change my life. • 18:43 JOHNSON [continued]: Living in Central Park is really notwhere I need to be after many, many years.So she came off the streets directly into an apartmentthat I was in, and it was beautiful, and it was hers.And she owned it, and she was a highly functioning personas a result of that trust in her.So I've talked about Housing First as a notion, • 19:04 JOHNSON [continued]: and that pertains to not just movinginto permanent housing for the chronically homeless,but this notion of rapidly re-housing somebody.Perhaps families with children that don't need long termpermanent subsidy, they're pretty high functioning,but they need a leg up.They need to get into an apartment,so they can stabilize, so they can get the kids back in schooland start looking for a job.That also is a notion of Housing First. • 19:26 JOHNSON [continued]: Moving them in.The assistance might not be that long,but they can stay in that housing going forward.There are some examples of the importance of evidence basedresearch in current homelessness policyand I really have come to appreciate evidence based.And it started out with that first research projectthat I worked with Marty Byrd on 30 years ago, • 19:47 JOHNSON [continued]: just understanding homelessness betterso you can be more informed on how you do the interventions.And I always try to look at the researchbefore we push any policy out there to the country,because if it's not steeped in research whoknows if it's going to work.We've done too much trial and errorin this country in trying to solve homelessnessover the years. • 20:07 JOHNSON [continued]: Another area where data and research has reallychanged the way we think is this connection between housingand health care.We do recognize that many people experiencing homelessnessare also experiencing physical or mental illness.Jim O'Connell and I have worked on different thingsover the years.And I think probably many of you know Jim. • 20:28 JOHNSON [continued]: Just the most humble guy in the world.I remember the first time I met him,I said so where did you go to school,and he kept saying well, I went here.I couldn't get into this school.I was too old.He went to Notre Dame, Brown, and Harvard for medical school.And he'll never tell you that.And he's been an outreach physician for 30 years • 20:49 JOHNSON [continued]: on the streets of Boston.And collecting data on the people that he serves.And he knows them all by their first name.He's collected amazing information on themthat really has informed me, and Ithink the whole country, on how weneed to be confronting homelessness,especially persons who are on the streets that are reallyat imminent risk of losing their lives. • 21:11 JOHNSON [continued]: That's been one of his focuses.So some of the research that he's foundis that people who are homeless, being out on the streets,are three to four times more likely to diethan the average population.The average death of a person who is homelessis between 42 and 52 years of age.That's a pretty stunning and concerning age, • 21:35 JOHNSON [continued]: given that I'm older than both of those ages.But it's amazing to think that the average personon the street is going to die between age 42 and 52.People who experience homelessnesswho die at a young age often are known to the health caresystem, which was kind of a illuminatingthing for me to appreciate.He did a five year study of 119 chronically • 21:55 JOHNSON [continued]: homeless individuals living on the streets of Bostonand the individuals totalled more than 18,000 visitsto the emergency room.So that's 119 people, 18,000 visits.And more than 80% of them had some type of health insurance.Nevertheless a quarter of them died. • 22:17 JOHNSON [continued]: So his conclusion from that study and a number of othersthat he's done is, quote, "This public health crisiswill not be ameliorated until the housing, health careand other supports become fundamental rightsfor every human being."And I think it's important to appreciatethat connection between housing and health care. • 22:37 JOHNSON [continued]: Cycling chronically homeless personsthrough very expensive public systems that were neverdesigned to solve homelessness is an inherently inefficientway to approach the problem.When you look at the costs of shelter or housing,compared to these other systems, it's kind of stunningthat we allow it to happen. • 22:59 JOHNSON [continued]: So the typical per day cost for shelter is$28.For affordable housing, supportive housing, I mean,that's $31 a day.You compare that to hospital inpatient treatmentof$1,900 a day, emergency room visit for $900,a psych ward visit,$600, or detox for $250 a day. • 23:23 JOHNSON [continued]: So housing is clearly a form of health care.And frankly, a much more cost effective one.One of the places where we, and I mean the federal governmenthere, have realized this is the HUD VASH program,where 20 years ago, a group of six of ussat down and said the VA has a great health care system, • 23:44 JOHNSON [continued]: but these homeless veterans need more than health care,they need housing.So how could we connect VA's health care systemto mainstream housing resources at HUD.And we created what's called the HUD VA Supportive Housingprogram, or HUD VASH.And it's been a true partnership in that we actually • 24:04 JOHNSON [continued]: co-administer this program in law.And we intentionally wrote the legislationthat way to force us to work together.And we do it all along the way.So, we jointly, for instance develop the policies of howthe program will operate.We jointly look at all the data on homeless veteransin the country through the point in time countand allocate together how many vouchers go to which city, • 24:27 JOHNSON [continued]: based on the number of homeless veterans who are there.We track the progress together, in termsof how successful the intervention is,how quickly people get housed, and how long they stay housed.Then we go out and do site visitsto see how well these local operators, whoare doing the real work, are functioningand try to help them improve.So I've learned through that effort over the last 20 years • 24:49 JOHNSON [continued]: that collaboration-- and I think all of usappreciate this-- collaboration is not natural, it's not easy.It takes a lot of time and it's often very, very frustrating.But certainly, my experience HUD VASH over the yearshas been-- if you're trying to do somethinglike connecting health to housing,then collaboration is the way to go.You can get resources from somebody else • 25:10 JOHNSON [continued]: and connect them to yours and make a much bigger differencethan you ever could on your own.Collaboration has also been very keyfor us recently in something called boot camps, wherea group called Community Solutions,a nonprofit, wonderful group, based out of New York,but is frankly, all over the place,is doing some really cool stuff, wherethey look at the processes that we're • 25:32 JOHNSON [continued]: using in how we house homeless people,homeless veterans in particular, but the chronicallyhomeless as well.And so we've partnered with them.We're providing assistance, financial assistance,to help make this happen.The VA's involved as well.And we're holding boot camps around the country.So we held 20 this last year.We had 20 different communities involved.And these are some pretty big places. • 25:53 JOHNSON [continued]: We've done them in New York City,we've done them in LA, and cities everywherebetween there.And we look at their processes to figure out how they couldbecome much more efficient.I remember New York City was first boot camp I went to.It took something like 330 days to house a homeless veteran.And so they got all the local stakeholders together, • 26:14 JOHNSON [continued]: including homeless veterans, to sayhow can we do better on this.This is ridiculous, for a homeless veteranto be outside for over 300 days waiting for the bureaucracyto house them.And they're shaving off days, and weeks, and monthsof this system by simply forcing collaboration among allof the local stakeholders.The local public housing authority, the local VA, • 26:37 JOHNSON [continued]: the homeless veterans themselves,and other service providers.So it's that kind of integration,at the local level, that really makes this a difference.So it's working at HUD VASH.It's working in all sorts of other ways too.And this boot camp thing is really quite impressive.And I love it because in three daysyou can start turning around an entire local system • 27:00 JOHNSON [continued]: by forcing that level of collaboration.We were serving only about 1,500 homeless veteransfive years ago.We're up to about 43,000 now.We have 60,000 units we're putting online through the HUDVASH program and things like the boot camp effortis helping us make that happen much more quickly. • 27:26 JOHNSON [continued]: So let me see, I just wanted to probably shareone or two last things.I guess I'll just end by saying we'rein a horrible financial situation in this country,as you know.Just to give my perspective, I have two jobs.One is the Deputy Assistant Secretarywhich oversees homelessness and special needs housing.And the other job that I've had for a year and a half • 27:48 JOHNSON [continued]: and will continue to have, I guess indefinitely,is the Acting Assistant Secretary.So I oversee that, and I also overseethe development of affordable housing and communitydevelopment.So the community development block grant, the home program,all disaster responses, like the Sandy recovery.And so when I look at the budget levelsthat I personally am getting for my area, • 28:09 JOHNSON [continued]: it's really depressing.My largest affordable housing programhas been cut in half, from nearly$2 billionto less than a billion dollars now.That's a program to create new affordable housing,so the people who are leaving homelessnesshave somewhere to go.And so it's tough to make progress whenbudgets are getting sliced.

• 28:31

JOHNSON [continued]: My largest community development block grant program,it was a $4.5 billion dollar program.It's now around$3 billion.It's been sliced 31% in just the last couple of years.It's awfully hard to make progresson that front in terms of creating more housing.So we're really feeling the pinch on the HUD side.The VA is starting to see that because they'regoing to sequestered this next round,

• 28:52

JOHNSON [continued]: but they haven't been cut with any of their programs,but they will be this coming round.So we're still seeing progress.We've seen progress of about 7% to 10% reductionin homelessness on veterans, and frankly,on chronic homelessness year in and year out.And what I've seen for 2013, we'reprobably going to continue that trend of reductions.

• 29:13

JOHNSON [continued]: My concern is that we're close to a plateauingthough if we continue to get actual real cutsto our programs.Even in the homeless programs, I have $2 billionin our homeless funding for continuum of care.And this is the first year we're actuallycutting homeless projects, because wedon't have an appropriation sufficient to actually fundthem all.So I don't want to be totally depressing on this. • 29:35 JOHNSON [continued]: But I don't I want to be a realist as well.And for me, having tough budget timesjust underscores the importance of looking at data,understanding the research, and beingas strategic as we can to confront problemswith the limitations that we've got.So let me close there and see if youhave any particular questions. • 29:56 JOHNSON [continued]: I don't bite, so feel free to-- • 29:58 STUDENT: Can I ask you a question? • 29:59 JOHNSON: Yes. • 29:60 STUDENT: You just mentioned affordable housingand the [INAUDIBLE] the best programthat you have was cut significantly.Which program was that? • 30:08 DR. RICHLER: The home program. • 30:10 STUDENT: Thank you. • 30:11 JOHNSON: So yeah, it was at about$1.9 billion.We got some bad press, in part, that wasthe start of the start of it.And then Congress said, we got a budget problem too,so you're going to-- the house actuallywas looking at funding it at like $700 or$600million dollars.You can't even create much housing with that, becauseby law, you spread it across hundreds of communities.

• 30:33

JOHNSON [continued]: So if your community gets \$30,000 for an entire homegrant, there's nothing you can do with that.So it's not just the level, it's the impactof how the funds are distributed.Yes?

• 30:46

• 30:48

JOHNSON: Yep.

• 30:48

STUDENT: Is that just for veterans,or could it be any community?

• 30:51

JOHNSON: It could be anything.We started out with veterans.We've now expanded to the chronically homeless as well.What we're seeing is-- our goal isending veteran and chronic homelessness for 2015,so that's our primary focus for the boot camps,is those two populations.As we and those population problems,

• 31:11

JOHNSON [continued]: you know by 2015, hopefully, perhaps slightly beyond that,we'd be more than interested in focusing on other populationsas well.

• 31:19

STUDENT: Do you go into the communities and do this?

• 31:22

JOHNSON: We do.So I do it mainly by Skype, because I can't travel anymore.But, I've been to many of them, or I Skype,or am at every one of them.And so we'll typically have eight cities in the room.And partly that's competition.So we might have LA, Atlanta, Buffalo, whatever in there.

• 31:42

JOHNSON [continued]: And about eight people on each team.So the local public housing director, the local VAdirector, the local continuum of care homeless provider,hopefully a homeless person as well.So key people in each of those.They all focus on reducing their own processesby many, many steps.And then they sort of have to call out

• 32:03

JOHNSON [continued]: what they're doing to other people in the roomduring the three day period.So there's a competition between themon how aggressive they can be.

• 32:10

STUDENT: So how would you be able to get your city involved?

• 32:16

JOHNSON: Well, we do it in a very strategic way.We look at how many homeless people are there.And so we're not looking at Peoria, frankly.If there's a city with 50 homeless people,we just don't have the time to do that, or the money.It's an expensive enterprise because we fly all these peoplein, we put them in hotels, we pay for their meals.And with these budget cuts, it's really, really tough.

• 32:39

JOHNSON [continued]: So we're looking at the cities thathave the most number of homeless people, veteransor are chronics, and invite them.Yes.

• 32:48

COFFMAN: I'm Linda Coffman, I work for Community Solutions.We work with HUD and the VA to put on the boot camps.We're in the process of developingsome kind of self-assessment and self toolsthat communities can use if they're notpart of this strategic group.So I can talk with you about that

• 33:09

COFFMAN [continued]: later if you're interested more in what communitiescan do if they're not in the strategic group of the top 25.

• 33:17

JOHNSON: They've subcontracted to Rapid Results Institute,which is a phenomenal small organization thatwill look at any problem, malariaor whatever, and breakdown the steps to figure outhow you can be more efficient.And it's an amazing concept, it really is.Questions?

• 33:37

STUDENT: I have a question.

• 33:38

JOHNSON: Yes.

• 33:40

COFFMAN: So, one of the things that I'vestruggled with over the years is that whenyou talk about affordable housingthe requirement is that it's for people who are at 60% of AMIor below, I think, for the HUD--

• 33:53

JOHNSON: It depends on the program.

• 33:54

COFFMAN: OK, yeah.And you know, I know that in orderto sign up to be on the waiting list for the Housing Authorityyou have to be under a certain level of income.And the folks that I work with are notat 60% of area median income, they're maybe at 6%.The folks that I want to get into the Housing Authorityare not people who are just poor,

• 34:16

COFFMAN [continued]: they are people who have nothing.So, would HUD ever be moving more,being more prescriptive about communitiesand how they use their funds to really go over the reallydeep-end people?

• 34:31

JOHNSON: That's a great question.It's a hard question.I appreciate it.Years ago, we had congressionally approvedfederal preferences.Homelessness, there were a whole bunchof different federal preferences.But Congress got away from that.Eliminated all federal preferencesand allowed complete local flexibilityin establishing preferences.

• 34:51

JOHNSON [continued]: So HUD's approach has been, given that reality--and I can't imagine, frankly that Congress would change,is that we've been encouraging localitiesto establish a local preference for that very reason,that there are really, really poor peoplethat literally have no income.And if you're a public housing agency,you may not want to serve homeless people

• 35:12

JOHNSON [continued]: for a couple different reasons.One is, there a little bit more high maintenance frankly,than somebody who has a job--

• 35:19

COFFMAN: A little bit?

• 35:20

JOHNSON: Just being kind here.And the other is that it takes a lot more of their money.So you pay 30% of your income.Well, if you have no income, then you'renot as a tenant contributing anything.And the public housing agency contributes everything.So they can serve nearly as many peopleif they serve only homeless people,

• 35:40

JOHNSON [continued]: as if they serve people that have higher incomes.We too, frankly, would prefer that all of themwould be serving more homeless persons.So we've done a couple things recently.One is we did a national study that just came out,probably three weeks ago-- I'm not sure it's public yet,but I could get it to you-- on all public housing agencies

• 36:00

JOHNSON [continued]: and what they do to confront homelessness,all the different ways they look at housing preferencesto serve homeless people.And it was much more complicated than HUD appreciated,in terms of how they do it locally and what they do.I was impressed that many, many committees haveestablished local preferences.The last time I had done a randomized sample

• 36:21

JOHNSON [continued]: of public housing agencies to see this, it was almost 30%of all public housing agencies choseto do a local preference on homelessness because theysaw the value of it.From the bully pulpit, we have really pressed hard.Our secretary really encouraged every communityto really focus on homeless persons

• 36:41

JOHNSON [continued]: with their homeless preferences.And that it's really turned out very well.The most recent success was Los Angeles.One of the two largest public housing agencies in Americajust decided that all of their turnover,so whenever somebody leaves their housing list,leave their Section 8 or public housing,the turnover will go to a chronically homeless person.

• 37:04

JOHNSON [continued]: So not even a homeless person, but a chronically homelessperson, somebody on the street.So even though it's going to cost them a lot more money,they see the inherent value of targeting the people thatare most in need.So we're going to be doing a lot more work on that.OK?Good question.Other questions?Yes.

• 37:22

STUDENT: So one of the difficulties for somebodyfrom a small town or a rural areais the very way that homeless is definedand the very way that [INAUDIBLE]make it very difficult for small towns and rural areas.I know you mentioned [INAUDIBLE],

• 37:42

STUDENT [continued]: but I wondered is that a function of the [INAUDIBLE],HUD, services start in certain areas, so we have [INAUDIBLE].We did research in a very small community,and it's not very long before you have a really large sample

• 38:05

STUDENT [continued]: of homeless persons.Very few of them show up in the [INAUDIBLE]surveys, because when you're coping with homelessness,it's very difficult, and [INAUDIBLE].So, I guess the question is, have federal agenciesthought about thinking differentlyabout homeless counts and [INAUDIBLE].

• 38:22

JOHNSON: Good.Excellent question.A longstanding topic.So let me give the context here.The act that created the federal homeless program back in 1987,called the McKinney Act, they defined homelessness for HUD.Which essentially is people on the street

• 38:43

JOHNSON [continued]: and people in homeless facilities,like emergency shelters and transitional housing.They then separately defined for their Department of Educationa different definition of homelessness, whichis what I just described, people on the streets and peoplein homeless facilities, and peoplewho live in trailer parks and aren't happy about it,and people who are living doubled up.

• 39:05

JOHNSON [continued]: OK?So I like that.I think it's great to have two different definitions.And normally, I don't.I'm a very simple minded kind of person.I like straight lines.I like to just figure it out black and whiteand move forward.But the reason I like two different definitions is this.Housing is not an entitlement.

• 39:26

JOHNSON [continued]: That's why we have 2 million homeless people out there.Education is an entitlement.Every child can go to school.The benefit of education defining homelessnessin this very broad way, including people living doubledup is, they can have school workers go to those homesand help those kids get back into school, which is fabulous.

• 39:48

JOHNSON [continued]: So having a very broad expansive definition to get kidsinto school is fabulous.If I transported that definition over to HUD,and my definition goes from 600,000at a point in time to whatever it is, 5 million,it doesn't help me at all, because I still have less moneythan I did last year.

• 40:09

JOHNSON [continued]: OK?I only have 200,000 beds that I fund.And I have 600,000 people.Giving me 5 million more people doesn't do anything for me,other than water down who I help.And I really want to focus my resources, my very limitedresources, on the people at most need.That is people literally who have nowhere to live.

• 40:31

• 40:32

STUDENT: Yeah, it is.

• 40:33

JOHNSON: That's the first part of my answer.

• 40:35

STUDENT: Sure.

• 40:35

JOHNSON: OK.Because here I go.We also appreciate that there are people thatare at risk of homelessness.And by saying that, we have no ideawho is going to become homeless tomorrow.I think New York City's randomized control studywas an eye opener for me, which basically

• 40:56

JOHNSON [continued]: found that 90% of the people that you think are at riskdo not become homeless.So they looked at-- and this was a very, very good study,looking at hundreds of people with a controlgroup-- people who lost their jobs, people who had evictions,people who were in shelter last year, they grouped all of that

• 41:17

JOHNSON [continued]: together, and they found that 90%of those people actually over time did not become homeless.So I don't want to spend, frankly,any of my targeted homeless money on homeless preventionif I'm going to be wrong 90% of the time.That's not to say I don't wholeheartedlybelieve in prevention using mainstream programs like TANF,like SNAP, like public housing, etc.

• 41:40

JOHNSON [continued]: So we do have a homeless prevention effortusing mainstream programs.And I think that's absolutely vital.If we could get-- and that's where Affordable CareAct's going to come in in a big way--if we could get our mainstream programs to betterinteract with people that are really, really poor,and stop or slow down the flow into homelessness,we would be doing a much better job on this problem.

• 42:02

JOHNSON [continued]: So I totally get your point.

• 42:03

STUDENT: [INAUDIBLE] when there'sno services in an area, [INAUDIBLE] the homeless,[INAUDIBLE], and then they don't get counted,so there's no services.And I think that's one of the difficult things.I think as time goes on, [INAUDIBLE] low ratesof homeless in rural areas, and I

• 42:24

STUDENT [continued]: think that has more to do with definition [INAUDIBLE].

• 42:29

JOHNSON: No, these are good points.There's no simple solution here.Yeah, that's a good point.Yes.

• 42:37

BONNIE: I'm going to just make that the last question.

• 42:40

JOHNSON: OK.

• 42:41

STUDENT: I work for [INAUDIBLE] in the health centerprogram, and specifically, collaboratingon technical assistance for healthcare for the homeless program.

• 42:49

JOHNSON: Sure.

• 42:50

STUDENT: From the HUD perspective, howbest do you see [INAUDIBLE], specifically in the housingprogram, as a partner, [INAUDIBLE].

• 43:01

JOHNSON: Well, I have with John Lazere for many years.I really wish to be candid that we had better connectionsbetween HUD and HHS.The challenge with HHS is that it's so huge.I think they have seven, or maybe it's eight,I think have eight separate agencies inside HHS,

• 43:22

JOHNSON [continued]: that are completely different, that work in different cities.You know, they're based in different cities.So they are not even able to collaborate that readilywithin the department.So I'm on a joint task force right nowfor ending family homelessness with two different partsof HHS, the side that does child assistanceand the side that does Medicaid.And there's just a lot more we could be doing there.

• 43:47

JOHNSON [continued]: We're jointly doing a data sharing, whereHMIS, the homeless management informationsystems on client level data for HUD, is hopefully,now going to be used by multiple parts of HHS.It's taken five years to get there.And that's part of the challenge,it is so big, it's so big, that it just

• 44:09

JOHNSON [continued]: takes a while to get there.So there's some good stuff we're doing,but we have a long ways to go.Because I really think, other than HUD and VA,the next best connection is between HUD and HHS.To really be connecting much better housing to healthcare than HHS has.All right, thank you very much for your great questionsand your time.

# Health, Homelessness, and Poverty: Keynote Address 2013

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## Abstract

Mark Johnston, from the Department of Housing and Urban Development, discusses his 30-year career working with homelessness. He stresses the importance of evidence-based policy, explains rapid rehousing, and addresses the difficulties of doing this work within a federal agency.

Health, Homelessness, and Poverty: Keynote Address 2013

Mark Johnston, from the Department of Housing and Urban Development, discusses his 30-year career working with homelessness. He stresses the importance of evidence-based policy, explains rapid rehousing, and addresses the difficulties of doing this work within a federal agency.

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