Putting housing first instead of last in homelessness policy

This blog post is authored by current MPP student Fiona Wilson, who prior to coming to Cambridge worked for a senior cabinet minister in Alberta, Canada.

The MPP provides several opportunities for students to explore areas of policy outside of the regular curriculum. These include the opportunity to customize research topics for two policy analysis papers, choose a work term organization, and attend lectures and seminars across the university. This flexibility has encouraged me to explore an interesting area of social policy – homelessness policy.

Before embarking on the Cambridge MPP, I worked for a senior cabinet minister responsible for human services in Alberta, Canada. Social policy has been a particularly interesting field in which to be involved, as it brings with it a set of special considerations. Policymakers may need to spend on preventative interventions that address the underlying causes of social problems, as opposed to costly remedial spending. Furthermore, a balance must be struck in policy development between providing the continuum of support clients require to transition to independence and preventing abuse of the system. At a time when many governments are particularly cautious with their finances, social policymakers must think outside the box to deliver policy solutions that make economic sense. In light of the above, the Government of Alberta has re-assessed its approach to homelessness policy by adopting a ‘Housing First’ approach. For this jurisdiction, and many others, this policy choice has marked an important transition from managing the issue to ending it.

The Housing First model was developed in New York City in the early 1990s, and has since spread due to its success in effectively housing homeless individuals with complex needs, and supporting them as they work towards independence. A distinction must be made between those who are chronically homeless and those who are homeless on an episodic basis, with the former group being the primary target of the Housing First approach. This approach provides chronically homeless individuals with permanent housing, whether it be a private rental or a unit in a purpose-built complex. Clients are then supported with services to address the underlying causes of their chronic homelessness, including employment assistance and mental health and addiction counselling.

The economic case for a Housing First approach is promising. Utah’s Housing First program has reduced homelessness in the state by 78% since its inception in 2005. The $11,000 cost of housing a client for one year has more than offset the $16,670 annual cost of publicly funded services for a chronically homeless individual, including emergency room admissions and policing costs [5]. In many other jurisdictions, including those with a high cost of living such as New York, the cost-benefit analysis has proved similarly strong [1].

The Housing First approach is developed based on two key principles: ‘that 1) housing is a human right, not a reward for clinical success and 2) once the chaos of homelessness is eliminated from a person’s life, clinical and social stabilisation occur faster and are more rewarding’ [1].  A feature of the Housing First model is its lack of stringent qualifying conditions for entry into the program, recognizing that the assessment of housing readiness before housing provision is a feature of alternative models that has served to perpetuate the cycle of homelessness.

Homelessness policy often constitutes a ‘housing readiness’ staircase, or continuum of care model, whereby homeless individuals are progressed through a system of emergency shelters and transitional housing programs, with each level moving them closer to independent living [1]. Housing First, by contrast, recognizes that stable housing is the most urgent and primary need for a homeless individual. The approach acknowledges that the very requirements of housing readiness, which often require clients to address addiction, employment and mental health concerns before moving up the staircase, are extremely difficult to address when the client is battling homelessness [1]. The challenges faced by the chronically homeless population can take years to overcome, and housing readiness policies can serve to make the end goal of permanent housing an impossible one. The immediate transition to permanent, independent housing has several structural advantages. One such advantage of the approach is that it does not encourage clients to mix with others at different stages of their recovery, thereby preventing relapse by association or cue. Furthermore, the approach does not base continued tenancy on coercion, including mandating abstinence from drugs or alcohol, recognizing that a harm-reduction approach to addiction is the most appropriate one for difficult and complex cases. Furthermore, a four-year longitudinal study has found that the cost of traditional housing readiness programmes is nearly double those of housing first initiatives, at $40K to $50K compared to $22.5K per annum [1].

Creative thinking in policy acknowledges and examines prevailing paradigms, and encourages new ways of approaching an issue. The housing readiness model seemed like a logical, risk-averse approach to homelessness policy. In hindsight, it has contributed no substantial reduction in homelessness. Perhaps the dominance of this programme is accentuated by the fact that the suggestion of giving homeless individuals housing with no strings attached has historically been met with considerable opposition. Housing First is a possibly permanent solution with a growing body of evidence to support its effectiveness– yet it is a policy option that many jurisdictions are reluctant to implement.

The MPP has encouraged us, as future policy professionals, to engage ourselves both creatively and critically at all stages of the policy process. When approaching a policy issue, we are learning to ask a number of probing questions. Are we applying evidence to policy too late in the process, in support of a predetermined ideology, or with improper causation? Is the current approach ignoring the true needs of the end user or suffering from an optimism bias? Are we confusing a means with an end, or asking the wrong question altogether?

In the case of homelessness policy, many jurisdictions have been missing the mark by failing to address the root cause of homelessness: the fact that an individual does not have a home. Perhaps the most ineffective policy choice adopted thus far has been the criminalization of homeless activity. This often occurs at the municipal level, in which ordinances are passed that prohibit activities such as sleeping or begging in public spaces by imposing criminal sanctions, such as fines or jail time, on offenders [2]. These policies have exacerbated the issue, as criminal records and fines create barriers to the ultimate goal of independence and re-employment. Further, they shift homeless populations away from services and create new costs associated with criminalization, including correctional and policing outlays.

A key feature of Housing First is its ability to empower and enable. I will not forget the day I accompanied my boss to the opening of a supportive housing facility. After touring the carefully designed complex, we met one of the tenants. At 60 years old, he had spent the majority of his life on the streets. For the first time, he told us, he had been treated with the dignity and trust that energized him to make a change. This sense of pride was something he had developed a fighting determination to keep. It was not until he had the stability of a place to retire to each night that he was able to deal with the issues from his childhood that led to his cycle of addiction, and ultimately kept him on the streets. It was difficult in the past, he said, to focus on the long-term when he had to concern himself with the short-term: his safety or where he would sleep that night. This first-hand account lends support to the notion that the ability to tackle difficult issues need not be a precursor to housing provision, but may indeed flow from it.

A 2006 article in the New Yorker by Malcom Gladwell drew attention to a misconception about the nature of homelessness by recounting the story of a chronically homeless man in Nevada struggling with alcoholism. ‘Million-Dollar Murray Barr,’ as he was called, was estimated to have run up hundreds of thousands of dollars in health care, social care and policing bills during his years on the streets [3].  Members of the local police force had reported that they routinely spent half of their days tracking cases like Murray. As Gladwell points out, the homelessness issue is often thought to be analogous with a normal distribution, in which the majority of the homeless population is in a ‘state of semi-permanent distress’, requiring policy interventions that would ‘raise the performance of the middle,’ including temporary shelters and soup kitchens. However, it has become clear over the years that the issue is more appropriately analogous to a power-law distribution, whereby a small population of the homeless population described as chronically homeless (often accounting for 10% of the total), weigh disproportionately on high-cost, publicly funded services [3]. A study by the University of California San Diego tracked 15 chronically homeless individuals over a period of a year and a half, recording 487 emergency room admissions for the group within that time period: a figure that equated to nearly 100,000 dollars in medical bills per person [3]. Medical professionals report that the chronically homeless often seek medical help for complex pneumonia or physical injury, exacerbated by addictions issues and weather conditions. From an economic standpoint, it makes sense to permanently house these individuals but from a moral standpoint, as Gladwell makes clear, the solution often seems unfair as millions of individuals across the country work, and at times struggle, to pay their own rent.

Nevertheless, if fairness were the only factor at play, we would have to ignore promising evidence and continue to invest in the management of homelessness. The fact remains that permanent housing is the only permanent solution, and by offering housing first instead of last, there is hope that we can end the cycle.

The MPP, with its makeup of international students and opportunities for individualized research, encourages the cross-jurisdictional and international comparison of policy approaches. Although Housing First is largely recognized as a best practice in North America, the concept is comparatively underdeveloped in a UK context. As I begin research for my second policy analysis paper, I look forward to examining the potential for Housing First to complement or replace existing provisions for homelessness policy in the UK.

References

[1] http://www.endhomelessness.org/library/entry/supportive-housing-is-cost-effective

[2] http://nationalhomeless.org/publications/crimreport/CrimzReport_2009.pdf

[3] http://www.newyorker.com/archive/2006/02/13/060213fa_fact

[4] http://england.shelter.org.uk/professional_resources/policy_and_research/policy_library/policy_library_folder/housing_first_-_a_good_practice_briefing

[5] http://www.nationofchange.org/utah-ending-homelessness-giving-people-homes-1390056183

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