During the first 10 days of 2017, four people living on the streets in Portland, Oregon, died from exposure to freezing temperatures. Effectively responding to homelessness is a matter of life and death.
One of Ben Carson’s most important responsibilities as secretary of the US Department of Housing and Urban Development (HUD) will be to prevent future tragedies by continuing the nation’s progress in preventing and ending homelessness. To do so, he should follow the evidence-based Housing First approach.
The Housing First approach’s first priority is to help people find and maintain their own housing. Under Housing First programs, additional services (e.g., job training, health care, and substance abuse treatment) are provided on a voluntary basis and not as a precondition for housing. Every effort is made to provide the services and flexibility to keep people in housing. This approach may not seem revolutionary, but it is a stark contrast to the traditional continuum approach, which asks people to demonstrate their readiness to live independently by moving through progressively less restricted housing settings (e.g., from emergency shelter to transitional housing to independent housing).
The George W. Bush administration’s adoption of Housing First helped spur a 30 percent reduction in chronic homelessness from 2005 to 2007. The Obama administration continued this support for Housing First when it released its Federal Strategic Plan to End Homelessness in 2010, and HUD and other agencies have made adopting Housing First practices a priority for their staff and grantees. Since 2010, there are 87,000 fewer people experiencing homelessness, nearly 35,000 fewer veterans experiencing homelessness, and 28,500 fewer chronically homeless people. Tens of thousands more people are now in their own homes and not in the streets, in shelters, emergency rooms, jails, or prematurely dying because they have nowhere to live.
During the HUD secretary nomination hearing, when Senator Brian Schatz of Hawaii asked Carson if he supported the Housing First approach to homelessness, Carson replied that Housing First is one of the programs he wants to study, and then he cited an anecdote about a homeless family that had benefited from a Housing First program and later went on to purchase a house.
When Carson looks at the data, he will find that randomized clinical trials, the gold standard for social science research, find that the Housing First approach has demonstrated its superiority over traditional models in reducing homelessness. People given the opportunity to live independently under the Housing First approach remain stably housed, while those in programs that require sobriety and adherence to a treatment plan tend to cycle between homeless programs, treatment facilities, psychiatric facilities, prisons, and jails. In one randomized controlled trial evaluation, 225 homeless people with mental illness were randomly assigned to either Housing First permanent supportive housing or housing contingent on treatment and sobriety. In the two years after random assignment, people assigned to the Housing First program had spent 80 percent of their time stably housed, while people assigned to the traditional treatment and sobriety program spent 30 percent of their time stably housed.
Housing First programs also create savings through reduced use of public systems, such as emergency departments, jails, and detox facilities. These savings can partially or totally offset the costs of Housing First programs. The quality and volume of studies demonstrating the success of Housing First has prompted the US Department of Health and Human Services to include it in its National Registry of Evidence-Based Programs and Practices.
No further study is needed. The challenge today is making sure programs have the proper resources and incentives to follow Housing First approaches and expanding access to effective Housing First programs. Returning to the traditional homeless model of treatment and housing readiness would lead to fewer people living independently in their own homes and more people in shelters, institutional care, and on the streets.