Long‐term care reform and the role of housing finance

Abstract

The Clinton administration's recently announced home and community‐based care proposals have potentially important implications not only for long‐term care policy, but also for housing policy in the United States. This article attempts to draw out some of those implications. The first section examines problems inherent in the current “medical/welfare” system of financing long‐term care, which constrains consumer choice by limiting the supply of providers to control costs and by increasing medical professionals’ control over the types of services provided in the name of quality control. The medical/welfare dominance of long‐term care policy has resulted in an overreliance on nursing homes as providers, resulting in both escalating costs and continued consumer dissatisfaction.

The second half of the article looks at recent market and policy developments in response to consumer demand for lower cost alternatives to nursing homes. These alternatives promote more consumer autonomy and control in supportive housing arrangements. A more comprehensive services and housing policy could promote these developments in an approach that combines the security of public financing of supportive services with the benefits of consumer choice, market competition, and legal protections that characterize housing markets. In such a scenario, housing finance institutions—including government agencies, lenders, developers, and investors—could play a pivotal role in the long‐term care debate not only by unlocking substantial financial resources but, equally important, by transforming the provision of long‐term care services to promote consumer choice and autonomy.     

Social services in interim housing programs and shelters

This study investigates the effectiveness in delivering social services of interim housing programs compared to shelters. Interim housing programs represent a new approach to housing and serving homeless adults, one which provides emergency housing in apartment-like units, and in which use of services is voluntary. Shelters tend to provide congregate care and to expect or rely on clients to access needed services in order to secure resources required to obtain housing. Analyses of original survey data, which correct for sample selection utilizing propensity scores, suggest that clients in interim housing programs obtain more professional, advocacy, and employment services than do clients in shelters. This differential service use is found to reflect not client incentives, but the service offerings and referrals made by the programs. In general, the findings suggest that interim housing programs hold particular promise in service rich environments. They also suggest that program contingencies are more important than certain individual client incentives in affecting service use. Finally, the results begin to suggest the value of this new, interim housing-based approach.     

The Mythology of Privatization in Contracting for Social Services

States and municipalities have privatized services in an effort to improve their cost‐effectiveness and quality. Competition provides the logical foundation for an expectation of cost savings and quality improvements, but competition does not exist in many local marketplaces—especially in the social services, where governments contract primarily with nonprofit organizations. As government increases its use of contracting, it simultaneously reduces its own public‐management capacity, imperiling its ability to be a smart buyer of contracted goods and services. This article examines two questions about the privatization of social services based on interviews conducted with public and nonprofit managers in New York state: Does social services contracting exist in a competitive environment? And do county governments have enough public‐management capacity to contract effectively for social services? The findings suggest an absence of competition and public‐management capacity, raising the question of why governments contract when these conditions are not met.     

The private safety net: The role of charitable organizations in the lives of the poor

Abstract

As welfare reform unfolds, nonprofit social service agencies will increasingly be called upon to help fill the gap between what unskilled and semiskilled mothers can earn in the low‐wage labor market and what they need to meet their monthly expenses. This article draws on in‐depth interviews with low‐income single mothers and multiyear observational studies of two nonprofit social service agencies.

Using these data, the authors show what kinds of resources these agencies provide low‐income single mothers, how mothers mobilize the resources available, to what degree agencies actually contribute to mothers’ cash and in‐kind resources, how agencies distribute their resources, and what effect agencies’ distribution practices have on these women. The analysis shows that although nonprofit social service agencies are a crucial part of many low‐income mothers’ economic survival strategies, they cannot come close to substituting for the eroding public safety net.     

What Interventions Work Best for Families Who Experience Homelessness? Impact Estimates from the Family Options Study

What housing and service interventions work best to reduce homelessness for families in the United States? The Family Options Study randomly assigned 2,282 families recruited in homeless shelters across 12 sites to priority access to one of three active interventions or to usual care in their communities. The interventions were long‐term rent subsidies, short‐term rent subsidies, and transitional housing in supervised programs with intensive psychosocial services. In two waves of follow‐up data collected 20 and 37 months later, priority access to long‐term rent subsidies reduced homelessness and food insecurity and improved other aspects of adult and child well‐being relative to usual care, at a cost 9 percent higher. The other interventions had little effect. The study provides support for the view that homelessness for most families is an economic problem that long‐term rent subsidies resolve and does not support the view that families must address psychosocial problems to succeed in housing. It has implications for focusing government resources on this important social problem.     

Counting homeless persons with surveys of users of services for the homeless

Abstract

Because of their comparative economy, the most commonly used methods for counting the homeless focus on users of shelters, food lines, health clinics for the homeless, and other services for the homeless. This paper argues that surveys restricted to shelter users are of limited usefulness, but that joint surveys of food‐line, shelter, and clinic users include very substantial proportions of the homeless in many communities. Such comprehensive surveys can provide an accurate basis for research on the homeless in communities with reasonably capacious service systems. The reliability of such surveys has grown as service systems for the homeless have improved. Groups of the homeless that tend to be missed in service user surveys include homeless youths on their own as well as substantial portions of the rural homeless population and of the doubled‐up or institutionalized homeless populations. Surveys of homeless persons sleeping in known places “on the streets” can be used to supplement surveys of service users. Research in Colorado suggests that such supplemental surveys of the street population provide a practical basis for comprehensive estimates of the homeless street population.     

Organizational form and performance: An empirical investigation of nonprofit and for‐profit job‐training service providers

While research on the distinctions between for‐profit and nonprofit organizations and their changing service sector shares is vast, there is comparatively little empirical evidence on the consequences of their differing attributes for social program outcomes. This article presents research on publicly subsidized for‐profit and nonprofit job‐training service providers, namely whether organizational form influences client enrollment, service delivery activities, or performance, as measured in terms of participant outcomes. The findings show that nonprofit providers were not more likely to serve more disadvantaged clients and that neither for‐profit nor nonprofit service providers were consistently more effective in increasing participants' earn‐ings and employment rates. When performance incentives were included in service providers' contracts, contractors of all forms performed significantly better across all participant outcomes examined. © 2000 by the Association for Public Policy and Management.     

Objectivity versus outrage

He wrote a background paper for the Committee on Health Care for Homeless Persons, “The Dynamics of Homelessness.” He has studied both the needs of homeless persons and the development of shelters and services for the homeless; he codirected a training tape for service providers; and he is coauthoring a book for shelter staff. He is author of Organization in a Changing Environment.     

Monitoring across Sectors: Examining the Effect of Nonprofit and For‐Profit Contractor Ownership on Performance Monitoring in State and Local Contracts

What is the effect of contractors' nonprofit and for‐profit ownership on the scope and nature of performance measurement used by government agencies? Quantitative and qualitative data were generated through semistructured interviews administered to a sample of state and local public agencies and private contractors across five jurisdictions. The findings of this study suggest that monitoring officers working with nonprofit rather than for‐profit contractors are more likely to rely on qualitative performance data and examine equitable access to services, contractors' reputation, and compliance with industry rules and regulations. Although organizational ownership may not be well understood by practitioners, performance appears to be conceptualized differently across sectors. The author calls for a better understanding of the impact of the identified differences in performance measurement on the effectiveness of contract monitoring.     

More Similarities or More Differences? Comparing Public and Nonprofit Managers’ Job Motivations

Existing research on career motivations tends to focus either on the difference between private and public organizations or on the difference between nonprofit and for‐profit firms. Although commonalities exist, the literature suggests that there also are many differences in what motivates public and nonprofit employees. Employing data from the National Administrative Studies Project III, this research examines how seven motivational aspects correlate with the choice between public and nonprofit employment. The authors find that managers who value advancement opportunities, a pension and retirement plan, and the ability to serve the public in their jobs are more likely to accept a job in the public sector, whereas managers who value family‐friendly policies and increased responsibility are more likely to accept a position in the nonprofit sector. Participation in volunteering is positively associated with nonprofit employment. The authors suggest a possible link between volunteering and the unique nonprofit motivation that is differentiated from public service motivation.     

Does the public sector outperform the nonprofit and for‐profit sectors? Evidence from a national panel study on nursing home quality and access

Are public and private organizations fundamentally different? This question has been among the most enduring inquiries in public administration. Our study explores the impact of organizational ownership on two complementary aspects of performance: service quality and access to services for impoverished clients. Derived from public management research on performance determinants and nursing home care literature, our hypotheses stipulate that public, nonprofit, and forprofit nursing homes use different approaches to balance the strategic tradeoff between two aspects of performance. Panel data on 14,423 facilities were analyzed to compare measures of quality and access across three sectors using different estimation methods. Findings indicate that ownership status is associated with critical differences in both quality and access. Public and nonprofit organizations are similar in terms of quality, and both perform significantly better than their forprofit counterparts. When compared to nonprofit and, in some cases, for‐profit facilities, public nursing homes have a significantly higher share of Medicaid recipients. The paper proposes strategies to address the identified long‐term care divide. © 2008 by the Association for Public Policy Analysis and Management.     

DOWN TO BUSINESS: THE COMMODIFICATION OF NONPROFIT SOCIAL SERVICES

Private nonprofit organizations play a major role in delivering a range of publicly funded social services. Aggregate data from a recent Urban Institute study reveal that recent federal cutbacks have affected the services, programs and clients of NPOs. An examination of specific agencies in Maricopa County (Phoenix) reveals that many service providers have adopted a business approach to their services and clients, treating them as commodities. In general, agencies serving clients with Resource Mobilization Potential-youth and elderly-have fared better than those dealing primarily with poor adults.     

The Challenge of Strengthening Nonprofits and Civil Society

The Winter Commission Report was centrally concerned with improving the performance of state and local governments. Since the issuance of the commission’s report in 1993, the delivery of services by state and local government has been substantially changed by the growing role of nonprofit organizations in providing public services and representing citizen interests. As a result, state and local governments and nonprofit agencies are faced with complex governance challenges. The central argument of this paper is that despite the dramatic changes in the relationship between government and nonprofit organizations in recent years, the key tenets of the Winter Commission report—the need for improved training and education, greater transparency and accountability, more emphasis on performance, and improved citizen engagement—remain deeply relevant in improving the governance of the public services in an increasingly complex policy process and service delivery system at the state and local levels.     

Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing

Abstract

This article assesses the impact of public investment in supportive housing for homeless persons with severe mental disabilities. Data on 4,679 people placed in such housing in New York City between 1989 and 1997 were merged with data on the utilization of public shelters, public and private hospitals, and correctional facilities. A series of matched controls who were homeless but not placed in housing were similarly tracked.

Regression results reveal that persons placed in supportive housing experience marked reductions in shelter use, hospitalizations, length of stay per hospitalization, and time incarcerated. Before placement, homeless people with severe mental illness used about $40,451 per person per year in services (1999 dollars). Placement was associated with a reduction in services use of $16,281 per housing unit per year. Annual unit costs are estimated at $17,277, for a net cost of $995 per unit per year over the first two years.     

Competition,commercialization, and the evolution of nonprofit organizational structures

This article explores competition both in settings where nonprofits compete among themselves and where they compete with for-profits. Growing competition among nonprofits raises questions as to the impacts of this rivalry. How does competition affect nonprofit behavior and does it cause nonprofits to become more commercial in orientation? Does it alter organizational structures and does it cause nonprofits to become less focused on their charitable missions? The answers to these questions can influence public policy toward the nonprofit sector. A definition of competition is presented and Porter's five competitive forces are introduced and used to explore competition in nonprofit marketplaces. Conditions under which commercialization is likely to occur are discussed and the nature of competition is then examined in settings where nonprofits compete in mixed (for-profit/nonprofit) markets. Organizational structures from the health care industry are then used to highlight the evolving legal structures that nonprofits employ in competition with for-profits. Five policy implications of the analysis are examined and the need for additional information is highlighted.     

社会制度与青年农民工的就业质量——基于湖南长沙市的实证调查

对长沙市301名青年农民工的实证研究结果表明,青年农民工的就业质量偏低,且受社会制度的显著影响。其中就业机构、就业培训和继续教育状况与职业声望和收入水平显著相关;就业机构和就业培训与职业稳定性显著相关;就业培训和继续教育与职业发展机会显著相关。因此,必须改革与完善户籍制度及相关制度,消除青年农民工就业的制度歧视,并大力加强青年农民工群体的自组织建设。     

Looking for Friends,Fans, and Followers? Social Media Use in Public and Nonprofit Human Services

This article uses interviews and Internet data to examine social media use among nonprofit organizations and county departments involved in the delivery of human services in a six‐county area in south‐central New York State. Social media use was modest, with nonprofit organizations much more likely to use it than county departments. Organizations used social media primarily to market organizational activities, remain relevant to key constituencies, and raise community awareness. Most organizations either had a narrow view of social media's potential value or lacked a long‐term vision. Barriers to use included institutional policies, concerns about the inappropriateness of social media for target audiences, and client confidentiality. Findings build on recent research regarding the extent to which nonprofit organizations and local governments use social media to engage stakeholders. Future research should investigate not only the different ways organizations use social media but also whether organizations use it strategically to advance organizational goals.     

Exploring the Role of Nonprofits in Public Service Provision: Moving from Coproduction to Cogovernance

This article investigates the determinants of nonprofits' involvement in cogovernance, or the planning and design of public services, using a unique data set of park‐supporting nonprofit organizations in large U.S. cities. The results indicate that nonprofits are more likely to get involved in cogovernance when they are younger, larger, and operate in communities that are more resourceful and stable. In addition, the likelihood of nonprofits' involvement in cogovernance is negatively associated with the level of social capital and government capacity to provide corresponding public services. The article points to an emerging mode of government‐nonprofit collaboration that goes beyond the production and delivery of public services. As public managers face extensive challenges in sustaining the desired level of public services, these findings have important policy implications for efforts to promote citizen participation and cross‐sector solutions to complex social problems.     

Child care quality in different state policy contexts

Using data from the Child Care Supplement to the Fragile Families and Child Wellbeing Study, we test associations between the quality of child care and state child care policies. These data, which include observations of child care and interviews with care providers and mothers for 777 children across 14 states, allow for comparisons across a broader range of policy regimes and care settings than earlier research on this topic. Using multilevel linear and logistic models, we found that more generous subsidy policies (that is, greater investment, higher income eligibility) were positively associated with the quality of care in nonprofit child care centers, as well as with the use of center care. The stringency of regulations (that is, teacher education requirements, teacher‐child ratios/thresholds) was also associated with both quality and type of care, but in more complex ways. Higher teacher training requirements were positively associated with the quality of both family child care and nonprofit centers, while more stringent regulations decreased the number of children attending center care. No links were found between state policies and the quality of for‐profit center care. The implications for policy makers, advocates, and policy analysts are discussed. © 2007 by the Association for Public Policy Analysis and Management     

Using local longitudinal records to estimate transient and resident homeless populations

Abstract

Many local agencies that provide services to the homeless have only limited data and resources to estimate the extent of need or the size of the local population at risk of requiring the services they provide. Methods exist, however, that are capable of providing reasonable estimates of underlying service populations with minimal record keeping. In this paper one group of such models, first‐capture models, is discussed as a resource‐efficient technique for estimating the underlying population consistently at risk ("residents") and those occasionally at risk ("transients") of requiring agency services.