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- "First Things First" is a winner of the 2008 Cushing Niles Dolbeare Award and the 2007 Clarion Award for best newspaper feature
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"First Things First"
'Housing first,' a radical new approach to ending chronic homelessness, is gaining ground in Boston.
By Florence Graves and Hadar Sayfan
June 24, 2007
At the Latin Academy, a majestic former school built in 1900 near Dorchester's Codman Square, Joe Jeannotte is participating in a social experiment.
Jeannotte lives in a sparsely furnished new two-bedroom apartment. Light streams through large windows, and a burgundy and forest green couch faces a small television. He looks older than his 38 years -- gaunt, scruffy, with dark brown hair -- and shares the place with his girlfriend, Judy, who asked that her last name not be used. Often, the noise of construction filters in as workers rehab other apartments, but the couple doesn't complain. Not long ago, they were convinced they would never have a place to live at all. When they moved into the new place, at public expense, they had no home and no money, and both had been struggling for years with heroin addiction.
In the past, society's approach to homeless people with chronic health problems such as addiction has been governed by tough love: Stay in treatment, or you don't get the opportunity for publicly supported housing. People who could not confront their addiction, the thinking went, could not handle an apartment.
But a new approach, called "housing first," is gathering momentum. The idea is to target the most difficult cases -- the chronically homeless who make up between 10 and 20 percent of the homeless population and spend years cycling between the streets, shelters, jail cells, and emergency rooms -- and give them apartments without requiring them to get sober, in the hope that having a place to live will help them address their other problems. More than 150 cities or counties around the country already have programs of some kind or plans to initiate one, and last month the Massachusetts Senate Ways and Means Committee recommended doubling the size of a small pilot program in the state. If the pilot succeeds, proponents say it could force dramatic changes in homeless policy -- and a recognition that the current shelter system, built on what they call a punitive moralism, has fundamentally failed.
"Shelters have become the poor houses of the 21st century," said Joe Finn, executive director of the Massachusetts Housing and Shelter Alliance (MHSA), who is administering Home and Healthy for Good, the pilot program.
The program's appeal reaches across the ideological landscape. In 1999, a Republican Congress endorsed the concept, requiring that the US Department of Housing and Urban Development devote at least a third of its homelessness funding toward putting the chronically homeless and chronically disabled in permanent housing. Cities like San Francisco, Atlanta, and Portland, Oregon, have become proponents after successful tests. The Bush administration has also been enthusiastic. In 2002, it hired Philip Mangano, who spent 25 years in Boston as a homeless advocate, to head its homelessness efforts, and he has evangelized widely for the housing-first approach.
Part of the program's broad appeal is its counterintuitive claim: That it can often break even or save money while providing housing. Academic studies, based on programs in New York City and Philadelphia, have found that cities spend almost the same or less money on the housing and other services than they would on shelter beds, emergency rooms, and other health care costs.
"Cost-benefit analysis may be the new compassion," said Mangano, the founding executive director of MHSA. He's now executive director of the federal Interagency Council on Homelessness.
There are also critics across the political spectrum who are uneasy about what they think amounts to rewarding bad behavior -- putting drug addicts and alcoholics at the front of the line for housing.
Yet the housing-first movement is part of a broader, more ambitious agenda: ending homelessness, not managing it. Many Americans forget that widespread urban homelessness is a recent problem that began in the early '80s, not an inevitable price of capitalism. For years, a great deal of money has been spent managing homelessness in various ad hoc approaches, particularly shelters.
In pushing the housing-first approach to municipal, county, and state governments, Mangano (and, by extension, the Bush administration) is rejecting the idea that chronic homelessness will always be with us. The problem can be solved, they argue, and, eventually, much of the social-services industry built up around it can and must be dismantled.
It is an argument that longtime advocates say brings a mixture of excitement at the possibilities and fears about what it might mean in practice. Nan Roman, president and CEO of the National Alliance to End Homelessness, says some shelter providers have said to her, "If we end homelessness, what are we going to do for a living?"
Many observers credit the birth of the housing-first concept to Sam Tsemberis, who calls himself a "recovering psychologist." While treating homeless people for their mental health or substance abuse problems, Tsemberis, who is based in New York City, recognized that "business as usual" was not working. His patients invariably told him that, before they could work on their other problems, they needed housing first. In 1992, he founded Pathways to Housing to provide mentally ill and substance-abusing homeless people with their own apartments immediately.
During the 1990s, Dennis Culhane, a sociology professor at the University of Pennsylvania, started collecting and analyzing the data on all that spending and its effectiveness. In a series of studies, he revealed, among other things, that the chronically homeless population -- the mentally ill and addicts who were spending years on the street, in and out of shelters -- made up only 10 percent of the homeless population but were using 50 percent of shelter resources. In follow-up studies, he revealed that by focusing on housing this subgroup, communities could better keep down costs and help turn around lives.
A landmark 2002 study by Culhane found that providing housing and other assistance to the homeless could bring down nonhousing expenses almost enough to pay for itself. The study followed mentally ill homeless people between 1989 and 1997 and found that each permanent supported housing unit saved $16,281 a year in public costs for shelter, health care, mental health, and criminal justice, offsetting most of the $17,277 cost of housing and other services.
Mangano, a former seminarian who had focused on housing for the mentally ill in Massachusetts, said he was so impressed by the New York Pathways to Housing program and Culhane's research that he decided to take the ideas and disseminate them nationally.
"[We] committed an act of legitimate larceny," Mangano said.
Medical bills for today's homeless are a large expense. For example, between 1999 and 2003, the Boston Health Care for the Homeless Program (BHCHP), a group that provides primary care for people living on the streets, tracked the medical expenses of 119 chronically homeless clients. All told, the group racked up 18,342 emergency-room visits, for an average of more than 36 visits per person each year. At a minimum cost of $1000 a visit, that's an annual emergency room bill of ,at least $36,000 per person. Lack of stable housing makes it hard for people to rehabilitate after an illness, properly care for wounds, or take medication consistently, according to Dr. Jim O'Connell, the president of BHCHP who headed the study and is also involved in the Home and Healthy for Good pilot in Massachusetts.
Last year, the state legislature allocated $600,000 for that pilot, which is being tried in locations across Massachusetts. Preliminary data from the program indicates that it is saving the state money, according to MHSA executive director Joe Finn. Home and Healthy for Good has put 155 formerly chronically homeless people into stable housing, paid for their apartments, and assigned them social workers to help them find the services they need. Finn's group concluded that the Commonwealth saved, on average, $918 a month during the fist six months in shelter and service costs (including health care, hospitalizations, emergency room visits, incarcerations, drug detoxification, and shelters) for each person housed. That's a projected annual savings of $11,016 per person. Federal figures suggest that there are at least 3,137 chronically homeless adults in the state.
The savings are impressive, but some worry they may be inflated. Jim Greene, who heads the city of Boston's Emergency Shelter Commission, suspects that some of the success stories from around the country are misleading, worrying that the people who ran the studies were selective about who they enrolled. But the Massachusetts program has specifically asked for the neediest and most challenging street people, according to Dr. Jessie Gaeta, an MHSA Physician Advocacy Fellow and a clinician for the Boston Health Care for the Homeless Program who is one of the study's investigators. Still, she said, she will not consider any of the results to be valid until they have at least a year's worth of data.
Even if the program does save money overall, it still poses a political problem: The agencies that save money on health care, for example, are not the same as those that spend money on housing and other services. That could lead to a budget turf war.
The program could also force changes in the shelter community. Romney appointee Linda Barton Fosburg, executive director of the Massachusetts Interagency Council on Homelessness and Housing, says that some advocates "don't want to see the shelter industry dismantled" because "they don't want to let go of their piece of the pie." Robert V. Hess, commissioner of New York City's Department of Homeless Services, said he has seen "a fair amount of push-back" from shelter providers to the idea of housing-first in New York, as well as in Philaldephia, where he introduced it.
But housing-first advocates say that some shelters can adjust programmatically and financially by becoming providers of transitional and permanent housing. Several homeless shelters in the area, such as Father Bill's Place in Quincy, have already started converting.
Yet even as the Massachusetts pilot has shown promise, critics have begun to express other concerns. One, they say, is that success would distract attention from the 80 to 90 percent of the homeless population who are not chronically homeless. Another is that lawmakers will be too quick to reduce funding for the state's many homeless shelters -- or that they will try to do housing-first on the cheap, which will cause it to fail.
"We don't want to rob Peter to pay Paul," said Lyndia Downie, president of the Pine Street Inn. The state is in dire need, she said, of a comprehensive plan to address homelessness.
Last October, the legislature created a commission to be co-chaired by Rep. Byron Rushing and Tina Brooks, Governor Deval Patrick's Undersecretary for Department of Housing and Community Development, to do just that. But Patrick, who has said he is committed to ending homelessness in Massachusetts, has not yet appointed any members.
Another open question is how much housing-first helps the homeless with their underlying problems. But advocates say that this is a very high bar; addiction, for example, is a notoriously difficult problem, and even modest goals make the idea worthwhile.
"If you measure success as complete abstinence, success rates are very low," said Culhane. "Many people relapse." But "in the public health field, there is a countervailing view, sometimes characterized as harm-reduction." In this view, minimizing harm -- as in the case of clean-needles programs to reduce the spread of HIV -- is every bit as important.
Joe and Judy, the couple who recently moved into the Dorchester two-bedroom, met five years ago at the Long Island Shelter in Quincy Bay while handing out blankets. On the street for years, they had both spent their nights bouncing from Boston Common park benches to various shelters and back to hang out on the Common during daylight hours. Now HIV positive from sharing needles, Joe says the simple act of taking his life-saving medications was often thwarted when his small bag of possessions was stolen as he tried to sleep on the streets.
For now, the two appear to be functioning well: They say they have been attending Narcotics Anonymous meetings three times a week, keep the place neat, and cook for themselves. Both say they are clean and want to kick cigarettes next. They say disabilities have kept them from working, but Judy wants to find a job.
"I have a lot more hope," she said.
Florence Graves is founding director of Brandeis University's Schuster Institute for Investigative Journalism. Hadar Sayfan is a senior research assistant at the institute.