In this series
In this series
Here’s a solution to homelessness: Give every homeless person an apartment! But the past and present of this approach suggest its simplicity is not paired with the realism, prudence, or community that will truly help many who are homeless.
Throughout much of the 20th century, compassionate Americans offered a basically consistent deal to homeless addicts and alcoholics: Get help for your addiction and we’ll help you get off the street. But in 2006, a New Yorker article by Malcolm Gladwell helped to turn that process upside down: First the house key, then—maybe—a change in behavior.
Gladwell’s “Milllon-Dollar Murray” narrated the picaresque tale of Murray Barr, a homeless man whose constant trips to emergency rooms ran up $1,000,000 paid by taxpayers. As bicycle cop Patrick O’Bryan explained, “He would get picked up, get detoxed, then get back out a couple of hours later and start up again.”
Sometimes police “drunk tanks” sufficed to handle these law enforcement encounters, but Dr. James Dunford detailed the issues inebriates like Murray faced: “They are drunk and they aspirate and get vomit in their lungs and develop a lung abscess. … [They’re] prone to just falling down and cracking their head and getting a subdural hematoma … [and] devastating liver disease that only adds to their inability to fight infections.” Individual hospital bills for Murray and others like him could run into the six figures.
Murray wasn’t helpless: Once forced to enter “a treatment program in which he was under the equivalent of house arrest,” Gladwell reported, “he thrived. He got a job and worked hard. But then the program ended.” Murray went back to the streets—and the hospitals.
Gladwell detailed research in Boston that followed 110 chronically homeless people for five years. In that time, 33 died and seven more went to nursing homes, but “the group still accounted for 18,834 emergency-room visits—at a minimum cost of a thousand dollars a visit.”
A San Diego study likewise tracked 15 chronically homeless addicts for 18 months: They had 417 emergency room visits with average bills of $100,000 each: “One person—San Diego’s counterpart to Murray Barr—came to the emergency room 87 times.” Such data led to debate. Social conservatives argued for tough treatment of the kind that had temporarily worked for Murray—but that cut against notions of self-expression.
Progressives asked: Weren’t constraints narrow-minded? Shouldn’t housing be a right for all, regardless of behavior? The leading progressive voice in this debate was Sam Tsemberis, a Columbia University graduate with a psychology PhD who in 1992 had founded Pathways to Housing New York City. Instead of saying people should escape addiction before receiving house keys, Tsemberis insisted on “housing first.”
The Washington Post later summarized his approach as “so simple children could grasp it”: “Give homes for the homeless, and you will solve chronic homelessness. … Give them final say in everything—where they live, what they own, how often they’re counseled.”
Tsemberis told the Post, “People thought this was crazy. They said, ‘You mean even when someone relapses and sells all the furniture you gave them … [to pay for] drugs, you don’t kick them out?’ And I said, ‘No, we do not.’”
Thanks to Gladwell, politicians and officials inclined to embrace housing first had an answer to those who thought it was crazy: Housing first would save money for taxpayers who’d been supporting million-dollar Murrays. Dennis Culhane of the University of Pennsylvania explained this to readers of the European Journal of Homelessness: Advocates inspired people to use “‘cost analyses’ of chronic homelessness as a means of generating political will to leverage funding for the local plans.”
Gladwell’s “story has served as an inspiration,” Culhane said. And yet, Culhane acknowledged, detailed studies of the human and financial results of giving no-strings-attached keys to homeless people were not convincing: “Few, if any, have involved comparison or control groups. … Collectively they demonstrate that homelessness among some people can be costly to society … [but] their real goal has been to garner more resources and support for local housing initiatives.”
Instead of saving tax dollars, housing first boosted government budgets. Critics note that these programs “significantly increased public expenditures for the homeless,” with almost all eggs placed in the housing first basket.
Nevertheless, in November 2013, the Department of Housing and Urban Development (HUD) started stipulating housing first as official policy: HUD’s Continuum of Care funding notice said housing should come “without preconditions (such as sobriety or a minimum income threshold) or service participation requirements.”
That was unusual for a state or federal program. Unemployment benefits require recipients to look for jobs. The Temporary Assistance for Needy Families program generally requires beneficiaries to work or advance their education. Housing first, which became known as Permanent Supportive Housing (PSH), did not. One result: A National Academies of Sciences, Engineering, and Medicine study in 2018 found “no substantial published evidence as yet to demonstrate that PSH improves health outcomes or reduces health care costs.”
A federal housing report in 2020 found the same, although progressive critics slammed its Trump administration origins and soon slapped an “Outdated” label on every page of the online version. Looking back at the fiscal appeal when housing first was introduced, it’s clear that fighting homelessness without dealing with untreated mental illness and substance-use disorder is a losing prop bet.
Rapid housing help can be useful for those thrown out of work and suddenly homeless. But former homelessness program administrator Michael Ullman in Household Deformation observed that after spending years on the streets, people “have a very high prevalence (over 50 percent) of serious mental illness (schizophrenia, bi-polar disorder, post-traumatic stress disorder) and debilitating substance-use problems (up to 80 percent).”
Housing First can work for people who realize they have serious mental illnesses—if it’s paired with 24-7 on-call assertive community treatment (ACT), the gold standard of community psychiatry. But ACT requires a large staff-to-client ratio that few programs have and, given financial considerations, are unlikely to muster. The flaws in housing first show once again how relationships outrank real estate: Some opposed to treatment may accept help once caseworkers have built trust, but without preliminary bonding, hope sinks.
Overall, Housing First did not improve health outcomes because isolating the ill in apartments often left them facing their demons alone. It placed people out of sight and left them sometimes out of mind. That’s convenient for our tendency not to love our neighbors as ourselves—but it’s not helpful.
What about the financial savings? They might have come had the housing in question been more affordable, single-room units with communal bathrooms and kitchens. But, as Ullman found, housing first apartments were “often cost-prohibitive to build in large numbers because they must meet the norms and expectations of the wealthy. Many middle-class advocates and social services professionals can’t imagine sharing a bathroom”—and everyone is supposed to have at least 500 square feet. In cities such as Los Angeles and San Francisco, housing first entailed per-person expenditures of more than $500,000.
Actress Greta Garbo complained in 1939, “I am almost always alone.” She was also desperately unhappy. Homeless people given their own apartments are often the same, for we are apparently made for life in community.
As for how to do better than Housing First, this is my last column on homelessness for Christianity Today before my retirement at the end of this week. If you wish to read the rest of the series, you can find it—and writing on other issues—at marvinolasky.substack.com.
