Lizzie Dickerson

28 December 2023

Rising homelessness rates across the country are obvious to anyone who cares to look. It’s an issue stemming from several complex roots, including the housing crisis and our country’s failure to adequately treat people with severe mental illnesses or substance use disorders. But rather than scrapping Housing First, our current national strategy to end homelessness, we should rework it, ensuring that the most vulnerable Americans have residential stability and professional support.

About 30 percent of unhoused people are chronically homeless, meaning that they haven’t had a home for the past year or have experienced extended homelessness periods over the past three years (1). This group is both the most visible part of the homeless population and the segment most difficult to assist due to their multiplicity of challenges. For some, the U.S.’s shortage of millions of affordable homes puts paying rent out of reach (2). For others, health issues complicate housing. A Los Angeles Times review of the city’s 2019 homeless survey found that around 76 percent of individuals living on the street “reported being, or were observed to be, affected by mental illness, substance abuse, poor health or a physical disability” (3). Since George W. Bush’s administration, federal policy towards chronic homelessness has focused on a policy called Housing First, which is based on the premise that basic permanent shelter will provide needed stability for chronically homeless people to reintegrate into society (4). This strategy was initiated in 1992 by Pathways to Housing, a New York nonprofit, and spread to other localities during the early 2000s. Housing First is targeted towards people who have been homeless for long periods of time and offers rapid and streamlined entry into permanent homes. Unlike previous programs that addressed homelessness, it does not require residents to attend counseling or rehab to access permanent housing (5). 

Recently, Housing First has come under fire from critics who point to high homelessness rates as evidence of the system’s failure. Republican congressman Andy Barr introduced the Housing PLUS Bill in 2020 to end Housing First’s priority treatment in national homelessness programs, pointing out that despite increased housing options, rates of unsheltered homelessness in America increased by 20.5 percent from 2014 to 2019. Conservative think tanks have argued that providers should not assume homeless people will automatically begin to thrive once they have homes and that the cost of providing these homes will be wasted if other factors, such as substance abuse, unemployment, and mental illness, aren’t addressed (6). To that end, Barr and others have promoted a traditional step-based system in which undergoing rehab and or job training are preliminary requirements for homeless people to access housing and emphasized the importance of “wraparound” services, which provide professional help for a multitude of challenges (7). 

These arguments should not be taken lightly. Decades of reduced funding for long-term psychiatric care (8), along with rising housing costs (9), have landed thousands of people on the streets. A number of well-publicized violent encounters with mentally ill homeless people in New York (10) emphasize that policymakers cannot overlook this neglected population. But, examining successful Housing First programs reveals that wraparound support is an integral part of their services. Rather than requiring that clients clean their lives up before entering permanent housing, effective Housing First programs give clients permanent housing alongside all the tools they need to become independent and healthy.

In the U.S., programs such as those administered by Pathways to Housing and the Department of Veterans Affairs (VA) are great examples of supportive Housing First initiatives. Housing First critics have rightfully pointed out that the program can easily become “Housing Only,” with participants receiving no additional support (11). But, many Housing First programs provide regular check-ins for clients with trained case managers. These professionals help clients manage their lives and apartments and encourage them to consider physical or mental health and addiction support. In New York’s Pathways program, this check-in is not optional, although the client is free to choose whether to enter recommended treatment or not (12). The program also has a team on call 24/7 that includes clinical staff, peer support workers, and case managers (13). Identifying clients who need additional support upon entry is also prioritized and paired with early and focused interventions to improve life skills and promote community integration (14). Similarly, the VA’s Housing First program for veterans combines case managers and clinical services provided by the VA with housing vouchers for veterans provided by the Department of Housing and Urban Development (HUD). Both programs have achieved high levels of residential stability. The VA’s program has reduced veterans’ homelessness by around 55 percent (15), and 88 percent of Pathways clients remained housed after five years. In contrast, only around 47 percent of clients in contemporary step-based programs remained housed in the same period (16). 

Although it seems counterintuitive, Housing First’s premise of guaranteed housing motivates chronically homeless clients to accept help. Traditional strategies that require homeless people to work their way up to permanent housing don’t provide caseworkers the necessary time to build relationships with clients (17). Speeding chronically homeless people through step-based programs will retain few participants, while Housing First’s long-term commitment results in long-term success. Programs in which retaining housing is contingent on sobriety also destroy trust between participants and case managers (18). A study from the New York University School of Social Work found that many homeless people engaged in these programs have higher rates of substance abuse and end up returning to the street, while those in Housing First programs tend to be more residentially stable (19). 

Successful Housing First programs are not outliers. A Canadian study of over 2,000 individuals with serious mental illnesses found that Housing First was far more effective than “treatment first” approaches (20). A French study done between 2011 and 2016 followed hundreds of clients and found that those in Housing First programs were more stably housed, spent less time in the hospital, and saved cities more money compared to those in traditional programs (21). Both programs included weekly caseworker meetings and an on-call team of professionals modeled after Pathways. 

But many American Housing First programs don’t achieve this level of care, in part thanks to HUD budgeting allocations. In 1998, 45 percent of the HUD’s homelessness assistance funds were spent on housing, with 55 percent given to supportive services. By 2021, those percentages had shifted to 68 and 22, respectively (22), lending credence to the argument that the federal government has been promoting a “Housing Only” program. To a certain extent, the critics are right—it’s time to rethink our approach to homelessness. Housing First can only be cost-effective if clients are provided with a substantial services network. And evidence shows that committing taxpayer dollars to Housing First rather than traditional strategies is worth it in the long run. Chronically homeless people consume tens of thousands of dollars of services cycling between jails and emergency rooms (23), but studies have found that every dollar invested in Housing First programs results in $1.44 saved (24), with reduced hospital visits (25) and interactions with the justice system (26) among participants. 

To help those people most neglected by our society, we need to refine and refocus existing policies rather than returning to traditional step-based programs. Although homelessness is a problem with many roots, Housing First is the best long-term solution to resolving it.

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Image via Wikimedia Commons under Creative Commons Attribution-Share Alike 4.0 International license, https://commons.wikimedia.org/wiki/File:Homeless_Encampment_Along_Coyote_Creek_Bikeway.jpg

Works Cited

1. “Homelessness in America 2023: Statistics, Analysis, & Trends.” Security.org, August 18, 2023. https://www.security.org/resources/homeless-statistics/#:~:text=About%2030%20percent%20of%20people,over%20the%20past%20three%20years.
2. Aurand, Andrew, Dan Emmanuel, Emma Foley, and Matt Clarke. “Addressing America’s Affordable Housing Crisis.” Housing Matters, April 12, 2023. https://housingmatters.urban.org/research-summary/addressing-americas-affordable-housing-crisis.
3. Husock, Howard. “A Bipartisan Approach to Helping the Homeless.” The Hill, November 25, 2022. https://thehill.com/opinion/civil-rights/3750292-a-bipartisan-approach-to-helping-the-homeless/.
4. Deparle, Jason. “Federal Policy on Homelessness Becomes New Target of the Right.” The New York Times, June 20, 2023. https://www.nytimes.com/2023/06/20/us/politics/federal-policy-on-homelessness-becomes-new-target-of-the-right.html.
5. Eide, Stephen. “Housing First and Homelessness: The Rhetoric and the Reality.” Manhattan Institute, March 3, 2023. https://manhattan.institute/article/housing-first-and-homelessness-the-rhetoric-and-the-reality.
6. Ibid.
7. Husock, Howard. “A Bipartisan Approach to Helping the Homeless.” The Hill, November 25, 2022. https://thehill.com/opinion/civil-rights/3750292-a-bipartisan-approach-to-helping-the-homeless/. 
8. Raphelson, Samantha. “How the Loss of U.S. Psychiatric Hospitals Led to a Mental Health Crisis.” NPR, November 30, 2017. https://www.npr.org/2017/11/30/567477160/how-the-loss-of-u-s-psychiatric-hospitals-led-to-a-mental-health-crisis.
9. Montoya, Daniel. “Reforming the Housing First Model: Expanding Resources for Chronic Homelessness.” The Center for Public Justice, November 15, 2022. https://cpjustice.org/reforming-the-housing-first-model-expanding-resources-for-chronic-homelessness/. 
10. Fahy, Claire, Maria Cramer, and Ana Ley. “Woman in Critical Condition after Man Pushes Her into Subway Train.” The New York Times, October 18, 2023. https://www.nytimes.com/2023/10/18/nyregion/subway-attack-nyc.html.
11. Eide, Stephen. “Housing First and Homelessness: The Rhetoric and the Reality.” Manhattan Institute, March 3, 2023. https://manhattan.institute/article/housing-first-and-homelessness-the-rhetoric-and-the-reality.
12. Cohen, Rachel M. “The Most Successful Strategy for Ending Homelessness Is under Attack.” Vox, December 15, 2022. https://www.vox.com/policy-and-politics/23504323/housing-first-homelessness-houston-homes.
13. “Assertive Community Treatment (ACT) Teams.” The Homeless Hub. Accessed November 29, 2023. https://www.homelesshub.ca/solutions/supports/assertive-community-treatment-act-teams.
14. Stergiopoulos, Vicky, Agnes Gozdzik, Patricia O’Campo, Alixandra R Holtby, Jeyagobi Jeyaratnam, and Sam Tsemberis. “Housing First: Exploring Participants’ Early Support Needs.” BMC Health Services Research 14, no. 1 (2014). https://doi.org/10.1186/1472-6963-14-167.
15. Cohen, Rachel M. “The Most Successful Strategy for Ending Homelessness Is under Attack.” Vox, December 15, 2022. https://www.vox.com/policy-and-politics/23504323/housing-first-homelessness-houston-homes.
16. Deparle, Jason. “Federal Policy on Homelessness Becomes New Target of the Right.” The New York Times, June 20, 2023. https://www.nytimes.com/2023/06/20/us/politics/federal-policy-on-homelessness-becomes-new-target-of-the-right.html.  
17. Tsemberis, Sam, Leyla Gulcur, and Maria Nakae. “Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals with a Dual Diagnosis.” American Journal of Public Health 94, no. 4 (2004): 651–56. https://doi.org/10.2105/ajph.94.4.651.
18. Loubière, S., C. Lemoine, M. Boucekine, L. Boyer, V. Girard, A. Tinland, and P. Auquier. “Housing First for Homeless People with Severe Mental Illness: Extended 4-Year Follow-up and Analysis of Recovery and Housing Stability from the Randomized UN Chez Soi d’abord Trial.” Epidemiology and Psychiatric Sciences 31 (2022). https://doi.org/10.1017/s2045796022000026.
19. Padgett, Deborah K., Victoria Stanhope, Ben F. Henwood, and Ana Stefancic. “Substance Use Outcomes among Homeless Clients with Serious Mental Illness: Comparing Housing First with Treatment First Programs.” Community Mental Health Journal 47, no. 2 (2010): 227–32. https://doi.org/10.1007/s10597-009-9283-7.
20. Goering, Paula, Scott Veldhuizen, Aimee Watson, and Carol Adair. “National At Home/Chez Soi Final Report.” Calgary: Mental Health Commission of Canada, 2014.
21. Cohen, Rachel M. “The Most Successful Strategy for Ending Homelessness Is under Attack.” Vox, December 15, 2022. https://www.vox.com/policy-and-politics/23504323/housing-first-homelessness-houston-homes.
22. Ibid.
23. Deparle, Jason. “Federal Policy on Homelessness Becomes New Target of the Right.” The New York Times, June 20, 2023. https://www.nytimes.com/2023/06/20/us/politics/federal-policy-on-homelessness-becomes-new-target-of-the-right.html.  
24. “The Case for Housing First.” Washington, D.C.: National Low Income Housing Coalition, n.d.
25. Montoya, Daniel. “Reforming the Housing First Model: Expanding Resources for Chronic Homelessness.” The Center for Public Justice, November 15, 2022. https://cpjustice.org/reforming-the-housing-first-model-expanding-resources-for-chronic-homelessness/.
26. Ly, Angela, and Eric Latimer. “Housing First Impact on Costs and Associated Cost Offsets: A Review of the Literature.” The Canadian Journal of Psychiatry 60, no. 11 (2015): 475–87. https://doi.org/10.1177/070674371506001103.