Homelessness is an issue for individuals all across the country who lack stable housing and the finances for other necessities like water, food and safety. Homelessness occurs for several reasons, including poverty, mental illness, and substance abuse. Many negative outcomes have been reported as a result of homelessness, including negative impacts on physical health, worsening of mental illness, worsening of substance abuse, and negative outcomes for children and youth. Several practices have been implemented to avoid such outcomes including emergency shelters, food kitchens, transitional housing, and Housing First approaches. Practices in Housing First have the greatest impact to report.
Homelessness - The U.S. Federal Government defines homelessness as individuals and families “who lack a fixed, regular and adequate nighttime residence who will imminently lose their primary nighttime residence,” or “who are fleeing, or are attempting to flee...dangerous or life-threatening conditions that relate to violence.” 1
Chronic homelessness - The U.S. Federal Government defines Chronic homelessness as homeless adults (age 18 or over) with a disability who have been continually homeless for a year or have been homeless for at least 12 months over the past 3 years. Persons in this group must have been living in places considered unsuitable for human habitation or an emergency shelter to be considered chronically homeless. 2
Disability - A disability can include a “diagnosable substance-use disorder, serious mental illness, developmental disability, posttraumatic stress disorder, cognitive impairments resulting from a brain injury, chronic physical illness or disability, the disease of AIDS, or any conditions arising from the etiological agency for AIDS.” A disability may also include multiple severe diagnoses in physical or mental health or those who suffer with addiction. 3
Poverty - The United States Census has defined a 2019 poverty threshold dollar amount determined by the number of persons in a household. This threshold is used to measure the spread of poverty in the nation. Households are considered in poverty if their income is below their threshold bracket. 4
Homelessness is a widespread issue in the United States, and it has a great impact on individual health and life satisfaction as well as community cost. On a given night in January 2018, it was estimated that approximately 552,830 individuals in the United States experienced homelessness, 33% of which were families. Among the homeless population, data suggests that nearly 24% were considered chronically homeless 5 and 35% were found in unsheltered living on the streets, in abandoned buildings, and in other locations unsuitable for living. 6
Although this data provides helpful insights, it can be difficult to gather more information on the homeless population due to the constant movement of individuals in and out of homelessness. In 2015, the national average of homelessness was 0.18% of the population, but the regions with the highest rates of homelessness were Washington D.C. with 1.2%, Hawaii with 0.5% and New York with 0.41%. 7 Since half of the homeless population is found in 5 states, namely California, New York, Texas, Florida, and Washington, most of the data in this brief will address these urban areas of the country. 8
Attitudes regarding homelessness have shifted substantially over the last 20 years. A 1997 study regarding the general population’s attitude toward people experiencing homelessness reported that people were more likely to respond to homelessness with high “social distance,” which was defined as a person’s unwillingness to associate with the individual in the community, at work or as a friend. However, a subsequent follow-up survey conducted in 2016 comparing general attitudes toward the homeless over the previous 2 decades reflects a shift in attitude with greater compassion towards those facing homelessness. 9 Participants attributed homelessness more to structural issues such as economic recessions and less to the “laziness” of homeless individuals, and the majority reported a desire to protect the rights of the homeless population. This report is significant when compared with the population in the 1990s that endorsed greater restrictions on sleeping and panhandling in public. 10 This shift in attitude toward acceptance of the homeless population could indicate greater public involvement in addressing the issue of homelessness in governmental aid, volunteer work, and political policy.
Poverty in the United States is defined as living below a certain monetary income threshold determined by family size and composition. As of 2017, 11.8% of the United States population was living below this threshold. 11 Among a sample of families across the United States that had spent at least 1 week in an emergency shelter, data showed that many were in deep poverty, with a median annual income of $7,440. 12 Many homeless individuals in deep poverty are especially affected by minimum wage and housing prices.
Minimum wage contributes to poverty in the United States, eventually leading some to live on the streets even if they are employed. 13 In order to cover the average cost of living in the United States in 2017, it was calculated that the minimum wage would need to be $16.07 per hour for a family of four. This amount accounts for expenses using data for food, childcare, health care, housing, transportation, and other basic necessities. 14 As of 2010, the federal minimum wage was changed to $7.25 per hour. 15 Though more than half of the United States have raised the state’s minimum wage to cover the cost of living in that state, 16 the Bureau of Labor Statistics found that 2.2 million U.S. workers in 2016 were receiving at or below the federal minimum wage rate, not taking tips and commission into account. 17
Studies show that affording a modest 2 bedroom apartment in the United States would require 3 times the minimum wage. 18 Unaffordable rent, especially combined with a low minimum wage, makes it difficult to obtain and retain housing. 19 Affordable housing is defined by the U.S. Department of Housing and Urban Development (HUD) as 30% of household income. 20 The HUD estimates that in 2019 over 12 million renters and homeowners spend more than half of their annual income on housing, often making housing unaffordable and unsustainable. 21
Homelessness most often occurs in urban areas where housing is most expensive due to higher demand for housing. 22 Research shows that price-to-income ratios, which measure the affordability for housing in an area using median house prices and median household income, are highest in densely populated urban areas along the western and eastern coasts of the United States. 23 The high price-to-income ratio does not support the high cost of living, leading many to lose their homes. Homeless rates are also highest in these areas with nearly 17% of the entire homeless population living in New York and 24% in California. 24
Among a sample of homeless U.S. families, 85% had to live in a unit with another family because they were unable to pay rent on their own. 25 This problem may be due to the fact that the nation experienced a $21 average rent increase when comparing inflation-adjusted 5 year estimates of 2007-2011 with 2012-2016 estimates, though there has not been a change in the minimum wage since 2010. 26 Due to the fact that rent and home prices increase year to year at a greater rate than wage increases, residents who do find housing are often unable to keep up with housing payments and struggle to maintain the housing they have. 27
Mental illness is reported among single adults as the third largest cause for homelessness, 28 and it is estimated that about one-third of the current U.S. homeless population struggles with a severe mental illness. This is perpetuated by the cyclical relationship of mental illness and homelessness, as many who are experiencing homelessness are often unable to receive care for mental illness. Individuals with schizophrenia and bipolar disorder are among the most at risk of becoming homeless. 29
Mental illness can affect daily life, often leading to difficulties in relationships with caregivers, family members, and friends who are necessary resources to keep individuals out of homelessness. Those struggling with mental illness may struggle to build healthy relationships and may react irrationally to the help and counsel of others. This behavior causes them to avoid and distance themselves from caregivers who could provide financial resources and shelter. 30
Experiencing mental illness may both contribute to initial home loss and continued inability to achieve housing after becoming homeless. Homeless individuals that have mental illnesses may struggle to escape homelessness because of the difficulty finding and maintaining stable employment. Many individuals suffering from mental illness experience cognitive and behavioral challenges that make it difficult to carry out daily work and earn a stable income in order to maintain housing. 31 A study conducted in 2010 supports this idea by showing that those with mental illness had decreased employment rates, lower wages, and greater rates of absenteeism. 32
Due to limited access to psychiatric help, individuals with mental illness may also self-medicate with drugs, which can lead to an increased risk for homelessness, violence, incarceration, and suicide. 33 Substance abuse can lead individuals to become homeless due to job loss, poorly used resources, and hurt relationships. In fact, substance abuse was responsible for 18.2% of those experiencing homelessness for the first time. 34 Two-thirds of homeless individuals in 2009 reported that substance abuse was a major factor in their becoming homeless, and young adults attributed it to be the single largest cause for their homelessness. 35
Substance abuse is oftentimes combined with one or more other contributing factors that lead to homelessness, including poverty. Statistically significant research suggests that the risk of homelessness increases when substance abuse is combined with poverty. In fact, over one-third of Americans experiencing poverty combined with alcohol or drug dependence were led into homelessness. These factors, when combined, increase the risk of homelessness.
Substance abuse can also lead to job loss because it can cause individuals to miss shifts at work due to disruptive addictions and, ultimately, lose their jobs. 36 In addition to job loss, substance abuse increases the likelihood of misusing finances. As substance abuse is linked to impaired psychosocial functioning, those struggling with substance abuse in poverty may be unable to cope with challenges and manage financial resources to maintain housing. Additionally, those in poverty who struggle to pay their bills often cannot afford the costs of an addiction and end up homeless. 37
Substance abuse and addiction can also disrupt relationships, estranging individuals from housing assistance when faced with extreme poverty. 38 Many homeless individuals report that their problems with drug addiction have created rifts in family relationships which in turn can lead to inability to access resources such as shelter. In fact, several homeless individuals report being evicted from their previous residence by a family member. 39 This loss of a family network removes the resources, financial support, and housing options that relatives could offer to help avoid homelessness.
Homelessness poses a great threat to the physical health of individuals, with more than one-third of homeless individuals experiencing poor health and mortality rates 3 to 4 times higher than the rates of the general population. 40 Poor health outcomes can be seen among homeless individuals staying in shelters and outdoors. Statistics show that the homeless are more likely to suffer from physical and mental illness and substance abuse, and often these individuals die earlier than the general population. 41
Many homeless individuals struggle with poor health due to irregular sleeping and eating patterns, dangerous living conditions, lack of resources, and high-risk behaviors. 42 Many become involved in risky and dangerous behaviors such as drug dealing, stealing, and prostitution in order to survive, the latter leading to health risks such as sexually transmitted diseases. 43 Diseases often advance to stages that are difficult to treat due to lack of prevention and early access to care. Poor hygiene and self-care, due to limited access to showers and clean clothing, also contribute to poor health and can pose a problem for those seeking employment and housing. 44
Additionally, many of those experiencing homelessness do not have the resources to manage physical self-care. Many face challenges in accessing oral and medical care, and oral health tends to be a low priority for those that cannot maintain a home or afford food. 45 In a study of the homeless population in the United States and the United Kingdom, only 27% of those who were homeless sought oral health care when it was needed due to barriers such as cost, fear of treatment, lack of knowing where to find dental care, as well as lack of Medicaid registration in order to receive governmental help. 46
There are many poor health conditions that arise for homeless individuals staying in shelters. Of the nearly 553,000 people experiencing homelessness in 2018, 65% were staying in sheltered locations including emergency shelters, transitional housing units, and safe havens. One study reports the occurrence of many health problems due to lack of hygiene within shelters that were run by the state or by faith-based organizations. Among the health issues noted were high occurrences of tuberculosis and other diseases. 47 Additionally, skin infection is often passed along by close contact in crowded shelters and contaminated sanitation facilities. 48
Several factors contribute to these health issues including poor ventilation and air supply, lack of procedures to confine contagious clients, substandard waste management, poor quality and shortages of drinking water, lack of access to toilets or showers, inadequate laundry services, poor personal hygiene, insufficient handwashing, and food handling strategies. 49 Even with the presence of sanitation structures such as bathrooms and showers, many individuals report feeling uncomfortable or unsafe using the facilities. Due to resource and budget constraints, many facilities are seldom cleaned and disinfected, 50 and there are also physical health threats that come from bedding, mattresses, flooring, and walls of shelters. Other environmental factors contributing to poor health include second-hand smoke, lack of pest control, insufficient fire prevention procedures, absence of areas for diapering infants, and dampness. 51
Many experiencing homelessness are hesitant to stay in shelters and prefer to camp outside due to the drug activity and violence within shelters. 52 However, these individuals are still exposed to unsafe conditions when outdoors. With 35% of homeless individuals sleeping outdoors in 2018, 53 and even more spending the daytime hours outdoors, these individuals must perform many activities outdoors including urinating, panhandling, eating, and sleeping. 54 In a study done on the hygiene of the homeless in Massachusetts, several factors were proven to contribute to poor health. Insufficient access to bathrooms and showers increased risk for infectious and diarrheal diseases such as typhoid and cholera, and lack of access to laundry services increased prevalence of lice, fleas, and mites that transmit diseases. 55 The illnesses and health problems that occur often worsen from poor living conditions on the streets and failure to receive treatment promptly. Limited access to sanitation can also intensify chronic diseases by creating obstacles for treatment adherence. 56
Mental illness is a cyclical issue that contributes to homelessness but is also amplified by homelessness. Among the homeless population, nearly 33% experience a severe form of mental illness 57 compared to only 4.5% of the general population. 58 The most common mental illnesses among the homeless population are depression, personality disorders, psychosis, and substance abuse disorders. 59 Homelessness and its duration can intensify the symptoms of existing mental illnesses and can lead to higher psychiatric distress and substance abuse and lower levels of recovery for those diagnosed with mental illness before becoming homeless. 60
Homelessness decreases the ability to overcome addiction for those already struggling with a substance abuse disorder. The National Coalition for the Homeless found that in 2009, 38% of the homeless population was alcohol dependent and 26% was dependent upon other substances. One obstacle to sobriety is the lack of housing stability and the frequent movement between hospitals and the streets. Another obstacle is the lack of social support due to being estranged from family and friends. 61 Often, those that are homeless prioritize survival and the need to find housing and food above addiction recovery. Others view substance abuse as a way of being accepted into the homeless community. Additionally, drugs are often used to self-medicate. 62
Substance abuse often occurs after becoming homeless due to the high stress of living on the streets, constantly seeking food, experiencing poor health, and being separated from loved ones. Homeless youth ages 12-17 are also very susceptible to substance abuse when homeless, with 71% of runaway, missing, or abducted children experiencing a substance abuse disorder. 63 This result often occurs due to family homelessness, abuse, stress, early substance use, and co-occurring disorders. 64
Children and youth are especially affected by homelessness. The HUD reported that there were 36,361 unaccompanied homeless youth under the age of 25 in 2018, nearly 7% of the total homeless population. This group is also more likely to be unsheltered compared to the general homeless population, with 51% of unaccompanied youth without shelter as compared to 35% of the general homeless population. 65 Of the children found in shelters or transitional housing, more than half are under the age of five. 66
Homelessness affects the emotional development of youth due to the stresses of homeless life. 67 Though many may have experienced trauma prior to becoming homeless due to sexual or physical abuse, the risk of trauma increases after leaving home to live on the streets. 68 Post-Traumatic Stress Disorder (PTSD) rates are reportedly higher among homeless youth than the general population; according to one study, 28% of homeless youth met the criteria for PTSD compared to 8% of youth in the general population. 69 Young children are especially susceptible to the challenges faced in homelessness and many have experienced language delays and emotional problems. 70 Homeless youth are also more susceptible to mental illness, social isolation, and suicide attempts. 71
Homelessness adversely affects cognitive development and academic performance in youth. In the 2011-2012 school year, only 48% of homeless children met math standards and 51% met reading standards. 72 Homeless children are also twice as likely to have a learning disability and 3 times as likely to have an emotional disturbance compared to children that are not homeless. Some of the academic concerns can be attributed to disrupted school attendance. Additionally, half of homeless students are held back for 1 year and 22% are held back for multiple years. 73
Many communities offer emergency resources such as emergency shelters and food kitchens to assist those with immediate needs. Of the nearly 553,000 people experiencing homelessness in the United States in 2018, 65% were found in one of over 10,000 emergency shelters 74 or in transitional housing. 75 Some shelters offer showers, laundry services, and meals for those staying in the facility. 76
One such organization is the Union Rescue Mission, which serves the homeless population of San Diego, California. The organization offers each guest a bed for 90 days, and provides 3 meals each day, showers, haircuts, clean clothes, and medical care. It also offers help in connecting individuals with nearby services. 77 Feeding America is another national organization that provides meals and groceries to individuals experiencing homelessness. This food is distributed through soup kitchens and food pantries. Many of its programs also provide snacks for children and mobile pantries for the elderly. 78
Organizations offering emergency resources do not report on intervention, impact, nor outcomes, because the primary purpose of their service is to temporarily relieve homeless individuals of immediate basic necessities. These resources do not lead to decreased homelessness, but do deliver many outputs assisting the homeless population. Such outputs include the number of individuals served, beds used, meals served, and days of service. Most homeless shelters provide shelter 365 days a year, including holidays, for everyone that comes. 79 Across the nation, over 286,000 beds are designated as emergency shelter beds. 80
The Feeding America Organization serves 46.5 million people each year through its 58,000 food-distributing programs, which include providing meals and groceries. 81 The Union Rescue Mission provides, on average, 3,000 hot meals each day of the year. The shelter also provides beds for an average of 924 men, women, and children, and 62 families each night. They also offer life management classes and referrals for employment, government aid, and housing to connect individuals to the care and help they need for recovery. 82
Although emergency resources can temporarily relieve the need for shelter and food on a daily basis, they do not provide sustainable change to overcome homelessness. Out of desire to accommodate the greatest number of people, these programs do not provide the resources required to connect every individual to therapy, programs for overcoming substance abuse, or providers that can help them find employment and housing. 83 Many homeless individuals also report that they avoid shelters because they prefer the autonomy of living on the streets and dislike the dirty and noisy facilities, crowding, unkind staff, or danger experienced in shelters. 84 Furthermore, despite the large number of shelter beds available nationally, these beds do not always align with the geographic population and may be insufficient for a given area. For example, a survey of shelters funded by the Los Angeles Homeless Services Authority found an overall utilization rate of 78%, yet a shelter in Colorado Springs reported having to turn away at least 20 people each night due to bed shortages. 85
Transitional housing provides individuals with a temporary residence for 24 months and rehabilitation that addresses the root causes of homelessness in order to increase independent living. The goal of these organizations is to end homelessness by helping people overcome the obstacles that contribute to homelessness. These residential treatment programs normally serve families in need of support to leave shelters, cope with trauma, practice job skills, overcome mental illness, or deal with the criminal justice system. They also serve veterans, those with low or no income, and those with unstable housing. 86
An example of a transitional housing program is Attain Housing, which serves a handful of cities in Washington state. They provide housing as well as case management services to help families get back on their feet and eventually attain their own housing. 87
There has not been impact data collected for transitional housing programs, but organizations do supply their outputs and outcomes. Outputs of this program focus on helping individuals get employed and find housing. 88 In the United States, 101,000 beds are currently dedicated to transitional housing units, 89 and shelters and transitional housing served 157,000 families nationally in 2015. Of these families, 70-80% of families exited homelessness to stable housing in 6 months. This intervention is reported to be especially beneficial to survivors of domestic violence or other severe trauma who prefer security and services in a group setting, unaccompanied youth who may be pregnant and are unable to live independently, and those struggling with substance abuse who need intensive support to recover. 90
Attain Housing’s output data states that the organization provides 33,000 bed nights each year for families in need of housing. According to the 2018 impact report, 141 families were served by Attain Housing and 101 moved into a stable home. They served 2702 meals and provided 3,000 hours of case management focused on developing skills for employment, improving credit, and furthering education. The organization’s outcomes include helping 91% of its clients move out of transitional housing to permanent housing. 91 In 2017, case managers helped to increase client income by 71.5%. Of the qualified families, 80% obtained permanent housing after exiting this transitional housing program; 95% of these clients retained permanent housing after 3 months. 92
A difficulty with this intervention that may prevent more individuals from being helped is that families are screened for eligibility. In a study of nearly 3,000 families, 51% lost access to at least 1 transitional housing program after screening. Many did not meet eligibility requirements for income, substance abuse, credit history, education, or work experience, and more than 20% failed to meet employment requirements. Another limiting factor for families is finding a suitable house for the family’s size and composition, which is often not possible. 93
Housing First is a method that uses 2 approaches including rapid rehousing and permanent supportive housing. These interventions challenge the traditional housing approach of providing services to homeless individuals and using progress benchmarks to assess their readiness for housing. Instead, Housing First places individuals in permanent housing without prerequisites beyond typical renters. The program allows clients to set up their own service plan or refuse services completely, recognizing that mental and physical well-being is much more attainable when people have stable housing. 94
The permanent supportive housing approach provides long-term rental assistance, such as rental vouchers, for as long as needed as well as optional services that are not required in order to obtain housing. 95 This approach focuses primarily on individuals who are considered disability who have been continually homeless for a year or have been homeless for at least 12 months over the past 3 years. Persons in this group must have been living in places considered unsuitable for human habitation or an emergency shelter to be considered chronically homeless..">chronically homeless and who are often resistant to the traditional models of service because of their specific needs. Most homeless people have many specific needs, such as chronic illness,disability, substance abuse disorder, and mental illness which can make it difficult to obtain and maintain housing. Rapid rehousing provides short term rental assistance and services. It is provided for a variety of people, including those who find themselves without housing due to a temporary personal crisis and need help to access housing rather than supportive services. This approach includes housing identification, move-in assistance, and case management to help individuals find housing, increase self-reliance, and remain permanently housed. 96
The Los Angeles Housing for Health program utilizes permanent supportive housing, offering rental subsidies and vouchers as well as providing resources for case management, health services, benefit assistance, housing location, eviction prevention, employment, education, and life skills. This program serves individuals with complex health needs and repeated users of hospital services. 97 Community of Hope in Washington D.C. also offers a rapid rehousing program. It provides short or medium-term rental assistance and employment search services. 98
Housing First has helped homeless individuals find housing more quickly, stay out of homelessness longer, and reduce community costs. 99 A randomly controlled experiment was conducted to compare those housed through the Housing First approach with those in a control group using various care programs. Those that were with Housing First reported that over the last 6 months, they had been housed 80–90% of the time, while those that were housed with other services reported only being housed 40% of the time. The Housing First group also used substance and psychiatric services less often than the control group.
Many housing services require sobriety and psychiatric help before allowing anyone to be housed. However, in the study that was mentioned in the previous paragraph, it was concluded by the researchers that, as those in Housing First without requirement of these services beforehand ultimately stayed in housing longer, this requirement shouldn’t be necessary. 100 While studies have shown that this approach improves the mental stability and health of its clients, it also reduces public costs including the cost of shelters, hospitals, mental hospitals, and incarceration. One study reported savings of $31,545 per homeless individual by using Housing First instead of emergency services such as hospitalization, shelter services, and jails. 101
Of those that received housing assistance from Los Angeles Housing for Health, 96% retained stable housing for at least 1 year. Costs for public services decreased by nearly 60% in the year after clients moved into supportive housing, decreasing from $38,146 to $15,358 on average. This reduction in cost reflects shorter hospital stays and fewer emergency room visits. 102 Housing for Health placed over 4,000 people in housing and provided more than 3,000 rental subsidies. They also screened 15,000 individuals for eligibility of federal benefits. 103 Approximately 34% of individuals who exited rapid rehousing services increased their income through paid employment. 104 Additionally, Community of Hope served 297 families in its rapid re-housing program and placed 97% in stable housing. It assisted 37% in gaining or retaining employment. 105
Some of the challenges for this model include funding issues. Some funding to housing programs is specifically time-limited or is intended to be put toward specific resources that do not fit within the goals of this new program. This funding issue has also been a problem for service providers seeking funding for case management and treatment. 106 Due to this issue, this approach has often not allowed for flexibility in personalized assistance. 107 Also, this approach has not normally gathered data to analyze service utilization in order to gain a better understanding of the population they are serving and their needs. Additionally, many are concerned that case managers in this program will struggle to manage the 2 different groups of clients, one they are assisting to progress toward independence preceding their housing and the other who is not under the same constraints and can obtain housing almost instantly with lasting help. 108 Lastly, many in rapid rehousing programs struggle to find landlords willing to rent to them. In Washington D.C., 45% of renters with vouchers faced discrimination from landlords. 109
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