iAUDIT - This is Part One of a two-part review of Housing First. Part One details how badly Housing First has failed. Part Two will look at successful alternatives.
Before critiquing Housing First’s performance, we need to look at its history, then define what it is and what it’s supposed to do. Housing First was developed in the early 1990’s by Dr. Sam Tsemberis, a faculty member of the Department of Psychiatry at New York University’s School of Medicine, based on his research on the positive outcomes when people were housed before receiving supportive services. At the federal level, Housing First was adopted as a service model during the George W. Bush administration and became HUD’s mandatory funding model for homelessness programs in 2013. In 2016, California made it a cornerstone of its funding to local governments. It has been supported by the federal and state administrations of both parties.
According to the State of California’s Housing and Community Development Department, Housing First is “an approach to serving people experiencing homelessness that recognizes a homeless person must first be able to access a decent, safe place to live, that does not limit length of stay (permanent housing), before stabilizing, improving health, reducing harmful behaviors, or increasing income. … anyone experiencing homelessness should be connected to a permanent home as quickly as possible, and programs should remove barriers to accessing the housing, like requirements for sobriety or absence of criminal history. It is based on the “hierarchy of need:” people must access basic necessities—like a safe place to live and food to eat—before being able to achieve quality of life or pursue personal goals. Finally, Housing First values choice not only in where to live, but whether to participate in services. For this reason, tenants are not required to participate in services to access or retain housing”.
Housing First was originally targeted at the chronically homeless, people who for a variety of reasons have been homeless for a year or more and require some level of supportive services. A report from the think tank McKinsey & Co. estimates 40 percent of L.A.’s unhoused meet the chronically homeless definition, and the number is increasing. Based on that estimate, about 18,400 of the city’s 46,000 homeless have spent a year or more on the streets. Chronically homeless people are the most difficult to house because they tend to have serious underlying problems, such as untreated mental illness and/or a history of substance abuse. Because it offers housing without condition, Housing First is typically paired with Harm Reduction, the practice of mitigating the danger of substance abuse by providing things like clean needles and the anti-overdose drug Narcan.
Several studies by academic institutions and homelessness agencies have touted Housing First’s success. For example, using the Housing First model, the State of Utah claimed a 91 percent reduction in its homeless population between 2005 and 2015. What made these success stories so attractive to government agencies was the purported cost savings; many studies offered evidence the long-term costs of Housing First were lower than allowing people to live on the streets or placing them in transitional shelters.
However, as time passed, agencies using Housing First saw homelessness increase and costs soar. In Los Angeles, LAHSA’s budget increased by 13 times, from $63 million in fiscal year 2014-15 to more than $800 million in fiscal year 2022-23. For the same period, homelessness in LA County increased 53 percent, from just over 40,000 to about 69,000. A well-known 2022 report from LA’s City Controller determined the average cost of Measure HHH-funded housing was about $591,000 per unit, plus another $134,000 in City-paid subsidies, costs the Controller called “staggering” and far above the $350,000 to $400,000 originally projected. Increasing costs are not unique to Los Angeles. In Utah, where the state’s Housing First program is considered the gold standard in the US, construction and program costs have also increased dramatically. A State Legislative Auditor’s report found the costs of homeless programs increased by 600 percent between 2016 and 2020. Building costs are between $250,000 and $275,000 per unit, which may not seem high by California standards, but are very high for Utah. During the same period, statewide homelessness remained fairly stable, between 2,800 and 3,200, but the number of unsheltered homeless—Housing First’s target population—doubled. One of Housing First’s claims to success--decreasing long-term costs—has failed to materialize. Governments find themselves trapped into paying for expensive construction projects that consume years of funding and result in little to no decreases in homelessness. You can find more details on the true costs of homelessness programs here and here. As they demand increasing financial resources, Housing First programs starve others of funding, especially the wraparound services that are key to its success.
No Barrier Housing First’s structure contains the seeds of its own failure. Housing is supposed to provide a stable environment for clients to receive needed support services. Because of the high incidence of mental illness and substance abuse among the chronically unhoused, these services should involve recurring therapy and recovery support. But residents are under no obligation to enter any kind of behavioral program; that can have serious financial consequences, as illustrated by Skid Row Housing Trust’s collapse, fueled in part by the costs of repairs from violent residents. In human terms, failing to provide the needed services leaves people on their own to deal with the problems that made many homeless in the first place. As reported in January 2022 in The Hill, “…those in recovery or who have completed their recovery can be sent to a Housing First community with active drug users. This undermines their efforts to stay clean and contributes to a revolving door, whereby individuals cycle between the streets and programs. An American Psychiatric Association report found that ‘[The] majority of studies found no effect of permanent supportive housing (Housing First approach) on psychological symptoms or alcohol or drug use.’” In a study from the Independent Institute, a Salvation Army official who works in homeless intervention programs refers to people in Housing First as “culturally homeless”, technically housed (often in incredibly austere apartments despite the astronomical costs), but denied the services that will keep them housed.
Besides optional participation and lack of funding, another reason for the dearth of wraparound services is poor coordination and management. While the City of Los Angeles is primarily responsible for housing, the County of LA is responsible for providing medical and mental health services. The two governments rarely coordinate their services, and LAHSA, the joint powers authority tasked with monitoring service providers, does a notoriously poor job managing its contracts. Supervisor Lindsay Horvath, in a May 22 speech at Belmont Senior Care, discussed the lack of coordination and accountability endemic to LAHSA’s structure. LAHSA has more than 1,000 contracts with about 100 service providers. As Horvath stated, such a complex network of contracts and organizations leads to decreasing levels of accountability, a view supported by the McKinsey & Co. report. In practical terms, this means the people who most need support services often receive no or minimal contact with the proper professionals.
When it comes to the number of people successfully housed, there is often a wide chasm between what advocates claim and reality. In Utah, initial claims of wild success were dampened when it was discovered many homeless people were classified as “housed” when they were really in long-term but temporary, (and expensive) shelter programs under the state’s “rapid rehousing” efforts. The arbitrary definition of “housed” is a national problem, as noted in a 2020 report from the US Interagency Council on Homelessness, (USICH), regarding an apparent decline in homelessness: “‘Reclassifying’ 101,746 individuals that moved from transitional programs to rapid rehousing programs as no longer experiencing homelessness has been cited as evidence of the reduction of homelessness. This reclassification has also been used to support the effectiveness of housing first, thus this may not represent a true reduction. The conclusion from ED and HUD data is that homelessness is increasing, irrespective of how it is defined.” Calling someone housed does not make them housed.
It is very challenging to determine how many people, if any, Housing First has benefited. Because some unhoused people use their “homes” as places to shower, eat and sleep, then return to street living (and its associated behaviors), during the day, it’s difficult to track the actual numbers housed. Those in rapid rehousing facilities are often counted as “housed” even though they have little or no ability to live independently. Because agencies like LAHSA track workloads instead of outcomes (e.g., the number of people contacted instead of the long-term results of those contacts), it cannot be said with any degree of accuracy how many people have successfully and permanently broken the cycle of homelessness due to Housing First.
But what of all the studies that prove Housing First’s success? The Independent Institute and others have pointed out many of those studies are produced by a relatively small cadre of academics, many of whom have a vested interest in Housing First’s success. The recent study from UCSF that “proved” homelessness is a housing problem was led by Dr. Margot Kushel, a Housing First advocate who has publicly testified in favor of Housing First, and whose study methodology and conclusions have been questioned. Other studies are sponsored or conducted by Housing First agencies, raising questions about objectivity. As I have noted in previous articles, several studies from neutral organizations and government agencies, such as Stanford University’s Economic Research Institute, the American Public Health Association, the National Institutes of Health and the USICH itself have found few or no long-term benefits to No Barrier Housing First, especially in terms of health outcomes.
What, then, is the reality of Housing First? Rather than decreasing homelessness and saving money, it has resulted in increasing homelessness and higher costs. Because it robs resources from other programs and subordinates support services, it may make the crisis worse. Many pro-Housing First studies cite the high percentage of people housed a year after receiving housing. But a year is not a lifetime. As I noted in my last article, the true long-term outcomes of Housing First are rarely mentioned, and many programs often lose more than half their participants within several years.
To put Housing First’s tragic failure in the starkest human terms possible, consider that the average number of deaths among LA’s unsheltered homeless is six per night. In one year, that will be 2,190 human lives lost, 5.7 times higher than the 382 murder victims LA counted in 2022. To 2,190, add the number of preventable deaths of people in No Barrier Housing First programs. Skid Row Housing Trust’s facilities are infamous for the number of overdose deaths. The fentanyl epidemic, which Housing First fails to address because of Harm Reduction and lack of support services, claims a devastating number of lives. Because they fail to provide consistent recovery services, many Housing First sites are nothing more than places where people can abuse drugs in private instead of on the street. Tragically, they also die in private.
The crisis seems overwhelming: governments, service agencies and a zealous cadre of advocates in the thrall of a failed program. Non-profits, developers, and labor unions making millions from construction and services contracts. And homelessness continues to increase. But no human-made crisis is unsolvable. In Part 2 of this article, I will describe programs that have a proven track record of success and see if how can be applied more broadly here in Los Angeles. There is still hope for the City of Angels.
(Tim Campbell is a resident of Westchester who spent a career in the public service and managed a municipal performance audit program. He focuses on outcomes instead of process.)