The State of Homelessness in America?

Report summary

Causes of homelessness

After describing the scope and variations in homelessness, the report identifies 4 key causes of the high rates of homelessness in the US:

• Overregulation of housing markets leads to higher housing cost which people with low incomes can’t afford, and thereby increase the number of people who are homelessness.
• Police policies that allow homeless people to stay and live on the street increase the number of people who are homeless. More tolerable conditions for sleeping on the streets (outside of shelter or housing) increases homelessness.  However, some communities, including several in Florida and Arizona, experience considerably lower rates of homelessness than others with a similar climate, such as southern California.  This suggests that other factors, for example “policies such as the extent of policing of street activities may play a role in these differences.”
• Increasing the number of beds in homeless shelters contributes to an increase in the number of people who are homeless. Cities with higher numbers of beds for homeless people, and in particular, those that have a right-to-shelter policy, have higher rates of homelessness, suggesting that “while shelter is an absolutely necessary safety net of last resort for some people, right-to-shelter policies may not be a cost-effective approach to ensuring people are housed.”
• “Severe mental illness, substance abuse problems, histories of incarceration, low incomes, and weak social connections each increase an individual’s risk of homelessness, and higher prevalence in the population of these factors may increase total homelessness.”

Previous failed policies

Next, the report assesses programs of previous administrations, particularly over the preceding decade, taking issue with permanent supportive housing (PSH) programs that adhere to the Department of Housing and Urban Development (HUD) and the Substance Abuse and Mental Health Services Administration (SAMHSA) guidance following the predominant evidence-based practice referred to as “Housing First.”  Housing First emphasizes providing permanent housing without conditions.  Supporting services, such as those for offender reentry, employment, physical health, mental health or addiction, are offered but not required.  The report notes that:

“While these policies increase the demand for homes and thus reduce homelessness in the short-run, this short-run reduction can be reversed in the long-run through unintended consequences. In fact, it is not clear that this strategy has been successful in reducing homeless populations. Research suggests that previous Federal policy is not capable of explaining a substantial portion of the reported decline in homelessness between 2007 and 2018. In addition, we show that contrary to reported trends, it is unclear whether homelessness in the United States has actually decreased since 2007, due to an inconsistent definition of homelessness and miscounting of unsheltered homeless populations.”

Thus, the authors are not really sure if there was a decline in the homeless population over the last decade, but if there was, that does not mean that the Housing First evidence-based practice (EBP) is the cause.  The report posits a few other possible alternative explanations.

The report goes on to say that the increase in beds for homeless people over the preceding decade has in fact increased the size of the homeless population.  Using a simple economic model of supply and demand, the report notes that one factor “that explains variation in homelessness is the supply of substitutes to housing through homeless shelters. Expanding the supply of homeless shelters shifts the demand for homes inward and increases homelessness.” (Emphasis added.)

Policy recommendations

Having identified both root causes and failed policies, the report proceeds to make the following policy recommendations:

• Remove regulatory barriers to housing construction that would increase supply and lower cost. The report estimates that removing regulatory barriers to construction should decrease overall homelessness across the nation by 13% while some cities would see a much bigger reduction.  The report estimates that San Francisco would see a reduction of 54% while Los Angeles would see 40% and New York would see 23% reductions. The report sites President Trump’s executive order of June 25 that establishes a White House Council on Eliminating Regulatory Barriers to Affordable Housing.
• Increase support for police efforts to remove homeless people from sleeping on the streets. “Another important factor that increases homelessness is the tolerability of sleeping on the street, which among other factors may be affected through policing of street activities. The administration has through a series of executive orders consistently supported the police.”  The report does not suggest how or where people removed from the streets should be housed.
• To address contributing factors like addiction, offender reentry, mental illness and unemployment, the report cites the Administration’s efforts in each area without noting its proposed decreases in funding. “Strong economic growth, historically low unemployment rates, and reductions in poverty have increased the incomes of people at the bottom of the distribution and can reduce their likelihood of falling into homelessness.”
• Reform the Housing First model by imposing “service participation requirements for participants after they have been stabilized in housing,” and to “more quickly transition [people] to private housing,” thereby freeing up beds for others still living on the street. The report cites the 2019 HUD funding guidance that already implements these changes.

Beyond the estimated measures projecting the reduction in homelessness from removing regulatory barriers to housing construction, the report does not propose either goals or anticipated outcomes from the policies.

The report in context

We’d like to consider this report on its own merit, but as we are often reminded, context is… if not everything… then it is most certainly critical to understanding.

As reported by the media, we know that President Trump’s first priority is the effect of homeless people on the “prestige” of American cities not individual health, population health or the cost to society.  “We can’t let Los Angeles, San Francisco and numerous other cities destroy themselves by allowing what’s happening.  We have people living in our … best highways, our best streets, our best entrances to buildings and pay tremendous taxes, where people in those buildings pay tremendous taxes, where they went to those locations because of the prestige,” he said. “In many cases, they came from other countries, and they moved to Los Angeles or they moved to San Francisco because of the prestige of the city, and all of a sudden they have tents. Hundreds and hundreds of tents and people living at the entrance to their office building. And they want to leave.” (Washington Post, 2019) 

Similarly access to homeless shelters is itself a topic of political contention.  For example, the U.S. Department of Housing and Urban Development’s (HUD) regulatory agenda this fall includes a new rule which says shelters that receive, manage, or operate HUD grants can essentially ignore nondiscrimination protections for unhoused trans people. (Quinlan, 2019)

Reflecting these priorities, the broad policy direction from the Federal government for housing may best be reflected by the Administration’s proposed budget that reduces HUD’s funding by $9.6 billion over the next 10 years (National Low Income Housing Coalition, 2019) and reduces funding for Medicaid by $1.5 trillion over 10 years.  (Golshan, 2019)

In contrast, states, payers and private foundations are developing innovative funding and service delivery solutions that improve access to housing particularly in concert with supporting services.  The report mentions a $1.5 billion bond issue that was passed in L.A. County in 2016 but it doesn’t mention the $2 billion program focused on housing and mental health that was approved by the people of California in 2018 which provides funding and services for every county in California, following the Housing First model.  Other states are showing similar creativity and early success with the integration of housing and supporting services.

Nor does the report mention initiatives by payers such as Kaiser Permanente, the nation’s largest nonprofit, integrated health system, which, in May, announced $200 million investment to address the pressing social needs including housing, food, safety, utilities and more for millions of people across the United States through a comprehensive, far-reaching social health network to connect health care and social services providers. (Permanente, 2019)

The report also does not mention private foundations, like Jeff Bezos’ First Day Fund, which announced in November, 2018, that it was providing $97.5 million to 27 housing agencies. (Debter, 2018).

Beneath these conflicting policies is a raging political debate between liberals and conservatives over the role that government should play to support the most vulnerable people which will be at the fore during the run up to the 2020 presidential elections and will shape the direction of the US for years if not decades.

The scope of this discussion

In this discussion, we do not address many of the obvious questions that come out of this report.  We do not evaluate the reasonableness of the very high estimated reduction in homelessness from reducing barriers to construction, or the possible damages or costs to society of abandoning these regulations.  We do not question the expressed causal relationship between the supply of PSH beds and the rate of homelessness.  We certainly do not delve into all the questions that arise from a policy of using the police to remove people from the streets and housing them in some un-named way other than PSH.  We do not consider the impact of massive budget cuts on related services such as Medicaid, or the proposed reduction in Federal funding for housing itself.  Finally, we do not consider the possible benefits to society if, through these policies, the number of people visible on the streets is reduced.  While these are each important questions with complex answers, we believe the scope of this discussion gets at the heart of the matter for housing service providers, healthcare providers, Medicaid, Managed Care Organizations and policy makers.

The association between housing and health status

It’s well established that there is a measurable association between housing and food insecurity and health status.  As shown in our earlier study, Measuring the Association between Food/Housing Insecurity and Health Status: An Analysis using the Behavioral Risk Factor Surveillance System, people who always or usually worry about having enough money for food or housing are about 3 times as likely to have self-reported poor or fair health compared to people who rarely or never worry, and are about twice as likely when compared to people who only sometimes worry about having enough money for food or housing.