The Argument for Housing First Policy in the United States

By Genni Bogdanowicz

Abstract
Homelessness is a pervasive issue in the United States that has worsened over the past two years. This issue is incredibly intricate, and few policies have been effective in solving it. Housing First policy has a strong evidence base that has been shown to keep individuals housed consistently. Conservative think tanks and politicians have recently begun to attack Housing First; I argue that much of this attack is part of a larger rhetorical strategy from the right and does not undermine the policy’s effectiveness. Finally, I recommend that the United States broadly implement Housing First.

Background

As of January 2022, almost 600,000 people in the United States were homeless, accounting for around 18 out of every 10,000 people (National Alliance to End Homelessness, 2023). Nearly three-quarters (72%) of this population consisted of individual adults, and 28% consisted of families with children (NAEH, 2023). Around 22% are “chronically homeless individuals,” meaning that they have been living in a place considered inhabitable for humans for either at least twelve months or on four different occasions over the past three years, totaling more than twelve months (HUD Exchange, n.d.).

Additionally, around 40% of homeless individuals live “unsheltered,” meaning that their main nighttime residence is considered inhabitable for humans (NAEH, 2023). This number is significantly higher for chronically homeless individuals, at 62% (NAEH, 2023).

This issue has strong disparities based on identity. Black Americans experienced homelessness at four times the rate of white Americans in 2022 (NAEH, 2023). Native Hawaiians or Pacific Islanders had the highest rate of homelessness out of any group in 2022 (NAEH, 2023). Furthermore, LGBTQ+ Americans have “particularly high rates of unsheltered homelessness” (NAEH, 2023). 

Between 2007 and 2016, homelessness in America generally declined, with a small but significant reduction of 17% over that period (NAEH, 2023). The issue has seen a slight increase over the past two years as the country has come out of the COVID-19 pandemic–a period in which the federal government implemented policies to keep many people housed (NAEH, 2023).

Homelessness has significant negative mental and physical health impacts (National Health Care for the Homeless Council, 2019). Unhoused people, on average, die 12 years earlier than the general US population and experience higher illness rates (NHCHC, 2019).

What is Housing First?
Homelessness is a significant issue in the United States. The question of how to address it has never been simple, especially given the many concurrent issues unhoused people often face. The classical approach to homelessness–the so-called “linear method”–is to address these concurrent issues–such as substance abuse and mental health problems–first, before offering permanent housing or as a condition of accessing permanent housing.

In the early 2000s, Pathways to Housing in New York City began to implement a new “Housing First” approach. The basic idea is simple–that homelessness is, at its core, a housing issue and can be most effectively addressed by offering permanent, safe, and affordable housing (HUD Exchange, n.d., p. 1). Supportive services, including treatment for substance use and mental health disorders, are offered alongside permanent housing but are not forced upon participants and are not a condition of housing (HUD Exchange, n.d., p. 1).

Giving participants the choice to participate in supportive services underscores HF’s tenant that “people experiencing homelessness have the right to self-determination and should be treated with dignity and respect” (HUD Exchange, n.d., p. 1). Housing First policy emphasizes the (evidence-based) belief that “exercising that choice is likely to make a client more successful in remaining housed and improving their life” (National Alliance to End Homelessness, 2022).

Housing First programs employ two main models: Permanent Supportive Housing (PSH) and Rapid Re-Housing. PSH targets individuals and families dealing with mental health issues or substance use disorders who have experienced repeated or long-term homelessness (NAEH, 2022). Rapid Re-Housing, in comparison, offers short-term rental assistance and services, aiming to help people obtain housing quickly (NAEH, 2022).

Evidence for Housing First

Since its inception, Housing First has earned a strong evidence base. PSH has shown a one-year housing retention rate of up to 98% (NAEH, 2022). Rapid Re-Housing has been shown to rehouse people in an average of two months, with studies showing that 75-91% of households remain housed within a year (NAEH, 2022). Studies show that PSH increased clients’ “perceived levels of autonomy, choice, and control” (NAEH, 2022).

The core of the Housing First Evidence base consists of four Randomized Control Trials (RCTs), often referred to as the “gold standard” in social science research, which compare Housing First programs to Treatment First programs. One of these RCTs is the At Home/Chez Soi Project in Canada. The project brief explains that Housing First is incredibly effective at keeping people housed, citing that “in the last six months of the study, 62% of HF participants were housed all of the time” compared to only 31% of treatment-as-usual (TAU) participants (Mental Health Commission of Canada, 2014, p. 17). Additionally, 61% of Housing First participants reported a “positive life course” since the beginning of the study, in contrast to only 28% of TAU participants (MHCC, 2014, p. 8). 

Systematic reviews of the literature support these results. One review found that “compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%” (Peng et al., 2020, p. 405). The same review found that HF “showed health benefits and reduced health services use” (Peng et al., 2020, p. 405). 

HF has also been found to reduce costs. One systematic economic review of 20 studies found a benefit-to-cost ratio of 1.80:1 in the U.S. (Jacob et al., 2022, p. e188). 

HF’s effectiveness is reflected in its endorsement by United States government bodies. The United States Interagency Council on Homelessness (USICH) and the Department of Housing and Urban Development (HUD) consider Housing First a “best practice” (NLHIC et al., 2023, p. 3). Most significantly, the Department of Veterans Affairs (VA) has implemented a Housing First approach in its HUD-Veterans Affairs Supportive Housing (HUD-VASH) program, which has seen great success in reducing veteran homelessness (NLHIC et al., 2023, p. 3).

Opposition to Housing First

Housing First has historically been widely embraced by both parties–until recently. Conservative politicians and think tanks like the Manhattan Institute have started to attack the merits of the policy. One Manhattan Institute brief argues that the policy does not address homelessness on a community level, lacks evidence that it is effective in addressing mental health and substance use issues, and does not do enough to address social isolation, which they cite as a main cause and effect of homelessness (Eide, 2020). Other conservative think tank briefs read similarly.

Even liberal-leaning sources admit that Housing First has its limitations. The New York Times points out that The National Academies of Sciences, Engineering, and Medicine found no significant evidence that PSH improved clients’ health or psychiatric problems (DeParle, 2023). Additionally, they say the program does not save money, with average costs in Los Angeles at $600,000 per unit (DeParle, 2023).

Despite this, you will be hard-pressed to find a source that denies Housing First’s ability to vastly improve residential stability for those it is able to reach. On this, the evidence speaks for itself. When considering Housing First at its word–that homelessness is first and foremost a housing crisis–these results start to look like it’s doing what the program aims to do. It is ending homelessness, whether that’s on an individual or community level.

The Manhattan Institute's brief brings up an important point–homelessness is both an individual and community issue. However, I question why the Institute does not suggest a strong effort toward preventing homelessness, given that we have strong research on risk factors (e.g., Shelton et al., 2015). Additionally, if we know how Housing First works, why not suggest ways to tweak the approach to address social isolation?

Conclusion & Recommendations

It is critical to recognize that although there are limitations to the Housing First model, the evidence shows that it is the best we’ve done so far at addressing homelessness. We have yet to see what might happen if the full force of the federal government were behind the model. Indeed, the small-scale approach they took with the VA shows incredible promise. Thus, it’s critical to question why we are suddenly seeing a partisan divide on a model that used to have bipartisan support.

One piece of the puzzle may be that Housing First does not fit into many people’s perceptions of people experiencing homelessness. The stigma against the homeless has been meticulously documented (e.g., Canham et al., 2022), perpetuating the idea that people become homeless primarily because of their choices.

I argue that this attack on Housing First has become a part of right-wing politicians’ growing narrative about Democratic cities being “overrun” because of rising crime rates (Resnikoff, 2023). The stigma against homeless people has been weaponized by politicians on the right to play into this narrative. A 2023 article from the Nation describes the increase in hatred and violence toward unhoused people and how it is a direct effect of a strategic rhetorical campaign by the right (Resnikoff, 2023). It is crucial to point out that much of this rhetoric includes thinly veiled racial cues, playing into people’s implicit biases against people of color, who are perceived to be more dependent on social services.

In the end, if we buy into Housing First’s idea that homeless people are human beings who are deserving of respect, autonomy, and housing, then Housing First becomes the obvious choice. We need to choose to support a policy that is not only proven to be effective but one that is humane and offers people autonomy and dignity.

I strongly support the widespread implementation of Housing First in the United States. Housing First advocates should consider where they can improve its effectiveness, especially regarding improving health outcomes and community-level trends, and work out the inevitable kinks in the system. I particularly echo the recommendations given in Ned Resnikoff’s The Nation article: advocates need to get on the offensive to combat conservative rhetoric, acknowledge the concerns of those living in areas with high rates of homelessness, and address the reasons why Housing First has not decreased homelessness on a community level (Resnikoff, 2023). In the end, although it is an imperfect policy, as all are, it is the closest we have come to ending homelessness. Most importantly, it gives human beings the dignity they deserve.

References

Canham, S. L., Rose, J. N., Weldrick, R., Siantz, E., Casucci, T., & McFarland, M. M. (2022, December 15). Understanding discrimination towards persons experiencing homelessness: A scoping review protocol. BMJ Open, 12. 10.1136

DeParle, J. (2023, June 20). Federal Policy on Homelessness Becomes New Target of the Right. The New York Times. https://www.nytimes.com/2023/06/20/us/politics/federal-policy-on-homelessness-becomes-new-target-of-the-right.html

Eide, S. (2020, April 21). Housing First Is Not the Key to End Homelessness. Manhattan Institute. Retrieved September 20, 2023, from https://manhattan.institute/article/housing-first-and-homelessness-the-rhetoric-and-the-reality

HUD Exchange. (n.d.). CoC and ESG Homeless Eligibility - Definition of Chronic Homelessness. HUD Exchange. Retrieved September 21, 2023, from https://www.hudexchange.info/homelessness-assistance/coc-esg-virtual-binders/coc-esg-homeless-eligibility/definition-of-chronic-homelessness/

HUD Exchange. (n.d.). Housing First in Permanent Supportive Housing Brief. HUD Exchange. Retrieved September 19, 2023, from https://files.hudexchange.info/resources/documents/Housing-First-Permanent-Supportive-Housing-Brief.pdf

Jacob, V., Chattopadhyay, S. K., Attipoe-Dorcoo, S., Peng, Y., Hahn, R. A., Finnie, R., Cobb, J., Cuellar, A. E., Emmons, K. M., Remington, P. L., & Community Preventive Services Task Force. (2022, March). Permanent Supportive Housing With Housing First: Findings From a Community Guide Systematic Economic Review. American Journal of Preventive Medicine, 62(3), e188-e201. https://www.thecommunityguide.org/media/pdf/he-ajpm-ecrev-housing-first.pdf 

Mental Health Commission of Canada. (2014). National Final Report. Mental Health Commission of Canada. Retrieved September 19, 2023, from https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/mhcc_at_home_report_national_cross-site_eng_2_0.pdf

National Alliance to End Homelessness. (2022, March 20). Housing First. National Alliance to End Homelessness. Retrieved September 19, 2023, from https://endhomelessness.org/resource/housing-first/

National Alliance to End Homelessness. (2023). State of Homelessness: 2023 Edition. National Alliance to End Homelessness. Retrieved September 16, 2023, from https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness/

National Health Care for the Homeless Council. (2019, February). Homelessness & Health: What's the Connection? National Health Care for the Homeless Council. Retrieved September 16, 2023, from https://nhchc.org/wp-content/uploads/2019/08/homelessness-and-health.pdf

National Low Income Housing Coalition, National Alliance to End Homelessness, & CWS. (2023, February 13). Research on Housing First. National Low Income Housing Coalition. Retrieved September 19, 2023, from https://nlihc.org/sites/default/files/Housing-First-Research.pdf 

Peng, Y., Hahn, R. A., Finnie, R. K. C., Cobb, J., Williams, S. P., Fielding, J. E., Johnson, R. L., Montgomery, A. E., Schwartz, A. F., Muntaner, C., Garrison, V. H., Jean-Francois, B., Truman, B. I., Fullilove, M. T., & Community Preventive Services Task Force. (2020, July 31). Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disabi. The Community Guide. Retrieved September 19, 2023, from https://www.thecommunityguide.org/media/pdf/he-jphmp-evrev-housing-first.pdf 

Resnikoff, N. (2023, August 24). Why the Right Is Winning Its War on Unhoused People. The Nation. https://www.thenation.com/article/society/unhoused-right-rhetoric-homelessness/ 

Shelton, K. H., Taylor, P. J., Bonner, A., & van den Bree, M. (2015, January 13). Risk Factors for Homelessness: Evidence From a Population-Based Study. Psychiatric Services, 60(4), 465-472. https://ps.psychiatryonline.org/doi/full/10.1176/ps.2009.60.4.465