Is it Time to Bulldoze Housing First? An Analysis of the Effectiveness of Housing First and its Alternatives

By: Zoe Hickey

I. EXECUTIVE SUMMARY

Homelessness rates have steadily increased since 2007. Since homelessness is often intertwined with substance abuse, addressing this issue is becoming increasingly complex. In light of the relationship between substance abuse and homelessness, two significant policy options have gained traction, Housing First and Treatment First. While Treatment First is great in theory, it fails to acknowledge a key issue, individuals with substance abuse issues often do not want help, so using housing as an incentive is ineffective. In contrast, psychologists developed the Housing First strategy to encompass a more comprehensive approach to addressing the issue. By having their basic needs met first, individuals are able to seek the help they need. While Housing First is more economically efficient and yields better results than Treatment First, there is still room for improvement. Increased group case management could boost permanent placement rates and overcome the isolation that Housing First allows. The economic efficiency could be increased by analyzing the overlap of the provision of services by partners receiving funding in close proximity. As the governing body on the issue, the HUD has an empirical and moral duty to aid homeless individuals in obtaining permanent housing.

II. HOMELESSNESS IN THE UNITED STATES

The Universal Declaration of Human Rights (UDHR) states that all individuals have the right to live in dignity. Yet this right is violated again and again, here, in the United States. Individuals experiencing homelessness are the epitome of this violation. Lack of access to food, safe drinking water and sanitation facilities plague the lives of the unhoused. An individual or family is considered homeless if they lack a fixed, regular, and adequate nighttime residence; this includes those living in emergency shelters, transitional housing, or places not meant for habitation (Substance Abuse and Mental Health Administration). In 2020, there were about 580,466 homeless people living in the United States (Statista). The number of people experiencing homelessness had been decreasing since 2007, however, it started to increase again in 2018. For context, ~580,000 equates to roughly 0.1% of the population of the United States. This increasingly pressing issue requires swift and immediate action.

In no case is the situation more pressing, than for those who experience chronic homelessness. According to the Department of Housing and Urban Development, a chronically homeless individual has lived in a shelter, safe haven, or place not meant for human habitation for 12 continuous months or for 4 separate occasions in the last three years (must total 12 months). It is important to keep in mind that the homeless experience is not homogenous as experiences vary in length, amount of street exposure, and more. Given the variety of homeless experiences, the implementation of policies that effectively aid our society’s most vulnerable is a complex task. Drug use and how to address drug abuse problems have become the center of debate on the issue of policy regarding homelessness. This focus is placed with good reason as alcohol abuse affects 30% to 40% and drug abuse 10% to 15% of homeless persons (McCarty). Currently, the two main theories about how to approach the issue of homelessness given the prevalence of drug abuse are Housing First and Treatment First. This policy brief will explore the merits and effectiveness of both theories with the goal of discerning whether the HUD should modify its existing stance, Housing First.

III. OVERVIEW OF PAST POLICY ACTIONS

In 1983, the McKinney-Vento Homeless Assistance Act established the U.S. The Interagency Council on Homelessness (USICH). The same act also introduced the Emergency Shelter Grants Program and the HUD’s Homeless Assistance Grants (Rufo). As the issue of homelessness worsened, policymakers introduced more measures in the years that followed. In the 1990s, the HUD introduced the Continuum of Care (CoC) Program which is currently the primary method of distribution of federal funds to homelessness programs. In 2007, the Bush Administration introduced the Housing First policy. Housing First has been the preferred policy by the HUD and CoC organizations since. This shift in methodology saw the number of Housing First beds increase from 189,00 to 361,000 and the number of transitional housing beds fall from 211,000 to 101,000 between 2007 and 2008 (Rufo). This shift signifies that currently, a higher percentage of bed spaces are open to all homeless individuals regardless of housing/drug abuse status than ever before.

Figure 1

McCarty, Maggie. “HUD Regular (Non-Emergency) Net Budget Authority, FY2002-FY2019 In Nominal and Real (2019) Dollars.” Department of Housing and Urban Development (HUD): Funding Trends Since FY2002, Every CRS Report, 2019, www.everycrsreport.com/reports/R42542.html#_Ref445979449.

As seen in figure 1, the HUD’s spending has been everything but constant since its inception. The steady decrease in the rates of homelessness between the 1980s and 2007 aligns with a steady increase in funding between those dates. Around the 2008 financial crisis, the HUD’s spending decreased significantly thus hampering its ability to implement its policies effectively. For this and other reasons such as population growth, rising socio-economic inequality, the financial crisis, and the COVID-19 pandemic, we cannot attribute the increase in rates of homelessness since 2007 to the introduction of Housing First. However, it is still fair to wonder, would Treatment First have yielded better outcomes?

IV. HOUSING FIRST VS. TREATMENT FIRST

Sam Tsemeris, a clinical psychologist, originally developed Housing First as a mental health program in the 1990s. The main pillar of Housing First is the provision of immediate access to housing regardless of employment or sobriety status (Massachusetts Housing and Shelter Alliance). The model relies on the idea that before homeless individuals can work on detoxification or find a job, they need to have their basic needs met. The idea is that creating such supportive environments will allow individuals to address their drug/ employment issues as they don’t have to worry about where they will be sleeping, whether they will have a police encounter, or where their next meal will come from. The model also relies on the heavy provision of drug addiction help and employment counseling. Every individual residing in Housing First facilities has an assigned case manager whose aim is to direct the individual to the necessary resources to achieve sobriety, if applicable, and permanent housing. Another of the main pillars of Housing First is a personal choice. Individuals entering the system have a say on the location and setting of their stay. This is very important as it may facilitate recovery by providing access to housing near the industry of their choice or access to harm reduction environments in the case of drug abuse.

As the name implies, the Treatment First approach prioritizes the provision of addiction treatment prior to any housing. Under this model, individuals need to be sober in order to be housed or enter the program in the first place. Certain variations of the model also have additional requirements such as employment status or proof of job search. This model is referred to as “linear” by its proponents as it relies on a guided progression through recovery programs, building human capacity, and treating addiction and mental illness (Rufo). This program was the prevailing policy supported by the HUD during the 1980s and 1990s, prior to the creation of the Housing First Model.

V. ECONOMIC EFFECTIVENESS

One of the most contested areas of Housing First is its cost. As housing/ service provision requirements are less stringent than with Treatment First, naturally stakeholders assume that Housing First comes with a heftier price tag; nonetheless, this is not the case. It is true that there are increased costs to the taxpayer associated with the provision of housing and counseling resources. However, the decrease in cost associated with police encounters, jail time, and healthcare greatly offset the increase in cost for the provision of housing and counseling resources. While chronically homeless people represent only 20% of shelter users, they consume the largest share of health, social, and justice services. A study on 5000 homeless individuals with serious mental illness/ drug abuse status in New York City found that the overall cost of service per person decreased significantly under Housing First. This study showed how Housing First is highly economically effective when dealing with high-cost users (Ly, Latimer). Based on this analysis, Housing First would be the appropriate policy from a monetary perspective for locations that have a high percentage of high-cost users, translating to users with serious mental illnesses and drug abuse problems.

A University of Colorado study focused particularly on the effects of Housing First and police interactions. The study found people referred to supportive housing experienced fewer police contacts and arrests than those who were offered Treatment First housing. In fact, the group that was referred to supportive housing spent 38 fewer days in hail than those who received different care (Urban Institute). 38 days of jail time per homeless person adds up to be a sizable expense for taxpayers. Not only is jail not aiding in rehabilitation but it is quite expensive. Based on this study, from a monetary perspective, Housing First seems like a prudent policy response given the significant decrease in jail/ police expenses.

Figure 2

Regueiro. Massachusetts Housing and Shelter Alliance, 2017, Permanent Supportive Housing: A Solution-Driven Model, archives.lib.state.ma.us/bitstream/handle/2452/782511/ocn887735103–2017.pdf?sequence=1&isAllowed=y.

On the medical front, a study conducted by the Massachusetts Housing and Shelter Alliance found a significant decline in public service usage among previously high-cost utilizers within the first months that individuals were offered supporting housing such as Housing First. The magnitude of these savings is illustrated in Figure 2. Furthermore, the total emergency-related costs for the aforementioned group decreased from $599,356 to $222,189, a 72.95% decrease. The total savings equate to $31,545 per participant (Perlman, Parvensky).

While the decreases in overall cost and cost associated with police encounters, jail, and healthcare are significant, it is also important to note that the studies referenced were conducted primarily using high-cost subjects, not an average representation of the homeless population. For this reason, we can only conclude that these findings regarding cost hold under the cases of cities with a high proportion of high-cost users, meaning individuals with serious mental illness and/or drug abuse issues.

VI. PERMANENT HOUSING PLACEMENT EFFECTIVENESS

A study conducted by Pathways to Housing found that Housing First has a housing retention rate of 80%-90%, this means that 80–90% of homeless individuals who receive help under Housing First are eventually placed in and able to independently maintain permanent housing. This 80%-90% success rate is a big step up from other housing alternatives which have a success rate of ~27%. However, roughly 2 years after placement, 38% out of the 80%-90% that succeeded in being able to independently maintain permanent housing, found themselves back in community housing (Tsemberis). This brings the overall success rate of the program down to 50–56% in the long term. The main issue with this approach is the lack of retention the 2 years following the intervention. This lack in retention has been attributed to issues including relapsing drug usage, lack of a support network, and more. While Housing First isn’t 100% effective, it definitely is more effective in housing placement than available alternatives, mainly Housing First.

While Housing First’s effectiveness in placing individuals in permanent housing is quite impressive, we must remember that Housing First only applies to Chronically Homeless Individuals who makeup roughly ~27% of the homeless population according to the Manhattan Institute. So these placements represent a fairly small share of the homeless population. The risk of this is that if too much funding is allocated to Housing First in proportion to transitional housing, we might see increases in rates of homelessness and specifically the number of people who become chronically homeless as there would be less help available for those who have been homeless for less than 12 months.

Researchers at the University of Alabama at Birmingham have studied Treatment First Programs extensively and coined the “Birmingham Model.” This model provides homeless individuals with abstinence contingent housing. Six months after interventions. 64% of subjects maintained sobriety. At the end of the study, the researchers concluded that the Birmingham Model, Treatment First, could contribute to the long-term housing of roughly 40% of homeless individuals (Heritage Foundation). The success rate of Treatment First is quite similar to that of Housing First which preliminarily indicates that both programs are equally effective in placing individuals in permanent housing. However, it is key to consider that not all individuals struggling with drug addiction want to get clean. Under Treatment First, that group of individuals is abandoned, and deemed beyond help. Additionally, that group of individuals would be less likely to enter a study that would require sobriety which potentially results in the overestimation of the success rate of Treatment First. Therefore…

The differences in drug abuse between those provided Housing First and Treatment First was found to not be statistically significant by the Urban Institute study. Unlike Housing First, Treatment First completely neglects the individuals who are the most vulnerable thus it truly does not provide a self-sustaining path to ending homelessness. Treatment First simply gives some chronically homeless individuals a way out with an equal likelihood of success as Housing First, which is open to all chronically homeless individuals. We may conclude that Housing First is more effective than Treatment First in the placement of permanent housing with no significant difference in rates of sobriety post-treatment.

VII. POLICY RECOMMENDATIONS

Chronic homelessness is often intertwined with serious mental illness or substance abuse, hence making it a very complex issue to tackle. While in the case of chronic homelessness, Housing First is more efficient than Treatment First in an economic and housing placement scope, there is no disputing that Housing First, as is, has fallen short next to the needs of American society. For this reason, I suggest the following enhancements to Housing First in order to increase its effectiveness.

1. Increased group case management

One way to help participants in Housing First programs may be to supplement one-on-one case management with group case management. The groups work together on issues like getting housing vouchers, staying sober, and other steps to reintegration. The program helped combat social isolation among participants of a study at Yale University, according to Dr. Tsai, the head of the study. This approach may also help mitigate the issue of self-sustenance years post-intervention. The formation of this community will help individuals stay clean and employed even after they have been placed in permanent housing and thus have lost access to their case manager.

2. Priority community method: Evaluate the role of providers in each area

This entails the evaluation of the roles of service providers in each area. Houston reduced its homelessness by 55% in the last 20 years (Jensen). This substantial decrease is attributed to the work by the city to understand the role of providers in the area and subsequent restructuring of their operations. Thibaudeau-Graczyk, who studied homelessness in Houston stated “Each provider acted as a jack-of-all-trades, undercutting efforts to reduce homelessness. We had financially overextended because we were trying to do all these things: employment program, food program, housing.” This strategy primarily refers to finding the overlap in service provision so that service providers in the city can cut redundancies and allocate resources more efficiently to have a greater impact. The HUD should allocate funding so that all cities can obtain this level of information about their services. While it is an expense in the short run, it will cut costs in the long run.

3. Implementation of a co-responder program:

A co-responder program consists of clinicians working closely with the police department to respond to calls that involve people suffering from mental health or drug abuse challenges. These calls more often than not involve those who are homeless. Denver piloted this program and saw significant cost savings from diverting high-cost users of services such as hospitalization, emergency medical services transport, and jail (Urban Institute). To implement this, the HUD has the power to advocate with elected officials and encourage cities to follow in the footsteps of Denver at the city level.

VIII. REFERENCES

“Chronic Homelessness.” HUD Exchange, US Department of Housing and Urban Development, www.hudexchange.info/homelessness-assistance/resources-for-chronic-homelessness/.

Cunningham, Mary, et al. 2021, Breaking the Homelessness-Jail Cycle with Housing First. https://www.urban.org/sites/default/files/publication/104501/breaking-the-homelessness-jail-cycle-with-housing-first_1.pdf

“Definitions of Homelessness.” SOAR Works!, soarworks.samhsa.gov/article/definitions-homelessness.

Eide, Stephen. Housing First and Homelessness: The Rhetoric and the Reality. The Manhattan Institute, Apr. 2020, media4.manhattan-institute.org/sites/default/files/housing-first-and-homelessness-SE.pdf.

“Homeless People in the U.S. 2007–2021.” Statista, 28 Mar. 2022, www.statista.com/statistics/555795/estimated-number-of-homeless-people-in-the-us/#:~:text=Estimated%20number%20of%20homeless%20people%20in%20the%20U.S.%202007%2D2020&text=In%202020%2C%20there%20were%20about,it%20has%20started%20to%20increase.

McCarthy, Dennis. “Apa PsycNet.” Alcoholism, Drug Abuse, and the Homeless., American Psychological Association, 1991, psycnet.apa.org/record/1992–09475–001.

McCarty, Maggie. “HUD Regular (Non-Emergency) Net Budget Authority, FY2002-FY2019 In Nominal and Real (2019) Dollars.” Department of Housing and Urban Development (HUD): Funding Trends Since FY2002, Every CRS Report, 2019, www.everycrsreport.com/reports/R42542.html#_Ref445979449.

Ly, Angela, and Eric Latimer. “Housing First Impact on Costs and Associated Cost Offsets: A Review of the Literature.” Canadian journal of psychiatry. Revue canadienne de psychiatrie vol. 60,11 (2015): 475–87. doi:10.1177/070674371506001103

Regueiro. Massachusetts Housing and Shelter Alliance, 2017, Permanent Supportive Housing: A Solution-Driven Model, archives.lib.state.ma.us/bitstream/handle/2452/782511/ocn887735103–2017.pdf?sequence=1&isAllowed=y.

Rufo, Christopher F. The “Housing First” Approach Has Failed: Time to Reform Federal Policy and Make It Work for Homeless Americans. The Heritage Foundation, 4 Aug. 2020, www.heritage.org/sites/default/files/2018-12/IB4930.pdf.

Rufo, Christopher. The “Housing First” Approach has Failed: Time to Reform Federal Policy and make it Work for Homeless Americans. The Heritage Foundation, 2020. ProQuest, http://libproxy.usc.edu/login?url=https://www.proquest.com/reports/housing-first-approach-has-failed-time-reform/docview/2468068076/se-2?accountid=14749.

“The State of Homelessness in America.” National Alliance to End Homelessness, 27 June 2019, endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-report-legacy/#:~:text=There%20are%20an%20estimated%20553%2C742,people%20in%20the%20general%20population.

Tsemberis, Sam J et al. “Consumer preference programs for individuals who are homeless and have psychiatric disabilities: a drop-in center and a supported housing program.” American journal of community psychology vol. 32,3–4 (2003), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448313/pdf/0940651.pdf

“Yale Study Examines People in Housing with Substance Use Disorders.” Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2020, www.samhsa.gov/homelessness-programs-resources/hpr-resources/yale-study-examines-people-housing