If you get sick with a mental illness in North Carolina, chances are you have at least two very big problems. First, of course, is your illness itself, and all of the misery, stigma and difficulty that can bring. There is another problem, however, that often presents a more severe disability than even your illness itself: the likelihood that you might be facing extreme poverty. And if you imagine having a mental illness would be hard, it becomes infinitely more difficult when you are financially indigent, without options. Not all people with mental illness are impoverished, of course. Many are able to work and support themselves; others are fortunate to have families with means.
      However, for far too many individuals with disabilities, having a mental illness means relying on SSI or SSDI payments of $6,000-9,000 a year to live. And as any housing developer or provider will assure you, an income like that doesn't open many doors. According to the Social Security Administration, over 23,000 North Carolinians draw SSI payments because of some type of disability, excluding those classified as "aged." For someone drawing straight SSI, this amounts to $512 a month, or an hourly equivalent of $3.20. Where do these people live?
      To begin with, over 9,200 of these individuals live in adult care homes. These privately-owned, state-licensed facilities are more commonly known as rest homes and family care homes. This is typically financed using the individual's SSI payment, together with funds from North Carolina's Special Assistance program (half county funds, half state). The population of people living in these homes was not always so large. Adult care home beds in North Carolina have mushroomed since 1974, when the State of North Carolina decided to restrict Special Assistance funds to use in adult care homes. Today, in fact, out of 44 states that provide Special Assistance - technically a state and local supplement to federal SSI payments - North Carolina is one of only 6 states that specifically restrict use of these funds to rest homes and family care homes.
      This policy, which effectively deems adult care homes to be the preferred type of housing for extremely low income North Carolinians with mental illness, has predictably stunted the growth of other subsidized housing alternatives, discouraged the private sector from providing mainstream housing, and severely limited individuals' ability to rejoin their communities. A report recently published by Housing Works explained how this works in simple terms. The publication, Making Independence Work: New Ways of Thinking About Special Assistance, told the story of Katherine S., a young woman with severe and persistent mental illness, and her struggle to find housing.
      Katherine, like many people with mental illness at some point in their lives, was hospitalized. Upon release, she had only her SSI income of $512 a month. But in North Carolina, according to statistics gathered by the Technical Assistance Collaborative (www.tacinc.org), she would need over 73 percent of that SSI income to afford a one-bedroom apartment in North Carolina, and 63 percent for an efficiency. In 38 other states, Katherine might have had access to a state and local supplement to her SSI, raising her income to a realistic level and allowing her to rent somewhere. However, in order to get Special Assistance in North Carolina, Katherine had to live in an adult care home, which is exactly what happened.
      The family care home where Katherine lived in Asheville was known as one of the best in the area. It was a small complex of ranch-style houses, where young adults with mental illness lived together with frail elderly. Medication was dispensed regularly by staff, and meals were prepared for the residents. Yet Katherine languished, without much stimulation or privacy - or hope for a return once again to independent living.
      There are an unknown number of persons with mental illness in North Carolina who follow a revolving door from hospital to homeless shelter to adult care home or jail. Point-in-time studies of homeless populations routinely show that between 30 and 50 percent have a mental or developmental disability, often complicated by substance abuse problems. Shelter providers know which adult care homes will take these individuals - as do jail outreach workers. Often a rest home operator will drive down to a homeless shelter - or directly to the hospital - and pick up a new resident. It is a grim and frustrating cycle that is painfully familiar to social workers and mental health providers. Many individuals choose to live in group homes, an option favored by many families, who want to know that their loved one is safe and around others. Many consumers complain that most group homes are too restrictive, although there is no reason they have to be, and at least one consumer-run group home is in existence.
      In the case of Katherine, another option was designed, and through the rare commitment of one mental health center, she was able to move into her own apartment, where a menu of mental health and social services was available. The Clearview Terrace Apartments in Asheville was one of a growing trend called supported housing, where federal, state, and private funds are used to develop independent living apartments with accompanying services. Supported housing units are now being developed, slowly but deliberately, across the state, thanks largely to a small but innovative program at the Division of Mental Health, Developmental Disabilities, and Substance Abuse. Through grants to area mental health centers, the Division has created a network of 16 housing specialists. As the capacity to develop supported housing slowly grows, so will choice and independence.
      Supported housing specialists do what other housing nonprofits either cannot or will not: develop housing that is financially feasible for people too poor to afford even traditional subsidized housing. To some extent, they are following in the footsteps of the most extensive, and until recently the only, viable-supported housing program, HUD's Section 811 apartments. The Mental Health Association of North Carolina has been a very successful developer of 811s, working with area mental health programs.
      By piecing together a Byzantine patchwork of federal, state, and private funding, together with whatever crucial rental assistance they can find, these new developers are making exciting progress. But it is glacial progress nonetheless. Without a serious commitment to community-based housing, North Carolina cannot expect to see much change. Supported housing developers desperately need bricks and mortar funding, as well as rental assistance. A serious commitment to a concerted statewide building program would allow not only these housing specialists to be successful, but it would bring their more seasoned counterparts in the nonprofit housing world to the table. We now have ample information and expertise to know what resources are needed to provide housing choice and community-based options to people with disabilities. Fortunately this is not a financial "black hole." Persons with mental illness are a fairly fixed, and relatively small, part of our community at large. A serious and sustained effort now could actually meet housing demand over the coming decade.
      And over the coming decade, North Carolina policymakers might want to ask: when it comes to affordable housing, is there anyone who needs and deserves our help more?