Comments to the National Council on Disability on HCBS

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Home and Community Based Services (HCBS) support people with disabilities to live in the community of their choice and are a key element of making disability-forward, inclusive housing a reality. The Kelsey issued this letter to the National Council on Disability in response to a request for comment on HCBS and the HCBS settings rule.

Dear Distinguished Members, 

Thank you for the opportunity to comment on NCD’s upcoming project examining the state of the nation’s home- and community-based services (HCBS) prior to, and during, the COVID-19 pandemic. At The Kelsey, we pioneer disability-forward housing solutions that open doors to more affordable homes and opportunities for everyone. We have 240 affordable, accessible, integrated, and inclusive homes in our pipeline and lead organizing and advocacy initiatives to support market conditions to make inclusive housing the norm.

Firstly, The Kelsey supports the robust recommendations to improve HCBS that are laid out in the version of Build Back Better passed by the House and the recommendations mapped out in the draft version of the HCBS Access Act. The Kelsey also supports the intention of the HCBS Settings Rule, the disabled leaders that advocated for its creation, to support truly integrated, community-based, inclusive housing options for people with disabilities that support choice and the realization of Olmstead and the ADA.

As a housing developer and social impact organization led by people with and without disabilities, we witness firsthand the extreme shortage of housing and services that people with disabilities need in order to thrive in their own homes and communities. We also know that the ability to successfully access home and community-based services is contingent on the ability to live in accessible, affordable, and integrated housing. Therefore, it is critical that as NCD pursues the examination of HCBS and provides policy recommendations to the Biden-Harris Administration, the “H” in HCBS is embedded in the analysis as well as the policy recommendations. 

To be clear, The Kelsey asserts the necessity for housing and supportive services to  come from separate systems (i.e. Department of Housing & Urban Development, other local and state housing programs, and Medicaid), yet both systems need to be more strategically coordinated, significantly more funded, and have greater implementation disability-forward policies. All of which must uphold and make the promise of the ADA and the Olmstead ruling a reality: that all people with disabilities, including those who need supportive services and particularly those who are multiply marginalized, can live and thrive in their own homes and communities of choice.

We strongly believe that the following policy interventions must be considered when analyzing how HCBS can be bolstered, including how to ensure all people can transition out of congregate settings into housing and communities of their choice: 

  • In addition to eliminating the Medicaid institutional bias, there should be robust increased investment in Money Follows the Person and HCBS Medicaid Waivers, including housing-related services. 
    • Within Medicaid HCBS, there should be specific bolstering of housing-related services, which increase people’s ability to transition out of congregate care facilities into community-based housing. We also recommend exploring ways that the housing-related services dollars can be more impactful and support housing stability and retention; for example, having the funds cover 1-3 months’ rent instead of just initial transition to housing costs.
    • As state programs decrease investment in institutional, licensed, and congregate housing models, a commensurate investment in the housing and service costs of those programs should be allocated towards the community-based models. Closure of institutional models is essential and federal and state governments must ensure that the land and funding previously and currently dedicated to those models is allocated toward the present and future housing needs of people with disabilities in inclusive, integrated models.

  • Increase alignment and coordination across HUD & HHS, in the following ways:  
    • Releasing joint guidance on how Public Housing Authorities (PHA’s) can better partner with disability serving organizations, to ensure that people with disabilities, particularly those who are currently in or at risk of institutionalization, can get easier access to Housing Choice Vouchers. 
    • Building off of The Medicaid Innovation Accelerator Program (IAP), effective from 2016-2019, when CMS worked with state Medicaid agencies and their state housing partners to develop public and private partnerships between the Medicaid and housing systems and when states were supported to in the creation of detailed action plans that foster additional community living opportunities for Medicaid beneficiaries. 
    • As the COVID19 crisis continues, we are concerned that in a rush to expand permanent supportive housing (PSH), including turning hotels and other non-congregate shelters into PSH,  “mini-institutions” will be developed.  As HUD leads in financing diverse housing options, housing options that do not meet CMS’s “HCBS settings rule” should not be eligible for Medicaid funding for these services. HUD, CMS, ACL, and DOJ must create an internal understanding of what constitutes qualities of community-based settings that distinguish them from institutional settings and issue guidance to all of its recipients and grantees.

  • Pilots to explore can include: 
    • A pilot mechanism for housing costs that can follow a person from an institutional setting into a community-based integrated setting. Medicaid funds support individual services—including those related to housing—but corresponding housing infrastructure is also essential in the form of HUD housing development subsidies and other federal housing incentives that support more noninstitutional, affordable, and accessible housing stock. In the long term, this federal investment would both be cost-effective and ensure that the right to community living for people with disabilities can be fully realized.
    • Pilot program to match HCBS users who match income eligibility with a housing voucher. A voucher for all individuals who utilize HCBS services or a capital subsidy for projects who designate affordable, accessible homes for people with disabilities ensures the housing right of people with disabilities, especially those who use supportive services, becomes a reality.

In conclusion, thank you again for the opportunity to comment. As a disability forward housing organization, we welcome follow-up discussion and collaboration for how to ensure that the “H” in HCBS is strong enough to ensure that all Disabled people who need services have affordable, accessible, and inclusive housing in the communities of their choice.


Allie Cannington
Manager, Advocacy & Organizing

Micaela Connery