The homeless population can be loosely divided into three groups: the transient homeless who use a shelter once; the episodic homeless who return to the shelter repeatedly, but for brief periods; and the chronic homeless, who rely on homeless shelters for long periods. The chronic homeless are also much more likely to have issues with substance abuse, disabilities, and health issues.

If one looks at all the people who are homeless during a year, the chronic homeless are a fairly small share–maybe 10% or so, depending on the details of how the group is defined. But this group also takes up half or more of all the homeless shelter days. When not at homeless shelters, or outside on the street, they may instead end up in hospitals or in some cases in jails. The chronic homeless may be the most visible, and most troubling, part of the homeless population.

There are two broad models for how to address the chronic homeless, which go under the headings of “treatment first” and “housing first.” Joseph R. Downes makes the case for the second in “Housing First: A Review of the Evidence” (Evidence Matters: US Department of Housing and Urban Development, Spring/Summer 2023, pp. 11-19).

As Downes described it, these two paradigms both emerged in the 1990s. With treatment first, the process is a “staircase” model where as the person shows a commitment to sobriety and treatment, they can move from emergency to temporary and perhaps to permanent housing. With housing first, an early program required only that participants pay 30% of income for housing (which in practice often meant 30% of the cash benefits they were receiving from Supplemental Security Income) and that they meet with a staffer twice a month. The George W. Bush administration endorsed a housing first approach, and it has guided federal homelessness programs since then.

My working assumption is that readers of this blog may have strong visceral or philosophical reactions to treatment first and housing first. But in addition, readers would like to know about the studies of what actually works. The gold standard for methodology in this areas are “randomized control trials,” in which people are randomly assigned to either a treatment first or a housing first approach. Downes writes:

To assess the effectiveness of Housing First and the role of consumer choice, a randomized controlled trial (RCT) was performed on the Pathways to Housing program in 2004. Participants were assigned randomly to either a Housing First experimental group or a local Continuum of Care control group to receive treatment as usual (TAU). Eligibility for this study reflected key characteristics of the chronically homeless population: participants must have spent half of the previous month living on the street or in public places, exhibited a history of homelessness over the previous 6 months, and been diagnosed with an Axis I mental health disorder. The results indicate that Housing First participants experienced significantly faster decreases in homeless status and increases in stably housed status than the TAU group did, with no significant differences in either drug or alcohol use. Overall, the Housing First experimental group demonstrated a housing retention rate of approximately 80 percent, roughly 50 percentage points above that of TAU, which, the authors noted, “presents a profound challenge to clinical assumptions held by many Continuum of Care supportive housing providers who regard the chronically homeless as ‘not housing ready.’”

Four major RCTs have been performed to compare the effectiveness of Housing First programs with treatment first programs. Three of these RCTs were conducted in the United States, and the other was conducted in Canada. In a review of these RCTs, Tsai notes that two RCTs conclusively found that Housing First led to quicker exits from homelessness and greater housing stability than did TAU. In the Canadian trial, an RCT in five of Canada’s largest cities known as At Home/Chez Soi, analysis revealed that, in findings similar to those of the American RCTs, “Housing First participants spent 73% of their time in stable housing compared with 32% of those who received treatment as usual.” Baxter et al. also performed a systematic literature review and metanalysis of these four RCTs, finding that Housing First resulted in significant improvements in housing stability. This study also found that no clear differences existed between Housing First and TAU for mental health, quality of life, and substance use outcomes …

In short, the findings seem to be that using permanent housing as a carrot to encourage the chronic homeless to go through treatment doesn’t work well. The result is too often that neither effective treatment nor permanent housing results. The housing first approach at least does better on providing housing, although by itself it doesn’t seem to improve the underlying issues that drive the problems of the chronic homeless, either.

However, the housing first approach may offer some additional benefits, although the evidence on these themes is not always consistent across studies. First, one of the randomized studies found:

[P]articipants in Housing First reported a significant reduction in costly emergency room visits and hospitalizations compared with TAU — 24 percent and 29 percent, respectively. Based on these findings, Basu et al. evaluated the relative costs of Housing First versus treatment first programs, assessing differences in hospital days, emergency room visits, outpatient visits, days in residential substance abuse programs, nursing home stays, legal services (including days in incarceration), days in shelter housing, and case management between the two programmatic models.26 Basu et al. found that participants in Housing First programs had decreased costs because they spent fewer days in hospitals, emergency rooms, residential substance abuse programs, nursing homes, and prisons or jail. On the other hand, Housing First participants incurred higher costs from higher outpatient visits per year and a greater number of days in stable housing than TAU participants. Ultimately, a comprehensive cost analysis from this RCT found that Housing First saved $6,307 annually per homeless adult with a chronic medical condition, with the highest cost savings occurring for chronically homeless individuals, at $9,809 per year.

Other randomized studies do not back up these cost savings, which often means that something is going on in the details of how the programs or run or how the costs are being measured that doesn’t match up across the studies.

The other gain from housing first involves family dynamics, like issues of spousal abuse and child welfare. Downes writes:

Recently, a team from Michigan State University, with support from the Washington State Coalition Against Domestic Violence, the Office of the Assistant Secretary for Planning and Evaluation in HHS, and the Gates Foundation completed a study to assess the effects of Housing First programmatic assistance on domestic violence survivors experiencing homelessness. For this program, adherence to the Domestic Violence Housing First (DVHF) model included mobile, housing-focused advocacy; flexible financial assistance for housing and other needs; and community engagement. The study found that adherence to this survivor-centered, low-barrier service model yielded a statistically significant difference between DVHF recipients and those receiving TAU, with DVHF recipients experiencing improved outcomes in the categories of housing instability, physical abuse, emotional abuse, stalking, economic abuse, use of the children as an abuse tactic, depression, anxiety, posttraumatic stress disorder, and children’s prosocial behaviors.

I wouldn’t want to downplay the practical and logistical difficulties of providing housing to the chronic homeless, and then working on their other life issues afterward. But in a situation of imperfect alternatives, the housing first approach seems the better option.