Housing First: Ending Homelessness, Transforming Systems, and Changing Lives
In February 2006, the New Yorker published an article by Malcolm Gladwell titled “Million Dollar Murray” about a homeless man who had cost the city of Reno, Nevada, about a million dollars in medical care. Murray was a “chronic inebriate”—a person whose alcoholism was debilitating and recalcitrant to treatment. Murray would drink and fall down, and because he was homeless and lived on the streets, he would be scooped up and taken to an emergency room, sometimes multiple times per week. The solution to this problem seemed both obvious and impossible—cure Murray’s alcoholism, and then he would need less medical care, plus he would be able to seek and maintain a home.
In the 1980s it became clear that a significant percentage of single, adult homeless people were suffering from serious mental illness or substance use disorders, or both, and that these conditions impaired people’s ability to seek and maintain housing. The approach adopted to address this, called the “continuum” or “staircase” approach, was to provide treatment to attain a “housing ready” state before moving homeless people into structured housing programs designed to maintain their mental health and sobriety. A major problem of this approach is that a significant number of people, like Murray, either resist treatment or fail treatment and therefore are never able to become or stay “housing ready.”
What would happen, wondered Sam Tsemberis, coauthor of Housing First: Ending Homelessness, Transforming Systems, and Changing Lives, if things were reversed: if housing came first and treatment followed? By the time Gladwell wrote “Million Dollar Murray,” Tsemberis, at the helm of Pathways to Housing, had been doing just that, utilizing a “housing first” model for almost 15 years. Housing First provides a clear history of what happened. People who were not housing ready—who were psychotic or using drugs and refusing treatment or failing treatment—were placed in apartments and offered care by assertive community treatment teams. People stayed housed to the tune of 85% over a period of years at no more cost to the system than business as usual. Furthermore, people’s mental illnesses and substance use disorders improved—stable housing proved to also be treatment.
Once given keys to an apartment, Murray not only stayed housed, but he ended up costing the city of Reno a fraction of the million dollars he had cost previously. Most of that cost was rent; Murray drank less. Murray’s apartment was treatment, plus it was cost-effective.
Despite the undeniable success of Housing First approaches to the homeless, the Coda of Housing First hints at a significant vulnerability to current iterations of the model. In December 2014 Pathways to Housing in New York terminated its operations. The funding for Pathways could not grow fast enough to keep up with New York City housing prices. In some cases the share of rent Pathways was paying exceeded the funding available for rent and services (although ultimately people did not lose apartments for this reason). Furthermore, as I write these words in December 2015 there are approximately 3,000 homeless people living on the streets of New York City, with an additional 12,500 adults staying in the city’s shelter system while New York City continues to gentrify and housing prices continue to skyrocket. A cost-effective social service model has come up against a dynamic housing market that is threatening to flip the economics of Housing First on its head. If homelessness is going to end, this economic reality will need to be reckoned with.
