Abstract
The United Nations declared housing to be a fundamental human right in 1991, and the United States reduced overall homelessness by 20% between 2005 and 2013. However, homelessness continues to be a recalcitrant public health problem in the United States, as those experiencing homelessness have high rates of chronic mental and physical health conditions, co-occurring disorders, and barriers to health care and affordable housing. Homeless individuals also overuse emergency services, leading to higher treatment costs. Numerous evidence-based strategies are being employed to end homelessness by increasing access to housing options and supportive services for housing stability; examples include the Housing First model, housing subsidies for extremely low-income families, permanent supportive housing services for those with complex health needs, and pathways to financial stability through access to disability income and employment support. Interventions in housing, health, and income stabilization should be holistically integrated, allowing individuals experiencing homelessness to find their unique path to recovery. To achieve an end to homelessness, APHA sets forth recommendations for federal, state, and local policymakers and agencies to work collaboratively in funding evidence-based housing acquisition practices and supportive housing stability services, as well as supporting future innovations in integrated services for individuals experiencing homelessness.
Relationship to Existing APHA Policy Statements
Problem Statement
The United Nations declared “the right to adequate housing” to be a fundamental human right in 1991.[1] Across the European Union, more than 400,000 individuals are homeless on any given night, with an estimated 4.1 million people experiencing a homeless episode each year (although varying definitions and methodologies make it challenging to determine precise numbers).[2] The United States has made significant progress in ending homelessness since its Opening Doors plan was implemented in 2010, but it remains a recalcitrant public health problem.
The 2016 U.S. Department of Housing and Urban Development (HUD) Annual Homeless Assessment Report to Congress estimated that 549,928 people experienced homelessness on a single night in 2016, with 32% of individuals staying in unsheltered locations. Demographically, more than 39% of individuals experiencing homelessness self-identified as Black or African American, a significant overrepresentation relative to the percentage in the U.S. population as a whole (13.3% in 2016). One in five people experiencing homelessness were Hispanic or Latino, 3% were Native American, 2% were of Pacific Islander descent, and 1% were of Asian descent. Men represented 60% of those counted; 40% were women, and less than 1% were transgender. Geographically, New York, Florida, and California had the highest numbers of people experiencing homelessness, although significant increases in the number of homeless people were seen in rural states such as Idaho, Wyoming, and Oklahoma. The count included 39,471 veterans, with 8% of that total accounted for by female veterans. Of all homeless individuals, almost 121,000 were children (22% of the total), 35,686 (7%) were unaccompanied young people 18 to 24 years of age, and more than a third were experiencing homelessness as part of a family.[3] It is important to note that these figures capture a single point in time, and millions more adults and children experience episodes of homelessness during a given year or are at risk of experiencing homelessness as a result of financial and housing instability.
It is difficult to obtain accurate data on the prevalence of youth homelessness in the United States; according to estimates, however. between 500,000 and 2.1 million young people 13 to 21 years old are homeless.[4,5] Homeless youths are typically defined as unaccompanied individuals 12 years or older (up to age 17, 21, or 25) who live in shelters, on the street, or in other unstable living conditions without family support.[4,6] Overall, homeless youths are more likely than their housed counterparts to experience negative health outcomes, including chronic health conditions or problems such as HIV, substance abuse, violence, and mental health issues.[4,5,7,8] Such risks are a consequence of street-entrenched lifestyles as well as early childhood traumas including family breakdowns, discrimination, and poverty.[5,9] In addition, historically marginalized groups are disproportionally represented in homeless youth populations. Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youths represent between 30% and 45% of the overall homeless youth population, as compared with an estimated 5% to 10% of the overall youth population. LGBTQ homeless youths are significantly more likely than their heterosexual homeless youth counterparts to have major depressive episodes, posttraumatic stress disorder, suicidal ideation, and at least one suicide attempt. In addition, they have increased rates of sexual and violent victimization.[10–12] Homeless youths are also three times more likely to be pregnant, to have impregnated someone, or to already be a parent.[5]
Many homeless youths seek health services only when peer advice and self-care are no longer effective, and minor, treatable injuries often escalate into more severe health problems.[5,13] This problem is compounded by limited access to health care among homeless youths, who frequently use drop-in centers that provide free, instant health care and emergency rooms that often fail to offer the necessary level of care and are much more expensive than the services of a primary care physician.[5,14] Access to preventative health care directly affects young people’s ability to safely and successfully exit the streets.
Similarly, housing instability and homelessness among children and families is a significant issue, with an estimated 2.5 million children (one in every 30) experiencing homelessness in a given year. Child and family homelessness is likely undercounted in national surveys, as many families “double up” with friends or relatives and may withhold information about their housing instability to avoid stigma. Furthermore, an estimated 51% of homeless children are younger than 6 years and may not be accurately counted, as they do not attend school.[15] Risk factors for family homelessness include inadequate social support, domestic violence, a history of children being placed in foster care, parental drug or alcohol use, parental mental illness, and racial/ethnic minority family background.[16] As a corollary, children who experience family homelessness are at risk of higher stress levels, health problems, and need for pediatric health care during and after such adverse episodes.[17] Homeless children display mental health symptoms requiring clinical evaluations at a rate of two to four times that of their low-income housed peers, and they often exhibit developmental or cognitive delays. Research indicates that 90% of mothers experiencing homelessness have been exposed to at least one form of severe traumatic stress, and between 20% and 50% of women cite intimate partner violence as the cause of their homelessness.[15]
Ending homelessness is a public health issue, as those experiencing homelessness have high rates of chronic mental and physical health conditions, co-occurring disorders, and barriers to care, such as inability to access care when needed or comply with prescribed medications. The correlation between disabilities and homelessness is high, with almost 20% of individuals experiencing homelessness in 2016 reporting a severe mental illness and 17% reporting a chronic substance use problem.[3] Research on personal and structural barriers in accessing treatment for co-occurring substance use and mental health disorders indicates that individuals experiencing homelessness or those with criminal justice involvement often have fewer treatment resources, lack transportation, and have more limited access to services, particularly those in rural areas.[18] These barriers to treatment may lead to increases in chronic conditions and may hinder housing and income stability.
Research also indicates that individuals experiencing homelessness have a risk of mortality that is 1.5 to 11.5 times greater than the risk in the general population.[19] Research across the European Union and Canada supports findings of higher mortality rates and chronic disease loads among individuals experiencing homelessness than among those who are housed.[2] Living in an unsheltered or temporary location can exacerbate conditions such as diabetes and hepatitis C, which a study in Boston showed to be two times and 12 times, respectively, more prevalent in a cohort experiencing homelessness than in the general population. Managing diabetes requires access to clean needles and testing supplies and refrigeration of insulin, and treating hepatitis C depends on detailed medication management, which can be difficult or impossible for individuals experiencing homelessness. Along with treatment of chronic health conditions, stable housing is integral in preventing communicable diseases such as tuberculosis and HIV.[20] In addition, food insecurity (defined as being without access to food or not having the ability to acquire food), as faced by many who are homeless , can further worsen mental health outcomes.[21]
Furthermore, individuals experiencing homelessness overuse emergency services, leading to higher costs for treatment. Studies report that a quarter to one third of homeless individuals are hospitalized during a given year and that these individuals have significantly higher rates of emergency department (ED) use than the general population.[20] A national study of ED use showed that homeless individuals were three times more likely than members of the non-homeless population to return to the same ED within 3 days of an evaluation in that department and twice as likely to use an ED within 1 week of a hospitalization. The study also revealed that homeless individuals were more likely to be transported to the hospital via an ambulance, further increasing treatment costs.[22]
Research on factors predicting ED use among individuals experiencing homelessness shows that unstable housing status and disease burden are more predictive of overuse than insured status. A study in Toronto reported that homeless insured adults visited an ED eight times more frequently than their low-income housed counterparts, while a study in Boston concluded that unstable housing, mental illness, and substance use disorders were significantly associated with frequent ED use among homeless insured patients.[23,24] These costs add up, and research estimates that maintaining a person living on the street or in a shelter can cost between $35,000 and $150,000 annually, accounting for added expenses due to ED use and contact with law enforcement.[25] As a result, increasing housing stability and ending homelessness are critical factors in reducing health system costs.
However, the lack of affordable housing and high rent costs are barriers to achieving housing stability. HUD defines households with incomes 30% or more below their area median as “extremely low income,” and in 2016 the National Low Income Housing Coalition found that only 3.2 million affordable housing units were available for the 10.4 million extremely low-income households in the United States. Without access to affordable housing, 75% of extremely low-income households are severely cost burdened, paying 50% or more of their income toward housing costs.[26] These housing shortages have a particular impact on individuals with disabling conditions. A 2014 study showed that the national average rent for a modest one-bedroom unit exceeded 100% of monthly Social Security Supplemental Security Income (SSI) payments, and the national average rent for a studio/efficiency was equivalent to 90% of monthly SSI payments.[27] Housing subsidies, such as HUD’s housing choice vouchers (HCVs), are critical to assisting individuals in accessing safe, affordable housing without being too cost burdened to meet other basic needs such as food and transportation.
Individuals with complex health needs, particularly those with severe mental illness and co-occurring substance use disorders, often have difficulty in maintaining housing without appropriate supportive services, even with the provision of affordable housing.[28] Increased access to low-barrier, permanent housing with wraparound supportive services is essential to meeting the needs of this population. Key supportive housing services include medical and psychiatric treatment, case management, and resources designed to support independent living, which are often funded through Medicaid.[29]
Income stability is critical to retaining housing for individuals who have disabling conditions, and cash benefits and health insurance provided by Social Security disability programs, SSI, and Social Security Disability Insurance (SSDI) make it possible for these individuals to access important treatment and supportive services. However, despite high levels of disabling conditions, many individuals experiencing homelessness never apply for benefits, and those who do have a very low chance of approval without receiving active assistance in documenting their disabilities.[30] Nationwide, an average of 28% of all initial SSI/SSDI applications are approved, and this figure can be as low as 10% to 15% among individuals experiencing homelessness.[31,32] Denials typically result from the Social Security Administration’s inability to contact individuals, missed appointments, and, more generally, lack of adequate documentation.[33] People experiencing homelessness face many challenges when applying for disability benefits, including inconsistent treatment, difficulty in locating medical records, lack of a stable address or telephone number for contact with Social Security, and difficulty in understanding complex and fragmented application processes.[32]
Further impeding income stability is the high prevalence of unemployment (estimated to be as high as 80% to 90%) among individuals experiencing homelessness, particularly those with severe mental illness. Frequently cited barriers to employment include difficulties in obtaining psychiatric care, substance use, criminal histories, lack of child care, and limited education. Lacking a stable address, phone, work attire, and transportation further compounds barriers to stable employment.[34,35] While day labor positions may provide limited income for homeless individuals, particularly those with lower educational attainment and criminal and alcohol use histories, they are not a reliable form of income due to exploitation and inequality in the day labor market.[35] Increasing access to permanent, supportive employment options among individuals experiencing homelessness is critical for income stability.
Finally, criminalization measures in effect across the United States that target activities associated with homelessness are not only ineffective in reducing homelessness and costly to enforce but serve as a barrier to income and housing stability. In 2016, the National Law Center on Homelessness and Poverty conducted a survey of the municipal codes in 187 cities and found that despite a shortage of housing and shelter options, many cities are choosing to criminally punish individuals for carrying out life-sustaining tasks such as sleeping in public, loitering, sitting or lying down in public, sleeping in vehicles, sharing food, and panhandling. The survey results showed that 53% of cities prohibit sitting or lying down in public places, 43% prohibit sleeping in vehicles, 76% prohibit begging in particular public places, and 9% prohibit sharing food with people experiencing homelessness. These criminalization measures do nothing to address the underlying causes of homelessness, as most police interventions are temporary and result in a fine that homeless individuals are often not able to pay, exacerbating their financial instability.[36] Criminalization of these measures is costly for taxpayers to enforce, and a study in Colorado showed that six of the state’s cities spent more than $5 million enforcing 14 anti-homelessness ordinances.[37] Criminal records negatively affect an individual’s access to housing, benefits, and employment, and these barriers are not limited to homeless adults. Homeless children and youths are also subject to liability under these ordinances, along with ordinances that apply uniquely to them such as status offenses and truancy.[36]
As documented above, individuals and families experiencing homelessness are more vulnerable to health inequities and have disproportionately poor health outcomes. The World Health Organization emphasizes that improving social determinants of health is critical in achieving health equity within a generation. Improving the conditions of daily life for vulnerable individuals, tackling the structural drivers of inequities (e.g., ineffective social programs or inequitable economic opportunities), and raising public awareness of social determinants of health are crucial to this process,[38] as are recognizing homelessness in the United States as a public health issue, addressing barriers hindering access to treatment and housing, and continuing to support research that measures the effectiveness of social policies designed to end homelessness.
Recent successes in addressing homelessness demonstrate that there are available solutions to this public health issue. From 2005 to 2013, overall homelessness decreased by 20%, while chronic homelessness decreased by 42% and homelessness among veterans by 24%.[3] These reductions have been attributed, at least in part, to concurrent dissemination and implementation of data-driven, results-oriented approaches to housing and homelessness.[25] These interventions vary, as does the quality of evidence supporting them, according to differing types or characteristics of homelessness and the unique barriers faced.
Evidence-Based Strategies to Address the Problem
Numerous evidence-based strategies are being employed to end homelessness by increasing access to housing options and supportive services for housing stability. Examples of these evidence-based strategies are described below.
Housing First model: The Housing First model was developed as an alternative to the paradigm that individuals need to achieve “housing readiness” by attaining sobriety, complying with psychiatric treatment, and learning skills for independent living prior to qualifying for a permanent housing placement. In contrast, the Housing First model is based on the tenet that housing is a basic right and should be provided without prerequisites; this harm reduction approach values consumers’ choices in terms of their own needs and readiness for treatment or substance use reduction.[39] While the Housing First model encourages the provision of supportive wraparound services, its use is not limited to permanent supportive housing, and the principles should be applied whenever housing services are provided to individuals experiencing homelessness.
A review of 31 studies focusing on outcomes associated with the Housing First model showed that the model resulted in faster housing placements than traditional treatment-dependent programs as well as increased levels of housing retention, including among individuals with co-occurring substance dependence and mental disorders. The increased levels of housing retention also led to decreases in costly shelter use and fewer jail stays. In addition, several of the studies documented that participants reported a higher perceived quality of life and sense of choice.[40] Conversely, in another study, individuals who had to enter interim housing and wait for an available permanent housing placement reported worsening mental health symptoms, reduced their engagement with service providers, and had inconsistent progress in non-housing-related recovery goals.[39]
Interventions incorporating the Housing First model are not limited to urban settings. While rural settings may have additional challenges (e.g., limited housing stock), the Housing First principles can be equally effective. An evaluation of Housing First interventions implemented in rural areas in Vermont demonstrated an 85% housing retention rate over 3 years.[41] A critical aspect of the successful implementation of this model was landlord engagement, particularly among tenants with criminal histories or substance abuse disorders. In a study of landlord perceptions of participating in Housing First, many of the landlords reported seeing the social value of helping individuals integrate into the community. These landlords indicated that they were more willing to rent to tenants whom they would have not rented to before.[42] Innovative landlord engagement at the community level can result in significantly increased housing opportunities for people experiencing homelessness. Policies aimed at ending and preventing homelessness should prioritize use of the Housing First model given its positive housing, health, and economic outcomes .
Housing subsidies, including housing choice vouchers: More than 5.1 million low-income households in the United States receive federal rental assistance so that they can afford housing, with funds directed to elderly citizens, people with disabilities, veterans, and working families. Federal rental assistance is delivered through a number of programs, including public housing, Section 8 project-based housing, U.S. Department of Agriculture initiatives, and the HCV program. The HCV program serves the largest number of households, 2.1 million, and allows very-low-income families, individuals with disabilities, and the elderly to choose safe, affordable housing in the private market. Public housing agencies (PHAs) receive HUD funding to administer the program and pay a subsidy directly to a landlord on behalf of the family; the family is responsible for the cost difference between the actual rent of the property and the subsidized amount, which is typically 30% of the family’s monthly adjusted income.[43]
Federal rental assistance allows individuals and families to exit homelessness and greatly reduces housing instability and overcrowding. In addition, research into the effects of vouchers on families with children indicates that voucher use cuts foster care placements in half (as children are not removed from homes due to housing instability) and greatly reduces the number of moves from one school to another, which in turn improves academic performance and reduces behavioral and attention problems. By spending less on rent, families are also better able to meet food and other basic needs such as transportation, educational support for children, and health care.[44] In HUD’s Family Options Study, which evaluated the effectiveness of various types of housing support for homeless families, researchers found substantial long-term benefits from the use of permanent supportive housing subsidies. Families who received priority access to these subsidies reduced their housing instability by more than half, as evidenced by reductions in subsequent stays in shelters and places not meant for human habitation. They also showed improvements in multiple measures of adult and child well-being and reduced their food insecurity.[45]
Permanent supportive housing: Permanent supportive housing is a combination of safe, stable housing and supportive services for individuals who have serious mental illnesses or other disabling conditions and who need additional services to remain stably housed. It is recognized by the Substance Abuse and Mental Health Services Administration, HUD, and the U.S. Interagency Council on Homelessness as an evidence-based practice for chronically homeless individuals or those with complex health needs. Through this model, individuals receive flexible support based on their choices and needs, which can include case management, substance abuse or mental health counseling, assistance in increasing their income through employment or disability benefits, training in independent living skills, vocational services, and other tenancy support services.[46] These supportive services are a critical part of improving housing stability outcomes in permanent housing programs. An example of a federal permanent supportive housing initiative is the HUD-VASH (Veteran Affairs Supportive Housing) Program, which combines HCV rental assistance for homeless veterans with case management and clinical services provided by the Department of Veterans Affairs (VA). From 2008 to 2015, more than 85,000 HUD-VASH vouchers were awarded.[47] A review of research on permanent supportive housing showed that this model is effective in reducing homelessness, increasing housing stability, and reducing hospitalizations and ED use.[48] There are multiple types of permanent supportive housing programs that can facilitate better health outcomes and promote housing stability, including Housing First, harm reduction, and consumer-driven program designs.[49,50]
Numerous additional studies have documented that supportive housing for chronically homeless individuals reduces expensive ED usage. A study in Oregon revealed a 55% reduction in Medicaid claims for individuals 1 year after they obtained housing, while research in Chicago showed that housing and supportive services led to a 29% reduction in hospital days and a 24% reduction in ED visits.[51,52] In addition, the New York Frequent Users Service Enhancement initiative, which provided supportive housing to 200 individuals with frequent jail and shelter stays, documented that 91% of participants remained stably housed after 12 months, and annual total costs for crisis medical and behavioral health care services were reduced by $7,308 per person.[53]
The levels and types of support services offered are intentionally designed to be flexible and adaptive to the population being housed by a given program. The variety and extent of the service needs of tenants in permanent supportive housing must influence the types of services provided. Funding for effective permanent supportive housing program delivery should ensure appropriate staff-to-tenant ratios and services. Some tenant populations (particularly those with special needs) and services are more resource intensive than others, requiring programs to increase the proportion of costs relative to housing subsidization and operating costs. Insufficient resources allocated to supportive services result in underperformance with respect to program outcomes (e.g., housing instability, unsafe conditions for tenants and staff).[54]
National Housing Trust Fund: The U.S. Congress established the National Housing Trust Fund (NHTF) under the Housing and Economic Recovery Act of 2008. This block grant, administered by HUD, is intended to supplement other federal and state efforts to provide safe, affordable housing for extremely low-income households and families experiencing homelessness. States are allocated a minimum of $3 million per year and use these funds to acquire or construct new affordable housing units and rehabilitate existing units; 80% of the funding is dedicated to rental housing. The NHTF began receiving contributions from Freddie Mac and Fannie Mae in 2014, and HUD allocated the first $174 million in May 2016.[55] This federal support for increasing the number of affordable housing units is invaluable in terms of ensuring housing stability and ending homelessness; however, additional funding mechanisms to increase contributions to the NHTF are necessary to ensure that states and the District of Columbia receive enough funds to support these goals.
Increasing income support to promote housing stability: The federal strategy to end homelessness, Opening Doors, emphasizes the need for individual economic security in order to achieve housing stability. Programs aimed at increasing income stability and financial independence should be integrated into housing and health interventions, as the provision of housing alone will not be sufficient to end and prevent homelessness.[56]
In the case of individuals with disabling conditions, increasing access to Social Security disability benefit programs or VA disability benefits for veterans helps provide the cash benefits and health coverage that are key for housing retention. With respect to overcoming barriers in application processes, research indicates that comprehensive application assistance can increase the approval rate for homeless individuals from 28% to 73%.[33] Additional research documents that programs providing SSI/SSDI application assistance to homeless individuals exiting the justice system report increased housing stability and reductions in rearrests and incarcerations, thus decreasing system costs.[57]
Increasing income stability through employment is also critical to housing stability, and while unemployment rates are high among individuals experiencing homelessness, research shows that most members of this population, particularly those with severe mental illness, want to work and are capable of working.[58] Supportive employment services have documented success in increasing access to and retention of competitive employment. A 2014 study revealed that, among individuals with psychiatric disabilities, those who received employer-provided accommodations for their disabilities worked 7.68 more hours per month and retained their job for almost 7 months longer; also, each job accommodation individuals received reduced their risk of job termination by almost 13%.[59] In addition, the Individual Placement and Support (IPS) model, which focuses on competitive employment, consumer preferences, rapid job search, and individualized job support and does not require extensive preemployment readiness or training, has demonstrated success across 23 randomized controlled trials involving individuals with mental illnesses. Across these studies, an average of 60% of individuals using the IPS model obtained competitive employment; also, these individuals retained their initial job placement for 8 to 10 months and reported higher self-esteem and reduced mental health service use.[58]
Homelessness prevention programs: While interventions for those experiencing literal homelessness are critical, public policy and resources should also focus on preventing homelessness, particularly among youths, families, and veterans. Youths exiting foster care are at high risk of homelessness due to lack of social support, poorer health outcomes, and underemployment, and many young homeless families are led by those who recently exited foster care.[16] Homeless prevention programs for youths transitioning from foster care should include increased access to mentoring, employment and education support, and connection with permanent housing.[16,25] In addition to educational and vocational resources, supportive services for families who are at risk of homelessness should focus on identifying and addressing developmental delays in children, increasing access to treatment for parental substance abuse or mental health conditions, and providing parental support.[15] Multidisciplinary teams working across schools, clinics, and social services are critical in identifying children and families in need and arranging for appropr
