Opinion: Housing First’s Critics

Some groups claim the prevailing U.S. policy to solve homelessness is flawed

By Contributor

‘Housing First’ Policy Has Failed the Homeless.” “‘Housing First’ approach won’t solve homelessness crisis.” “‘Housing first’ wastes time and money amid a crisis.” “Another ‘housing first’ fail.” “Housing First and the Homelessness Crisis: What Went Wrong?”

These recent headlines bring criticisms of the nation’s leading homelessness intervention — Housing First. They claim there’s a growing number of studies and reports questioning its impact on homeless individuals’ wellbeing, ability to reduce aggregate homelessness, and cost savings to the public — with critics further pointing to systemic corruption and indefinite wait times.

The prevailing policy since the Bush Jr. era, Housing First provides housing without conditions like employment, job training, sobriety, treatment, or the absence of a criminal record, and has been met with broad bipartisan support. The model “prioritizes providing permanent housing to people experiencing homelessness…serving as a platform from which they can pursue personal goals and improve their quality of life,” according to the National Alliance to End Homelessness

The Manhattan Institute, a conservative think tank and criticizer of the policy in a report titled Housing First and Homelessness: The Rhetoric and the Reality, characterizes this description as an example of advocates’ “rhetorical suggestiveness about the link between permanent housing and behavioral health that seems intended to convince the public of evidence that does not exist.” 

The report continues that over the past decade the government has funneled billions of dollars into Housing First, leading to funding reductions in other programs. The Manhattan Institute claims such reductions force major federally funded providers of homelessness services — like Continuums of Care — to adopt a “‘one-size-fits-all’ approach” to meeting “the multi-faceted needs of homeless persons in the nation’s communities.”

In a different report, titled The ‘Housing First’ Approach Has Failed: Time to Reform Federal Policy and Make it Work for Homeless Americans, The Heritage Foundation — another conservative think tank — mirrors the concern over funding: “Despite concerns from service providers that this policy would reduce resources for emergency shelters, transitional housing, and treatment programs, the Housing First coalition plowed ahead…Today, the vast majority of federal homelessness funding is spent on Housing First programs.”

An outcome of Housing First that these critics don’t dispute is improved residential stability. A literature review in the Australian Economic Review that discusses US results, concludes that Housing First’s “housing retention rates are superior to those obtained from traditional programs.”

The Manhattan Institute describes the debate between Housing First and its alternatives “as one of different ‘paradigms’ — the dispute concerns not just the best way to achieve a mutually agreed-upon goal but a dispute over which goals to pursue.”

The Australian Economic Review notes that different views of what Housing First is could also be at play in the disagreement: “In the processes of transferring Housing First to different countries, it is equally clear that there are now diverse views on what constitute the core components of a Housing First approach.”

Some, however, argue that residential stability is not the only metric homelessness policy should focus on.

They continue, saying, “The drift away from many of the original concepts, coupled with limited appreciation of the challenges to effective implementation of the model, has created a risk of underperformance. If underperformance is accompanied by outsized claims regarding the economic or health benefits Housing First can deliver, then there is risk of policy overreach.”

Housing First’s record on these other metrics — like health, independence, sobriety, and social connectedness — is the focus of some arguments, as well as claims that the evidence in favor of Housing First is settled. 

One claim that The Manhattan Institute sees as overstating the evidence is a statement by Department of Housing and Urban Development Secretary Ben Carson where he says, “a growing mountain of data show[s] that a Housing First approach works to reduce not only costs to taxpayers but the human toll as well. The evidence is clear…we can say without hesitation that we know how to end homelessness,” along with a Coalition for the Homeless description of Housing First as “a proven solution.” 

Focusing on evidence for Housing First’s effect on quality of life outcomes like health and social integration is a National Academies of Sciences, Engineering, and Medicine study. It found that “there is no substantial published evidence as yet to demonstrate that PSH [a Housing First intervention] improves health outcomes” except in individuals with HIV/AIDS, and a Psychiatric Services study found that “chronically homeless adults showed substantial improvements in housing but remained socially isolated and showed limited improvement in other domains of social integration.”

Looking at the policy’s ability to address particular mental or behavioral health challenges is a Journal of Dual Diagnosis study in Canada, where it found that homeless individuals with problematic substance use who did not participate in Housing First showed more improvement on drug and alcohol abuse, mental health, and quality of life metrics than those who did. At the two year mark, Housing First participants were no more satisfied with their living conditions than the control group. 

Similarly, a U.S. Department of Housing and Urban Development Office of Policy Development and Research report found that Housing First did not clearly impact participants’ “level of psychiatric impairment, frequency of psychiatric medication use, impairment related to substance use, impairment related to co-occurring disorders, and income and money management.” 

The Manhattan Institute, referring to a ProPublica report, says they “profiled a few seriously mentally ill clients of a supported housing program in New York, and how an excess of independence led to decompensation and even death. These individuals were, in some cases, stably housed, but living in apartments strewn with waste, swarming with bugs, and living with untreated infections and other health problems, and extremely isolated.” 

Another metric publications have focused on is family outcomes. 

Urban Institute, a partially federally funded think tank, released a report finding that in rapid rehousing — another program generally seen as falling under the Housing First umbrella, although it comes with some conditions — families met “modest” employment and income gains, had high rates of residential instability, and “still experienced significant challenges one year after exit (even when housed).” 

A Heritage Foundation report author, Christopher Rufo, comments on the research that it “demonstrates reasonably high rates of housing retention, but consistently fail to report any improvement in overcoming substance abuse, reducing psychiatric symptoms, or improving general well-being — the ‘human outcomes.’” 

He continues that “in its most important responsibility — to improve human lives — the Housing First philosophy has failed,” comparing Housing First to “little more than homelessness within a residential setting.” He concludes, “In some studies, even overdose deaths in permanent supportive housing units do not count as a negative outcome; they simply reduce the denominator for analysis, which, perversely, increases the apparent success of the program.” 

The Council argues that short-term reductions “can be reversed in the long-run through unintended consequences,”

The Manhattan Institute comes to a similar conclusion, arguing that “there is no evidence-based proof of Housing First’s ability to treat serious mental illness effectively, or drug or alcohol addiction. Housing first is not a reliable solution to social isolation, a very significant cause and effect of homelessness.” 

The Heritage Foundation’s and The Manhattan Institute’s reports fail to mention a 2015 Drug and Alcohol Dependence study that found a Housing First intervention reduced alcohol problems — but not drug problems. The Manhattan Institute did acknowledge a Community Mental Health Journal finding that a Housing First intervention correlated with “social integration.”

Advocacy groups like the National Alliance to End Homelessness argue that Housing First, “a philosophy that values flexibility, individualized supports, client choice, and autonomy,” doesn’t preclude additional interventions that can address these so-called human outcomes. 

The voluntary nature of these interventions is what draws concern from critics, however. 

Two affiliates of Saint John’s Program for Real Change, a rehabilitative program, write in CalMatters, “Proponents suggest that, once housed, people can opt for services to treat their addiction or mental illness. This fails to consider that people trying to escape the grip of addiction or mental illness or both are rarely able to make such a decision.” Essentially, they say, “they’re too ill to know they’re ill.”

The Manhattan Institute drills down on this concern on the effectiveness of voluntary treatments saying, “A common refrain among advocates is that ‘Housing First’ does not mean ‘Housing Only.’ This is not an evidence-based claim,” continuing that further research is necessary. “Surely, some programs are far more inventive in getting service-resistant clients to accept treatment and services than are others. A supportive housing program that systematically fails to engage any of its clients is, practically speaking, a ‘Housing Only’ program.”

The Manhattan Institute argues Housing First advocacy is also marred by potentially misleading claims that the model is proven to end homelessness, saying that, contrary to generalized claims like Urban Wire’s statement that Housing First “can effectively end homelessness,” most studies look at temporary individual outcomes, not long-term or aggregate data. 

Housing First can end homelessness at least temporarily for the person provided with housing, but, reports by the Manhattan Institute and Council of Economic Advisors — an agency tasked with “offering the President objective economic advice on the formulation of both domestic and international economic policy” per the White House website — say this positive individual outcome is subject to a “fade-out” effect over time, and does not translate into general population-level reductions.

The Council argues that short-term reductions “can be reversed in the long-run through unintended consequences,” concluding that, “in fact, it is not clear that this strategy has been successful in reducing homeless populations.”

Columbia University Economics professor Brendan O’Flaherty agrees that there is a lack of evidence for reductions to total homelessness, saying, “What has been missing in studies of Housing First are estimates of aggregate impact: does operating a Housing First program actually reduce the total amount of homelessness in a community?”

The Council outlines several mechanisms by which they think short-term reductions could be undone: “Increasing housing demand may increase the price of housing, drawing additional people into homelessness and weakening the initial reduction in homelessness further…The people who live in the new permanent beds may remain there longer than they would have otherwise remained homeless. To the extent that housing programs over time house people who otherwise would have no longer been homeless, they no longer have any effect on reducing homelessness until the unit becomes vacant and a new person is removed from homelessness.”

They also say that “the promise of housing for homeless people could encourage people to stay homeless longer in order to qualify. Thus, the long-run reduction in the number of homeless people may be smaller than the original decline in homelessness that mechanically occurs from housing homeless people.”

Crisis counselor and director of New York’s Neighborhood Coalition for Shelter, Jeff Grunberg, says Housing First disincentivizes recovery and job-seeking: “Here’s the problem with housing. They can’t ever get better, or they lose their housing. If you have stabilized, and you say, ‘Now I want to work,’ they tell you, ‘Sorry…you can’t look for work.’”

As for the evidence on Housing First’s cost-effectiveness, the National Alliance to End Homelessness’ states that “providing access to housing generally results in cost savings for communities because housed people are less likely to use emergency services, including hospitals, jails, and emergency shelter, than those who are homeless.”

According to O’Flaherty, marginal costs, not average costs, are the relevant metric when looking at things like emergency services though, and short term interventions like shelter stays are less expensive than a lifetime of rental subsidies The Manhattan Institute argues.

Long wait times are another issue and reality that’s faced by people awaiting housing from Housing First programs, with one homeless woman interviewed by Filter Magazine claiming to have been on waiting lists in Dallas, Fort Worth, and San Antonio for years. “I’m still waiting for a Housing First anything to give me a home,” she said.   

“…homelessness is not a monolith, and different interventions may work for different subpopulations.”

Grunberg explains why these exist: “Who gets housing first? One out of a hundred people…Here’s the problem. One third of America needs affordable housing…You need land, land zoning, you need a building, approvals, the community has to approve it, you need funding, and then when you’re done, after a year and a half of struggle, you have 47 units.” 

“So this is what really saddens me,” he continues. “That hundreds of thousands of people are sitting in a shelter bed, in repose, in wait for housing that’s never going to come. It’s like a religion. It’s not coming in their lifetime. So I’m turning my back on that as a solution.”

UCLA Community Health Sciences professor Randall Kuhn expressed a similar worry to the LA Times: “If being on the streets is bad for your health, then ‘housing first’ would be fine if everyone was going to be housed overnight. In the meantime, thousands will go unsheltered for years and thousands will enter homelessness directly to the streets. What are we supposed to do to help those people?”

Alternatives to the Housing First model have been presented by groups like the California Wellness Foundation, emphasizing that homelessness is not a monolith, and different interventions may work for different subpopulations. 

Some researchers say Housing First combined with an additional intervention, Assertive Community Treatment (ACT), shows promise. An Ontario Housing First Regional Network Community of Interest policy brief explains that in ACT programs, “a multidisciplinary, community-based treatment staff provides intensive support around the clock.” 

Individuals with serious mental illness who participated in a BMC Public Health study of Housing First plus ACT demonstrated gains in self-reported quality of life and perceived recovery. The individuals were required to participate in weekly meetings and were provided with “home visits and a range of individual services that included life skills training, counselling, crisis intervention, and referral to health and social services.” 

Another option is a full-fledged treatment-first model. 

Citing a Journal of Consulting and Clinical Psychology meta-analysis of randomized clinical trials, the Heritage Foundation argues, “The key to success, according to researchers, was the combination of housing and treatment with obligations and enforcement; in other words, the relinkage of compassion and responsibility…While there is still a need for permanent supportive housing for the severely disabled and chronically homeless, the vast majority of the homeless would be better served in treatment and recovery programs that promote self-sufficiency.”

The report concludes, “In short, recovery achieves better human outcomes and can serve a much larger number of people, given limited resources. Treatment First comes closer to fulfilling the real purpose of public assistance: to enable human flourishing, even for those who face the greatest challenges.”

Grunberg thinks the treatment-first model is another failure though, and supports a jobs-first approach, explaining homelessness as a crisis in social status: “I found that almost every homeless person will say if they had a job it would solve their problems…The adult is telling me he wants to work…Why should I not believe them?”

One outreach program he ran in New York, that he considers a success, took advantage of this job-based process.

“Instead of trait-centered, I came up with status-centered outreach. And what I did was I targeted the fact that they feel left out…When you don’t feel needed by society, certainly by employers, you go into a certain kind of funk…People cannot get [mental health treatment] unless they have something to lose by not getting it. So if you ain’t got nothing, you’ve got nothing to lose, that’s how it goes. You’ve got to give them a job, then they’re going to want to scramble to keep it,” he explained.

Then there’s the money-first approach. O’Flaherty writes, “The major lacuna in all of these RCTs about ending individual homelessness is a study of simply giving money rather than housing. Every step away from paternalism seems to result in better outcomes, and so why not take the next step? I have very weak priors about how such an experiment would turn out, but it would probably provide a useful benchmark against which other interventions could be assessed. Do housing subsidies work well because they are housing, or because they are subsidies?”

Housing First may be argued against, but no single solution is, so far, perfect. A combination of solutions, or a not-yet-known perfect one may appear in the future, but at least at the moment there is not a draught of ideas — nor criticisms for them.

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