What Can Be Done About Homelessness?

“It’s the saddest sound in the world,” said Joey, a homeless veteran who was begging on the street. “The sound of footsteps speeding up as they hurry to get by me. For most people, it would be better if I didn’t exist.”¹

The Scourge of Homelessness

According to the most recently published official count, in January 2023, there were more than 650,000 homeless people in the United States, the highest number since annual surveys began in 2007. Some, particularly families with children, were dealing with transient life crises, but more than one-third of homeless individuals had a chronic pattern of living without shelter.² Many in this group suffer from severe and persistent mental illness, addictions, or both. Whatever their health conditions had been before they became homeless, life on the streets is guaranteed to make them worse. As one shelter director put it, “The longer they stay here, the crazier they become.”³ A recent study found that the mortality rate for unsheltered homeless people in Massachusetts was 10 times that of the general population.⁴

A Brief History of Homelessness

It wasn’t always this way. Homelessness as we know it began in the 1980s, during the presidency of Ronald Reagan. Reagan himself opined that many such people were “homeless by choice.”⁵ In fact, the main contributors to this complex problem, which has become endemic in America, were his administration’s austerity policies, with deep budget cuts to disability benefits and social services and to the Department of Housing and Urban Development. These drastic cuts in the social safety net were implemented just as people with chronic mental illness were being discharged from state hospitals in record numbers.

Deinstitutionalization was adopted as a national mental health initiative during the Kennedy administration (see "Our Broken Mental Health System"⁶). It was argued, plausibly at the time, that since antipsychotic medications had become widely available, people with chronic mental illness could be cared for both more humanely and more economically in their home communities, rather than being warehoused in isolated, prison-like asylums.

Federal seed money was appropriated for the development of model programs, including community-based halfway houses and day treatment centers. One of us (JLH) participated during the 1970s as a staff psychiatrist at a day treatment program, where the patients, many of whom had paced the back wards of the state hospital for years, gathered each day for a community meeting and an exercise class, followed by a hot lunch that they and the staff prepared together. The patients named the program “The House That Cares.”

Between 1960 and 1980, the number of patients living in state hospitals declined by about 75 percent, from 535,000 to 137,000.⁷ The original expectation was that as the state hospitals closed, the state funding would be redirected to support community-based services. But since mental patients don’t exactly have a powerful lobby, that never happened. Once the federal grant money was gone, the patients were left to languish on the streets or in prison. Currently, the institutions housing the largest number of people with severe mental illness in the United States are jails in Los Angeles, Chicago, and New York.

Homes Provide a Foundation for Improving Mental Health

It may seem obvious that homeless people need homes. And, in fact, many studies over the past two decades have shown that a policy approach called Housing First significantly reduces homelessness. But Housing First doesn’t mean housing only. The chronically homeless population also needs all the wrap-around social and mental health services initially envisaged by the deinstitutionalization movement. This means that many agencies that usually work in their own silos need to work together in a well-coordinated program.

The Ending Veteran Homeless Initiative

One particularly successful model, the federal Ending Veteran Homelessness Initiative, began in 2010. The Veterans Health Administration (VA) partnered with civic leaders and community organizations to provide housing vouchers plus case management and other supportive and clinical services. Between 2010 and 2022, veteran homelessness decreased by 55 percent. Almost a million veterans and their families were either placed in permanent housing or prevented from becoming homeless.⁸

Interviews with people who had leadership roles in the VA program identified the synergy between a Housing First approach and engagement with community partners as the key element of success. They reported that this policy initially encountered resistance from many who felt that homeless people had to “earn” the right to housing, by first being stabilized on psychiatric medication or getting sober. Having real-time outcome data was critical in convincing skeptics that the Housing First approach was working.

Successful programs aren’t cheap. To fund the homelessness initiative, the VA’s appropriation was increased from $400 million in 2010 to more than $1 billion in 2016.⁹ But such costs are more than offset by the savings in hospital and emergency health and mental health care, emergency shelter, sanitation, and public safety. And nothing exceeds the taxpayer expense of housing people in prison.

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The Choice

As Joey, the homeless veteran observed, the public appears to wish that homeless people did not exist. Current public policy, to the extent that any can be discerned, seems to consist of malign neglect, punctuated by police sweeps when the encampments become too annoying. But ignoring the problem has not made it go away. We face a moral choice between implementing an effective, albeit imperfect, approach that has considerable upfront costs but also proven results and long-term savings or just kicking the can on down the road, leaving the enormous, accruing costs and missed opportunities to burden future generations.