Disabilities, Housing of Persons with

The understanding of disability has expanded as reflected in the Americans with Disabilities Act (ADA) of 1990 and other works on the disablement process, which address disability in relation to a person's physical, emotional, sensory, or mental functioning problems that coexist with levels of social participation activities. The law defines a person as having a disability if the individual has a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment, or is regarded as having such an impairment. The ADA Amendments Act of 2008 noted that this definition shall be construed in favor of broad coverage and that the determination of limiting a major life activity is to be made regardless of the ameliorative effects of mitigating measures, such as medications or assistive technology. There are several definitions of disability, and estimates of prevalence vary. The Centers for Disease Control and Prevention estimate that 49 million Americans aged 15 and older (21%) have some kind of disability, with half (52%) of those aged 65 and over. People with disabilities have typically moved out of their homes as their needs changed, into more restrictive forms of housing in a type of continuum model that includes group homes, assisted living, and nursing facilities.

One option in this continuum is a group home, in which two or more individuals with disabilities live together. While the residents may help each other, there are often staff who regularly supervise and support the residents. As people become more dependent in their activities of daily living (ADLs), either with age or as a degenerative disease progresses, assisted living may fit their needs. In cases [Page 135]where a person requires help with only some ADLs and partial supervision but not full-time nursing care, assisted living has emerged as an alternative to the nursing home. The definitions and labels (e.g., board and care, adult homes) vary, but this level of care has become increasingly taken over by large assisted-living facilities, which are often amenity-rich and have corresponding costs. For most individuals, these expenses would come out of pocket, costing an annual average of $40,000 in 2010, although monthly fees range as high as $5,000 or more.

As individuals become more severely dependent, nursing homes and other institutions have typically been the ultimate answer. Current nursing home residents generally have high care needs. While many individuals enter as private pay, most generally “spend down” their savings and then become eligible for Medicaid. Medicaid is a federal-state program, meaning covered services vary from state to state, but it has become the primary payer for nursing homes, covering two thirds of nursing home residents nationally. Medicare pays for only limited nursing home care and only under circumstances that require a physician-designated “skilled care” need. Medicare will also cover home health care under these same limited circumstances. Thus, our payment systems have been slanted toward institutional housing for people with disabilities. Exemplifying the continuum model for older adults is the continuing care retirement community, which provides independent living, assisted living, and nursing home care on the same campus, and the individual moves from one level to another as needed.

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