When the Trump administration announced plans last month to redistribute billions of dollars in homelessness aid, the move capped a conservative attack on the once-bipartisan philosophy that has guided federal work for a generation, an approach called Housing First.
The administration called the policy a permissive approach that had let homelessness rise, while supporters said Housing First was backed by proven science.
Housing First provides chronically homeless people long-term subsidized housing and offers, but does not require, treatment for mental illness or addiction. It contrasts with programs that condition help on sobriety or work, which Trump officials want to encourage, though there is less direct research to suggest their efficacy.
Few aid policies have been studied as extensively as Housing First, and supporters’ faith that it is “evidence based” lends the debate special intensity.
Extensive research shows that Housing First places large shares of its clients in housing. It also appears to have played a major role in cutting homelessness among veterans, which has fallen by more than half.
“The primary goal of Housing First is to get people out of homelessness, and that’s what it does,” said Dennis P. Culhane, a professor at the University of Pennsylvania.
At the same time, Housing First programs have not consistently improved clients’ mental or physical health, as the success in finding housing would predict. And while Housing First is sometimes called lifesaving, the evidence does not clearly show it lowers mortality rates.
“The phrase I often hear is ‘evidence based’ or ‘we know what works,’” said Judge Glock of the conservative Manhattan Institute. “But we don’t know what works. There’s a lot of debate — not just about what the evidence shows but what counts as success.”
In seeking new rules to guide $3.9 billion in grants, the administration would sharply limit Housing First and promote treatment-focused alternatives. Two federal lawsuits seek to halt the change, and a judge in December temporarily blocked it.
Here is what the evidence says about Housing First:
Does Housing First help the homeless find housing?
Yes, at least for a year or two, the period most studies cover.
The Lancet, analyzing 15 studies, found that Housing First, often called permanent supportive housing, “significantly improved housing stability.” Another journal, examining 26 studies, found that Housing First programs “more effectively reduce homelessness” than alternatives did.
In Santa Clara County, California, 86% of people randomly placed in Housing First secured housing, versus 36% of those in “usual care,” meaning whatever mix of services a locality provides.
Such results are significant because they show that even people with untreated addiction or mental illness can be housed, especially with attentive casework. That contrasts with efforts to make people “housing ready” by treating their afflictions, at the risk of leaving homeless those who cannot or will not comply.
Still, many studies follow people for only a year or two, and the Housing First advantage may narrow over time, as a six-year study in Toronto found. A small Boston study examined outcomes more than a decade after clients were housed. The initial housing rate fell to 12% from 82%.
Even clients who stay housed often need significant support amid physical and mental health problems. In Santa Clara, the average tenant moved twice in a little more than two years.
“I question how much housing retention tells us about how people are doing,” said Stephen Eide of the Manhattan Institute.
Does Housing First improve mental or physical health?
There is little consistent evidence to show it.
The National Academies of Sciences, Medicine and Engineering found “no substantial evidence” that permanent supportive housing “improved health outcomes, notwithstanding the intuitive logic that it should.” The Lancet found “no measurable effect” on the severity of psychiatric issues or substance abuse.
Another academic survey concluded that permanent supportive housing produced “no additional health benefit” over other programs, a result researchers called “puzzling” since housing predicted better health.
Under federal definition, the chronically homeless, which most Housing First programs target, are people with physical or mental disabilities.
While some evidence of health benefits does exist — a program in Denver reduced the use of detoxification services by 65% — few clear patterns have emerged.
Housing First does seem to benefit the health of people with HIV, perhaps because housing stability makes it easier to manage medication.
Perhaps housing lacks consistent health benefits because people get it too late, after they have grown very sick. With aid in short supply, many wait years for help.
“You have to catch people earlier, and to do that you have to create more housing,” said Dr. Margot Kushel, the director of the Benioff Homelessness and Housing Initiative at the University of California, San Francisco.
But critics see a need for treatment mandates.
“A core claim of Housing First is that it provides a platform upon which people can address their issues,” said Devon Kurtz of the conservative Cicero Institute. “Instead, we’ve seen a lack of services and a lack of pressure for clients to engage in those services.”
Does Housing First save lives?
Most researchers have not found that the policy lowers death rates.
A study of a five-city Canadian program, Chez Soi, found “no statistically significant differences in mortality risk” between people in Housing First and those placed randomly in other programs.
In Santa Clara, evaluators found no statistical differences in four-year death rates among people in Housing First and those in usual care. Mortality in both groups was high (19% for Housing First). But researchers said the non-Housing First group was harder to track so the study might have undercounted their deaths.
In Denver, 10% of Housing First participants died in three years, about the same as those in usual care. The Boston study followed Housing First clients for up to 14 years and found that 45% died, though the sample was small and had no control group.
“If the person in the program is just as likely to die, then what’s the case for Housing First?” Glock said.
Is the treatment-first approach the administration favors also evidence based?
No, treatment-first programs have not been studied as rigorously, and direct comparisons show that Housing First helps more people become housed.
“There’s nothing that shows that what they’re putting forward works,” Samantha Batko, a researcher at the Urban Institute, said of those who push treatment-first alternatives to Housing First.
But about 60% of federal homelessness aid goes to Housing First programs, which skeptics say is more than the evidence justifies.
“I support permanent supportive housing, but we need other approaches, too,” Eide said.
Is Housing First responsible for the large drop in veterans’ homelessness?
It appears to have played a major role. A Housing First program for homeless veterans provides so many vouchers that most avoid the long waits that plague others on the street.
The program, called HUD-VASH, combines vouchers from the Department of Housing and Urban Development and casework from the Department of Veterans Affairs. Since a large expansion 15 years ago, veterans’ homelessness has fallen by more than half, while homelessness overall has grown by nearly a quarter.
“Think of what we could achieve if we summoned the same political will to support other homeless people,” Culhane said.
Beyond generous funding, the veterans’ program also benefits from the VA’s unique geographic reach and casework expertise — advantages that could be hard to replicate for other homeless people.
Some analysts argue that veterans’ homelessness would have dropped anyway since the veteran population has declined (by about a quarter in a dozen years).
But William N. Evans, an economist at Notre Dame, notes an offsetting rise in the number of disabled veterans, who face the highest risk of homelessness. Analyzing the effects of HUD-VASH on hundreds of localities, he and three co-authors found that “veterans’ homelessness would have risen substantially” without the expanded aid.
If Housing First works, why has homelessness grown?
There is a difference between reducing homelessness for individuals and reducing it for communities. Housing First has failed to reduce community-level homelessness, opponents say, partly because it reaches people who would have escaped homelessness anyway.
Kevin Corinth, an economist at the American Enterprise Institute, estimates that it takes about 10 units of supportive housing to reduce the homeless population by a single person.
Those advocating alternatives to Housing First also warn that the cost of permanent housing — about $20,000 a year for rent and support services — prevents cheaper responses at larger scale. Glock argues that Housing First fueled the growth of encampments by leaving less money for alternatives, like designated sleeping sites with security and services.
Housing First supporters say homelessness has grown for one reason: Affordable housing has vanished. Rents have soared, wages have lagged and federal housing aid reaches fewer than 1 in 4 eligible households. Only a much larger Housing First program, they say, could overcome such headwinds.
Tying housing costs to homelessness rates, researchers have identified inflection points: When rents in a community exceed about a third of the median income, homelessness escalates. “As the share of low-income households with severe rent burdens grows, so does their risk of homelessness,” said Thomas Byrne of Boston College, an author of the study.
Gregg Colburn, a housing expert at the University of Washington, found that Seattle and San Francisco, with soaring rents, had homelessness rates four to five times as high as those in Cleveland or Detroit, where rents were lower. California’s homelessness rate was more than five times as great as Mississippi’s.
“If we had scaled Housing First — with fidelity to the evidence-based model — we wouldn’t have had such a big problem,” he said.
This article originally appeared in The New York Times.
