Homelessness and housing are issues of public health significance. This month, we published a Special Commentary about homelessness in Medical Care, informed by the 2017 policy statement we co-authored for the American Public Health Association (APHA) about homelessness and how federal, state, and local authorities can use evidence-based solutions to help bring an end to this enduring crisis.
While APHA has long supported a discussion of the economic and social drivers of health disparity (as the Executive Director, Dr. Georges Benjamin, said in 2011: “Housing is a human right” and “Housing is healthcare”), the prior policy language dated back to the mid-nineties. The new policy statement represents a major advance to the current landscape and provides evidence for the economic and social programs used to address homelessness. For more about the APHA policy, check out last year’s Nation’s Health article with interviews and commentary on what these advances mean for the public health system.
Evidence-Based Strategies to End Homelessness
Our framework for the policy statement considered the interwoven influences of housing, health, and income stability that drive and reinforce gains or failures in the socioeconomic context of homelessness. For that reason, the recommendations focused largely on housing and income stabilization programs in order to influence public health outcomes. There is now a strong and growing record of support for housing interventions such as permanent supportive housing (PSH) and housing choice vouchers (HCV). The Federal voucher program serves a large number of households (2.1 million) including low-income families, people with disabilities, and the elderly. The National Housing Trust Fund (NHTF) is another program with a demonstrated track record for increasing affordable housing units through block grants to states, which are used for new property construction or rehabilitation of existing units.
The model of housing entry known as “Housing First” is another absolutely critical advance [PDF] in the provision of housing which the APHA now recognizes as a best practice. This model flips the previous thinking about housing entry on its head by taking a harm-reduction approach to working with individuals experiencing homelessness. It acknowledges that housing should be provided without requiring clients to meet prerequisites which are more effectively addressed once they have a stable place to live. Rapid re-housing is an (ideally Housing First) intervention that has demonstrated success in quickly connecting individuals and families to permanent housing through tailored assistance that may include time-limited financial supports and targeted supportive services.
Income support and stabilization is a key process as well, empowering individuals to exit homelessness by opening up additional housing opportunities or avoiding the experience entirely through prevention measures. For individuals with severe mental illness and/or medical conditions who are experiencing homelessness, Social Security disability benefits are key to providing income assistance and health insurance, but are difficult to obtain. Comprehensive application assistance for homeless individuals increased approval rates for such individuals from 28% to 73%.
Finally, the policy presents several alternative models to criminalization of activities associated with homelessness (such as sitting on sidewalks or sleeping in public places), which has been shown to be an ineffective method to solve or end homelessness in a community. In many ways, criminalization actually makes solving homelessness much harder by increasing financial and societal barriers to obtaining housing.
A Call to Action
The #1 recommendation in APHA’s policy is a call for federal agencies and state and local service providers to prioritize housing programs that adhere to the Housing First model. We also call for increases and diversification of funding sources for the federal housing programs that successfully contribute to ending homelessness – such as the NHTF, HCV, and PSH units. In addition, income supports like disability benefits and homelessness prevention programs need to be expanded and improved through innovation and evaluation. Finally, the criminalization of activities related to homelessness must be curtailed at the state and local levels in order to give these programs a chance to succeed.
Permanent supportive housing holds potential for improving health.
Communities are quickly recognizing the public health benefits of Housing First programs. Several more high-level reports were produced around the time this policy was adopted, confirming the evidence cited by APHA. An evaluation of the Housing for Health PSH program in Los Angeles showed that public service costs dropped by almost 60% and participants’ mental health functioning improved in the year after receipt of supportive housing.
In 2018, a consensus report from the National Academies of Sciences, Engineering, and Medicine (NASEM) took the issue of homelessness and health head on. Under a program titled “Housing, Health, and Homelessness: Evaluating the Evidence”, the authors spent two years reviewing evidence around the relationship between health, homelessness, and the ability of PSH to improve health. On the road to the conclusion that PSH can improve health, the expert panel summarized the evidence and discussed program and policy barriers to scaling supportive housing programs in order to effectively address homelessness. The NASEM PSH evaluation report also called for further research (as does the APHA policy statement) to conclusively demonstrate the impact of housing, including the need to understand housing-sensitive health conditions.
Homelessness has always been a public health issue, and APHA has long been a leader on issues of poverty and health. Now we have the commitment of the largest professional association in the field, armed with the evidence and the action steps needed to move us forward.
Ben King
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- Homelessness as a Public Health Issue - June 13, 2019