Housing First
Voters across the United States should support a ‘housing first’ approach
to ending homelessness. Many American cities have already tested the housing
first model and found that it works very well. Therefore, housing first should
be expanded where it is already used on a small scale, and implemented where it
is not public policy.[1]
Despite the immediate costs and political resistance with building housing for chronically homeless people, the shift to putting homeless people in permanent, personalized shelter is justified on a range of grounds. Housing homeless people reduces the total public expense of housing, medical care, family services, and other welfare provided to such vulnerable people. Housing homeless people also increases their opportunities to live more productively, thereby generating before-unrealized personal and societal benefits. In addition to the additive public purse and utilitarian arguments, communities should change their approach to homelessness because a lack of housing is itself a human rights violation and it also contributes to the violation of other basic human rights.
I. Homelessness Today and the ‘Housing First’ Concept
There are estimated to be about 500,000 homeless Americans on any given night.[2] Of these, about 80,000 are thought to be chronically homeless.[3] This number is under-representative for two reasons. First, it does not capture the turnover among homeless people. It is estimated that about 2 million Americans experience homelessness during any given year.[4] Second, the census of homeless surely undercounts people. Homeless people are often good at sleeping in places where they are hard to find. Doing so ensures a complete night’s sleep. The Nathan Kline Institute for Psychiatric Research found that, in New York City, 1 in 3 homeless people go uncounted in the official census.[5]
Unsheltered homelessness is also a uniquely West American phenomenon. To be sure, there are unsheltered homeless people everywhere but, as anyone who visits San Francisco can tell you, homeless people in the street are much more prevalent on the West Coast. In California, Hawaii, Nevada, and Oregon more than 50% of homeless people are unsheltered.[6] Meanwhile, in New York, 5% of homeless people are unsheltered.[7]
However, sheltering homeless people takes various forms. For example, many cities take a ‘progressive approach’ to homeless: moving homeless people into a temporary shelter, then into transitional housing, and hopefully eventually into permanent housing. Alternatively, and the model advocated in the following paragraphs, cities can provide homeless people with permanent housing right away, called the housing first model. The major difference between the progressive approach and housing first is that housing first provides permanence and reliability for both the homeless person and those with whom they interact. In contrast, progressive models suffer from an inherently unstable structure whereby the homeless person may move to a different location if their circumstances, or those of the shelter, change.
Change undermines the chances for successful rehabilitation of chronically homeless people; they often suffer other challenges that lead to their homelessness. “Estimates suggest that at least 40% have substance use disorders, 25% have some form of physical disability or disabling health condition, and 20% have serious mental illnesses.”[8] These people require as much stability as possible, including a permanent physical location, where community support and social services can help them.
Housing first, as an alternative option for dealing with homelessness in America, is a relatively new development. It was first implemented in Los Angeles and New York City in the late-1980s and early-1990s in response to the combined threats of social welfare cuts and rising real estate markets. It has since grown in popularity, adopted to varying degrees by cities like Cleveland, New Orleans, and Minneapolis, supported by the Interagency Council on Homelessness,[9] and advocated by various NGOs.[10] Most important for present purposes, housing first has already proven to be effective despite its relatively recent appearance on the public policy scene. There is little need to debate about whether it should be adopted at all, but a critical need to raise awareness about its benefits in reducing chronic homelessness and thereby improving the lives of the chronically homeless, improving the communities in which they live, all while reducing their burden on welfare programs.
II. Evidence for Reduced Costs with a ‘Housing First’ Approach
Evidence showing that housing first programs reduce the cost of chronically homeless people on government welfare programs is overwhelming. A review of literature from 2011 said, “[a]ll studies reviewed for this study concluded the Housing First model saves money for communities where the program is implemented.”[11] That review looked at programs in Denver, Portland (Maine), and Massachusetts. Below are a few examples of how, and how much, costs are saved.
The Colorado Coalition for the Homeless provides housing for 2,500 homeless people in Denver.[12] They reported in 2006 that emergency room costs related to the chronically homeless that they housed reduced by 34%, inpatient hospital costs went down by 66%, detox visits reduced by 82%, and incarceration costs reduced by 76%.[13]
Researchers also assessed the impact of the housing first program in Seattle. The Robert Wood Johnson Foundation funded research showing that housing first initiatives targeted to chronically homeless alcoholics can save 50% of the health and social services costs relative to current models, including the cost of providing housing. This cost saving amounted to $2,500 per person per month.[14] This study is particularly important because it was a randomized control trial; the gold-standard of scientific process.
The cost savings of housing first programs have also been documented in Albuquerque[15] and Salt Lake City,[16] among many other cities. In fact, the demonstrated effectiveness of housing first programs led the Bush Administration, not known for its progressive social policies, to be the first administration to adopt housing first as official federal policy. Monetary support for housing first was expanded in the American Recovery and Reinvestment Act of 2009, with $1.5 billion earmarked for the Homeless Prevention Fund, and the policy has been retained as a recommended best practice by President Trump’s Interagency Council on Homelessness.
III. Evidence for Increased Benefits with a ‘Housing First’ Approach
The effectiveness of housing first programs is not limited to cost savings. A 2015 randomized controlled trial of housing first programs in five Canadian cities found that housing first participants “reported greater gains in quality of life, and demonstrated greater improvements in community functioning compared with participants in treatment as usual.”[17] Such benefits are unsurprising. The most basic insight is that people’s quality of life improves when they have housing versus when they do not have housing. Often about 75% of housing first recipients are still in their housing after 2 years, compared with only 25% of homeless people in other systems. But the benefits are more extensive than that simple change.
There are a range of ancillary benefits that contribute to an improved quality of life. Recipients of housing first accommodations are more likely to maintain their medication regime.[18] This result supports the inference from many studies documenting the reduced medical costs of housing first programs that health outcomes for participants are at least equivalent as they are for control groups.[19] Anecdotally, participants’ levels of trust increase.[20] Evidence that housing first programs lead to other benefits like reduction in substance abuse[21] or increased job placement are hard to find, supporting the notion that housing first programs should or must be coupled with other social support programs. It is likely that other support programs, such as substance abuse support, education and job training, and food vouchers are all more effective, if not just as effective, and less costly when paired with a housing first model then when homeless people are transitory.
IV. Ongoing Violations of Legal Rights if Systems Do Not Change
Finally, in addition to the public savings and social benefits of housing first programs, such systems also directly tackle an internationally recognized human right. “The States Parties to the present Covenant recognize the right of everyone to an adequate standard of living . . . including adequate food, clothing and housing.”[22] The United States signed the International Covenant on Economic, Social and Cultural Rights in 1977 and the Covenant has been recognized, by signature, ratification, accession, or succession, by 166 nations.
Moreover, “[a]ccess to adequate housing affects the enjoyment of a wide range of human rights. . . . The World Health Organization has stated that housing is the single most important environmental factor bearing upon the incidence of disease and the extent of life expectancy. Access to adequate housing also affects the right to work, in that the prospects of earning a living are severely reduced when a person is homeless . . . Where people are forcibly evicted from their homes, this may also have implications for the right to education. Forced evictions frequently result in children’s schooling being disrupted or stopped altogether. . . . Women and girls become particularly vulnerable to violence, including sexual violence, when deprived of any, or any safe, home. Furthermore, access to housing is a crucial element in the right to privacy. . . . Finally, inasmuch as people’s homes are often symbols of identities and traditions, housing affects rights to free expression and rights that protect the members of minority communities against cultural assimilation.”[23] The continued disrespect of this laundry list of basic rights of our fellow citizens, many of them military veterans, is unacceptable.
Housing first is a sound policy option to implement respect for our country’s most vulnerable citizens.
Despite the immediate costs and political resistance with building housing for chronically homeless people, the shift to putting homeless people in permanent, personalized shelter is justified on a range of grounds. Housing homeless people reduces the total public expense of housing, medical care, family services, and other welfare provided to such vulnerable people. Housing homeless people also increases their opportunities to live more productively, thereby generating before-unrealized personal and societal benefits. In addition to the additive public purse and utilitarian arguments, communities should change their approach to homelessness because a lack of housing is itself a human rights violation and it also contributes to the violation of other basic human rights.
I. Homelessness Today and the ‘Housing First’ Concept
There are estimated to be about 500,000 homeless Americans on any given night.[2] Of these, about 80,000 are thought to be chronically homeless.[3] This number is under-representative for two reasons. First, it does not capture the turnover among homeless people. It is estimated that about 2 million Americans experience homelessness during any given year.[4] Second, the census of homeless surely undercounts people. Homeless people are often good at sleeping in places where they are hard to find. Doing so ensures a complete night’s sleep. The Nathan Kline Institute for Psychiatric Research found that, in New York City, 1 in 3 homeless people go uncounted in the official census.[5]
Unsheltered homelessness is also a uniquely West American phenomenon. To be sure, there are unsheltered homeless people everywhere but, as anyone who visits San Francisco can tell you, homeless people in the street are much more prevalent on the West Coast. In California, Hawaii, Nevada, and Oregon more than 50% of homeless people are unsheltered.[6] Meanwhile, in New York, 5% of homeless people are unsheltered.[7]
However, sheltering homeless people takes various forms. For example, many cities take a ‘progressive approach’ to homeless: moving homeless people into a temporary shelter, then into transitional housing, and hopefully eventually into permanent housing. Alternatively, and the model advocated in the following paragraphs, cities can provide homeless people with permanent housing right away, called the housing first model. The major difference between the progressive approach and housing first is that housing first provides permanence and reliability for both the homeless person and those with whom they interact. In contrast, progressive models suffer from an inherently unstable structure whereby the homeless person may move to a different location if their circumstances, or those of the shelter, change.
Change undermines the chances for successful rehabilitation of chronically homeless people; they often suffer other challenges that lead to their homelessness. “Estimates suggest that at least 40% have substance use disorders, 25% have some form of physical disability or disabling health condition, and 20% have serious mental illnesses.”[8] These people require as much stability as possible, including a permanent physical location, where community support and social services can help them.
Housing first, as an alternative option for dealing with homelessness in America, is a relatively new development. It was first implemented in Los Angeles and New York City in the late-1980s and early-1990s in response to the combined threats of social welfare cuts and rising real estate markets. It has since grown in popularity, adopted to varying degrees by cities like Cleveland, New Orleans, and Minneapolis, supported by the Interagency Council on Homelessness,[9] and advocated by various NGOs.[10] Most important for present purposes, housing first has already proven to be effective despite its relatively recent appearance on the public policy scene. There is little need to debate about whether it should be adopted at all, but a critical need to raise awareness about its benefits in reducing chronic homelessness and thereby improving the lives of the chronically homeless, improving the communities in which they live, all while reducing their burden on welfare programs.
II. Evidence for Reduced Costs with a ‘Housing First’ Approach
Evidence showing that housing first programs reduce the cost of chronically homeless people on government welfare programs is overwhelming. A review of literature from 2011 said, “[a]ll studies reviewed for this study concluded the Housing First model saves money for communities where the program is implemented.”[11] That review looked at programs in Denver, Portland (Maine), and Massachusetts. Below are a few examples of how, and how much, costs are saved.
The Colorado Coalition for the Homeless provides housing for 2,500 homeless people in Denver.[12] They reported in 2006 that emergency room costs related to the chronically homeless that they housed reduced by 34%, inpatient hospital costs went down by 66%, detox visits reduced by 82%, and incarceration costs reduced by 76%.[13]
Researchers also assessed the impact of the housing first program in Seattle. The Robert Wood Johnson Foundation funded research showing that housing first initiatives targeted to chronically homeless alcoholics can save 50% of the health and social services costs relative to current models, including the cost of providing housing. This cost saving amounted to $2,500 per person per month.[14] This study is particularly important because it was a randomized control trial; the gold-standard of scientific process.
The cost savings of housing first programs have also been documented in Albuquerque[15] and Salt Lake City,[16] among many other cities. In fact, the demonstrated effectiveness of housing first programs led the Bush Administration, not known for its progressive social policies, to be the first administration to adopt housing first as official federal policy. Monetary support for housing first was expanded in the American Recovery and Reinvestment Act of 2009, with $1.5 billion earmarked for the Homeless Prevention Fund, and the policy has been retained as a recommended best practice by President Trump’s Interagency Council on Homelessness.
III. Evidence for Increased Benefits with a ‘Housing First’ Approach
The effectiveness of housing first programs is not limited to cost savings. A 2015 randomized controlled trial of housing first programs in five Canadian cities found that housing first participants “reported greater gains in quality of life, and demonstrated greater improvements in community functioning compared with participants in treatment as usual.”[17] Such benefits are unsurprising. The most basic insight is that people’s quality of life improves when they have housing versus when they do not have housing. Often about 75% of housing first recipients are still in their housing after 2 years, compared with only 25% of homeless people in other systems. But the benefits are more extensive than that simple change.
There are a range of ancillary benefits that contribute to an improved quality of life. Recipients of housing first accommodations are more likely to maintain their medication regime.[18] This result supports the inference from many studies documenting the reduced medical costs of housing first programs that health outcomes for participants are at least equivalent as they are for control groups.[19] Anecdotally, participants’ levels of trust increase.[20] Evidence that housing first programs lead to other benefits like reduction in substance abuse[21] or increased job placement are hard to find, supporting the notion that housing first programs should or must be coupled with other social support programs. It is likely that other support programs, such as substance abuse support, education and job training, and food vouchers are all more effective, if not just as effective, and less costly when paired with a housing first model then when homeless people are transitory.
IV. Ongoing Violations of Legal Rights if Systems Do Not Change
Finally, in addition to the public savings and social benefits of housing first programs, such systems also directly tackle an internationally recognized human right. “The States Parties to the present Covenant recognize the right of everyone to an adequate standard of living . . . including adequate food, clothing and housing.”[22] The United States signed the International Covenant on Economic, Social and Cultural Rights in 1977 and the Covenant has been recognized, by signature, ratification, accession, or succession, by 166 nations.
Moreover, “[a]ccess to adequate housing affects the enjoyment of a wide range of human rights. . . . The World Health Organization has stated that housing is the single most important environmental factor bearing upon the incidence of disease and the extent of life expectancy. Access to adequate housing also affects the right to work, in that the prospects of earning a living are severely reduced when a person is homeless . . . Where people are forcibly evicted from their homes, this may also have implications for the right to education. Forced evictions frequently result in children’s schooling being disrupted or stopped altogether. . . . Women and girls become particularly vulnerable to violence, including sexual violence, when deprived of any, or any safe, home. Furthermore, access to housing is a crucial element in the right to privacy. . . . Finally, inasmuch as people’s homes are often symbols of identities and traditions, housing affects rights to free expression and rights that protect the members of minority communities against cultural assimilation.”[23] The continued disrespect of this laundry list of basic rights of our fellow citizens, many of them military veterans, is unacceptable.
Housing first is a sound policy option to implement respect for our country’s most vulnerable citizens.
[1]
Some researchers have criticized housing first programs as (1) diverting
resources from other welfare programs and (2) being too narrowly focused. See, e.g., Seema L. Clifasefi, Housing First, But What Comes Second? A
Qualitative Study of Resident, Staff and Management Perspectives on Single-Site
Housing First Program Enhancement, 44(7) J. of Community Psychology 845
(Sept. 2016). A few responses are in order. First, to the extent that funds are
diverted, dollar for dollar, from one program to a more effective program
(effectiveness measured by specific outcomes in narrowly defined goals), then
diversion is not a problem. Second, the demonstrated reduction in costs across
a range of outcomes from housing first programs means that advocates have
strong empirical arguments that equivalent welfare spending across the body of
programs, even though spending in one program may now be lower, leads to better
overall outcomes. Third, and relatedly, it is clear that implementing housing
first programs in addition to other welfare is better than it contributing to
welfare diversion. However, local and state governments face strict budgetary
tradeoffs that limit welfare spending. Lamenting the fiscal starvation of an
alternative social program does not, in itself, undermine the diversion of
those funds to another social program.
[2]
Alastair Gee et al., How America counts
its homeless – and why so many are overlooked, The Guardian (Feb. 16,
2017).
[3] U.S. Dep’t of Housing and Urban Dev., The
2016 Annual Homeless Assessment Report (AHAR) to Congress 4 (Nov. 2016).
[4]
Gee, supra note 1.
[5]
Id.
[6]
Id.
[7]
Id.
[8]
Paul Guerin, City of Albuquerque Housing
First Cost Study Final Report 2, Institute for Social Research prepared for The City of Albuquerque
Office of the Mayer (May 2011)
[9] An
executive branch agency dedicated to homelessness solutions.
[10] E.g., https://endhomelessness.org/resource/housing-first/
[11]
Guerin, supra note 7, at 2.
[12] https://www.coloradocoalition.org/
[13]
Jennifer Perlman & John Parvensky, Cost
Benefit Analysis & Program Outcomes Report, Colorado Coalition for the
Homeless (Dec. 11, 2006).
[14]
Mary Larimer et al., Health Care and
Public Service Use and Costs Before and After Provision of Housing for
Chronically Homeless Persons With Severe Alcohol Problems (Apr. 1, 2009)
[results found in the abstract].
[15]
Guerin, supra note 7, at 17.
[16]
Lloyd Pendleton, Homeless Advocate, The Housing First approach to homelessness,
Speech at TEDMED 2016 (Nov. 2016).
[17]
Tim Aubry et al., One-Year Outcomes of a
Randomized Controlled Trial of Housing First With ACT in Five Canadian Cities,
66(5) American Psychiatric Association Publishing 463 (Feb. 2, 2015).
[18]
Stefanie N. Rezansoff, Housing First
Improves Adherence to Antipsychotic Medication Among Formerly Homeless Adults
with Schizophrenia: Results of a Randomized Controlled Trial, 43(4)
Schizophr. Bull. 852 (Sept. 24, 2016).
[19]
Ann E. Montgomery, Housing Chronically
Homeless Veterans: Evaluating the Efficacy of a Housing First Approach to
HUD-VASH, 41(4) J. of Community Psychology 505 (2013).
[20] Lloyd
Pendleton, Homeless Advocate, The Housing First approach to homelessness,
Speech at TEDMED 2016 (Nov. 2016).
[21]
Sam Tsemberis et al., Housing First,
Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual
Diagnosis, 94(4) Am. J. Public Health 651 (Apr. 2004).
[22]
Article 11(1), International Covenant on Economic, Social and Cultural Rights.
[23]
Susan Marks & Andrew Clapham, International
Human Rights Lexicon 210–11 (Oxford Univ. Press, 2005).
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