1 March 18, 2020 Dr. Benjamin Carson U.S. Secretary of Housing

March 18, 2020

Dr. Benjamin Carson

U.S. Secretary of Housing and Urban

Development

451 7

Street, SW

Washington, DC 20410

Joe Grogan

Director of the Domestic Policy Council

The White House

Eisenhower Executive Office Building

1650 Pennsylvania Ave, NW

Washington, DC 20502

Robert Marbut

Executive Director

U.S. Interagency Council on Homelessness

301 7

Street, SW, Room 2080

Washington, DC 20407

Dear Secretary Carson, Mr. Grogan, and Mr. Marbut:

We, the undersigned researchers on homelessness, write to urge the use of evidence-based approaches

in addressing America’s homelessness crisis. This requires continued adherence to Housing First and the

provision of adequate shelter wherever permanent housing is unavailable.

Over the last couple of decades, there have been efforts to increase and improve the federal

government’s use of evidence-based policies and practices. This goal has been bipartisan. Both the

George W. Bush and Barack Obama Administrations shared it. Within Congress, members of both

parties supported legislation creating the Commission on Evidence-Based Policymaking (which cited

current efforts to provide chronically homeless individuals with permanent supportive housing as a best

practice). And President Donald J. Trump signed the Foundations for Evidence-Based Policymaking Act

of 2018.

We encourage a continued emphasis on evidence-based policymaking, which has particular implications

in the field of homelessness.

Housing First

The weight of existing evidence favors the Housing First approach to ending chronic patterns of

homelessness. The two-decades-old initial evaluations produced findings that have been repeatedly

replicated since then. It has been shown that Housing First is associated with greater housing stability

and better treatment outcomes than transitional housing (or stair approaches) approaches to

homelessness.

Understanding this research requires understanding the model. “Housing First” does not mean “housing

only.” Rather, Housing First is housing plus voluntary services. Harm reduction is an aim—but services

can take the form of sober living or other rule-based programs when participants believe such services

match their needs and current stage of recovery. Housing is the priority. It stabilizes lives and allows

individuals to participate more effectively in mental health, physical health, and substance abuse

services. It eliminates the challenges tied to maintaining treatment plans, keeping appointments, or

being located by a provider when individuals are constantly moving from location to location.

The multiple evaluations of Housing First highlight a pattern of success that includes:

• Housing Stability. Housing First participants are more housing stable than those enrolled in

programs that condition housing on participation in services (transitional housing or residential

treatment). This finding is consistent across all relevant evaluations, including those focused on

individuals with severe mental illnesses, substance abuse disorders, and chronic patterns of

homelessness.

The research outcomes have been striking. For instance, an early evaluation of Pathways (the

initial Housing First program) found that 88 percent of tenants remained housed five years later

compared to only 47 percent of those in residential treatment. A subsequent Canadian study

with a more significant number of subjects found 62 percent of Housing First participants still

housed two years later compared to only 31 percent of those required to participate in

treatment before being placed in housing.

The Pathways and Canadian studies were among others included in a thorough literature review

completed by the National Academies of Sciences, Engineering, and Medicine in 2018. The

resulting publication concluded that Permanent Supportive Housing (PSH) following Housing

First principles “effectively maintains housing stability for most people experiencing chronic

homelessness.”

These findings partially reflect an important virtue of Housing First. It serves and shelters

everyone right away—not just those who are ready to participate in treatment and who are

good at following a list of rules.

• Treatment. Various services are available via Housing First programs. A 2015 evaluation found

that, with their housing stabilized, Housing First participants with severe mental illness

increased their participation in outpatient mental health services.

Treatment outcomes have been neutral or positive. An early study compared Housing First

participants to individuals with housing conditioned on sobriety and participation in treatment.

There was no difference between the two groups on substance use or psychiatric symptoms.

More recent evaluations indicate that Housing First participants are more likely than others to

report reduced usage of alcohol, stimulants, and opiates.

• Service Use. Aside from the positive individual-level outcomes, Housing First reduces acute care

services use for some populations. People with severe mental disorders, frequent jail users, and

“superutilizers” have been found to reduce use of acute care systems once housed. The aging of

the adult homeless population is also projected to increase services use and costs substantially

over the next decade, so a housing first strategy targeting the aged homeless could help to avoid

costs associated with excess hospital days and nursing home stays.

Adequate Shelter

We are aware that the Council of Economic Advisors’ recent The State of Homelessness in America

report suggests that the availability of shelter beds increases homelessness. We are not aware of any

studies that confirm these conclusions (finding that people living in communities respond to the

existence of shelters by choosing to become homeless).

Further, we are concerned about the health consequences of an insufficient number of shelter beds and

unsheltered homelessness.

Various studies have shown that unsheltered individuals have far more health challenges than those in

shelter. Most recently, the California Policy Lab examined multiple communities across the country,

finding physical health conditions being reported by 84 percent of unsheltered individuals compared to

19 percent of those in shelter. Mental health challenges were reported by 78 percent of unsheltered

individuals compared to 50 percent of those in shelter. These challenges extend to higher mortality

rates. For instance, a Boston-based study found that unsheltered people had mortality rates that were

nearly three times as high as those who spent significant amounts of time in shelter.

People experiencing unsheltered homelessness are exposed to the elements—snow, rain, and extreme

cold and heat. This contributes to their health conditions. Living outside complicates one’s ability to

take care of their personal health needs. This includes routinely taking medication, attending regularly

scheduled doctor’s appointments, healing from infections and injuries, getting sufficient uninterrupted

rest, and accessing healthy food and clean water. Living unsheltered is also associated with

victimization, including violent crime.

Health concerns point towards the need for permanent housing with services (Housing First). Where

that’s unavailable, individuals should have access to low-barrier emergency shelters that are focused on

getting people into permanent housing as quickly as possible.

Criminalization

We are unaware of any studies demonstrating that criminalization reduces homelessness.

Rather, a detailed review of community policies and practices concluded that criminalization disperses

unsheltered homelessness into smaller areas. Away from larger groups and highly visible locations,

individuals can be less safe and more vulnerable to victimization. Further, repeated stays in jail disrupt

contemporaneous efforts to find and keep work and housing. A well-established body of research

demonstrates that having a criminal record makes it more difficult to find employment and housing.

Providing permanent housing is a proven method of 1) reducing homelessness and 2) preventing

unnecessary cycles of incarceration. For example, New York City’s Frequent Users Service Enhancement

(FUSE) Initiative offered PSH to chronically homeless individuals. Two years later, 86 percent of

participants but only 42 percent of the comparison group were still permanently housed. PSH

participants spent 40 percent less time in jail than the comparison group. And the city’s shelter and jail

costs were reduced by $8,372/person each year.

Investments in criminalization are costly and avoidable if permanent housing is made available.

Data Collection

The Council of Economic Advisers report alludes to imperfections within the Point-in-Time (PiT) Count.

While HUD’s data on sheltered homelessness offers useful and reliable insights into just how many

people experience homelessness over the course of the year, the PiT is the best available snapshot of

both unsheltered and sheltered homelessness in America. Recognizing its imperfections (it is not a

funded activity, and so a post enumeration survey is not feasible), no other source offers nation-wide

data of this type. And no other source offers such data over time, allowing for trend analyses.

Importantly, over the years, there have been consistent improvements in PiT data collection process.

Such efforts are ongoing, benefiting from the contributions of researchers, data experts, and local

service providers.

More statistically robust approaches are available, including post-enumeration surveys. However, such

elements require far greater government investments. Congress has yet to allot such funds. In the

meantime, the best available information comes from the PiT, which should be read in conjunction with

other available data.

Conclusion

High-quality information about what works will help the nation end homelessness. Thus, we welcome

an ongoing dialogue about 1) available research and evidence, 2) potential new research aimed at

addressing unanswered questions, and 3) methods for improving data collection efforts. We believe that

great things can happen when we work together!

Sincerely,

Samantha Batko

Urban Institute

Walter Leginski, PhD

Former Senior Advisor on Homelessness (Retired)

Office of the Assistant Secretary for Planning and

Evaluation

U.S. Department of Health and Human Services

Molly Brown, PhD

Department of Psychology

DePaul University

Jeanine Borland Mann, MPH

College of Health Sciences

Western University

Rebecca Brown, MD, MPH

Perelman School of Medicine

University of Pennsylvania

Meghan Mason, PhD

School of Public Health

St. Catherine University

Barbara Brush, PhD, ANP-BC, FAAN

School of Nursing

University of Michigan

Kelly Melekis, PhD, MSW

Department of Social Work

Skidmore College

Thomas Byrne, PhD, MSW

School of Social Work

Boston University

Stephen Metraux, PhD

Biden School of Public Policy & Administration

University of Delaware

Varon Cantrell, MD

HealthNet

Norweeta Milburn, PhD

Department of Psychiatry and Biobehavioral

Sciences

University of California, Los Angeles

Melissa Chinchilla, PhD, MCP, MS

The AltaMed Institute for Health Equity

Ann Elizabeth Montgomery, PhD

School of Public Health

University of Alabama at Birmingham

Seema L. Clifasefi, PhD, MSW

Co-Director, Harm Reduction Research &

Treatment Center

School of Medicine

University of Washington

Forrest Moore, PhD, MBA

Chapin Hall

University of Chicago

Susan Collins, PhD

Co-Director, Harm Reduction Research &

Treatment Center

Department of Psychology

University of Washington

Matthew Morton, D.Phil., M.Sc.

Chapin Hall

University of Chicago

Dennis Culhane, PhD

School of Social Policy and Practice

University of Pennsylvania

Mahasin Mujahid, PhD, MS, FAHA

School of Public Health

University of California, Berkeley

Mary Cunningham, MPP

Urban Institute

Geoffrey Nelson, PhD (Emeritus)

Department of Psychology

Wilfrid Laurier University (Canada)

Barbara DiPietro, PhD

National Health Care for the Homeless Council

James O’Connell, MD

Boston Health Care for the Homeless Program

School of Medicine

Boston University

Kelly Doran, MD, MHS

Ronald O. Perelman Department of Emergency

Medicine

Department of Population Health

School of Medicine

New York University

Deborah Padgett, PhD, MPH, MA

Silver School of Social Work

New York University

Amy Dworsky, PhD, MSW

Chapin Hall

University of Chicago

Gary Painter, PhD

Director, Homelessness Policy Research Institute

Chair, Department of Public Policy

University of Southern California

Anne Farrell, PhD

Chapin Hall

University of Chicago

James Petrovich, PhD, MSW

Department of Social Work

Texas Christian University

Sara Goldrick-Rab, PhD

College of Education

Temple University

Tara Prairie, PhD

Tennessee Wesleyan University

Ronni Greenwood, PhD

Department of Psychology

University of Limerick (Ireland)

Harmony Rhoades, PhD

Suzanne Dworak-Peck School of Social Work

University of Southern California

Laura Gültekin, PhD, FNP-BC, RN

School of Nursing

University of Michigan

Debra Rog, PhD

Vice President

Westat

Amy Hagopian, PhD

School of Public Health

University of Washington

Janey Rountree, JD, LLM

California Policy Lab

University of California, Los Angeles

Seiji Hayashi, MD, MPH, FAAFP

Mary’s Center

Beth Shinn, PhD

Department of Human and Organizational

Development

Vanderbilt University

Benjamin Henwood, PhD, LCSW

Suzanne Dworak-Peck School of Social Work

University of Southern California

Lori Thomas, PhD

UNC Charlotte Urban Institute

Department of Social Work

University of North Carolina Charlotte

Stephen Hwang, MD, MPH

Unity Health Toronto

St. Michael’s Hospital

Paul A. Toro, PhD

Department of Psychology

Wayne State University

Mitchell Katz, MD

NYC Health + Hospitals

Dan Treglia, PhD, MPP

School of Social Policy & Practice

University of Pennsylvania

Stefan Kertesz, MD, MSc

School of Medicine

University of Alabama at Birmingham

Sam Tsemberis, PhD

Founder/CEO

Pathways Housing First Institute

Randall Kuhn, PhD

Fielding School of Public Health

University of California, Los Angeles

Ping Wang, PhD

Department of Economics

Washington University in St. Louis

Margot Kushel, MD

Director, Benioff Homelessness and Housing

Initiative

School of Medicine

University of California San Francisco

Beth Weitzman, Ph.D., MPA

Steinhardt School of Culture, Education, and

Human Development

New York University

Barrett Lee, PhD (Emeritus)

Department of Sociology and Criminology

Pennsylvania State University

Suzanne Wenzel, PhD

Suzanne Dworak-Peck School of Social Work

University of Southern California

Resources

Evidence-Based Approaches

Commission on Evidence-Based Policymaking, “The Promise of Evidence-Based Policymaking,”

2017.

Hart, N. and Newcomer, K., “Presidential Evidence Initiatives: Lessons from the Bush and

Obama Administrations’ Efforts to Improve Government Performance,” Bipartisan Policy

Center, 2018.

Housing First

Aidala, A., et. al., “Frequent Users Service Enhancement `Fuse’ Initiative: New York City FUSE II

Evaluation Report,” 2014

Aubry, T., et. al., “A Multiple-City RCT of Housing First with Assertive Community Treatment for

Homeless Canadians with Serious Mental Illness,” Psychiatric Services 67(3), 275-281, 2016.

Center of Evidence-Based Solutions to Homelessness, “Housing First,”

http://www.evidenceonhomelessness.com/factsheet/housing-first/.

Davidson, C., et. al., “Association of Housing First Implementation and Key Outcomes Among

Homeless Persons with Problematic Substance Use,” Psychiatric Service 65(11), 1318-1324,

2014.

Gilmer, T., Stefancic, A., and Ettner, S., “Fidelty to the Housing First Model and Variation in

Health Service Use Within Permanent Supportive Housing,” Psychiatric Services, 2015.

Homelessness Policy Research Institute, “Outcomes in Single-Site and Scattered-Site Permanent

Supportive Housing,” 2019.

Larimer, M., Malone, D., Garner, M., “Health Care and Public Service Use and Costs Before and

After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems,”

JAMA 301(13), 1349-1357, 2009.

Mental Health Commission of Canada, “National Final Report: Cross-Site At Home/Cez Soi

Project,” 2014.

The National Academies of Sciences, “Permanent Supportive Housing: Evaluating the Evidence

for Improving Health Outcomes Among People Experiencing Chronic Homelessness,” 2018.

Shinn, M. and Khadduri, J., In the Midst of Plenty: Homelessness and What to Do About It.

Hoboken, NJ: Wiley, 2020.

Tsemberis, S., Gulcur, L., and Nakae, M., “Housing First, Consumer Choice, and Harm Reduction

for Homeless Individuals with a Dual Diagnosis,” American Journal of Public Health 94(4), 651-

656, 2004.

Y-Foundation, “A Home of Your Own: Housing First and Ending Homelessness in Finland,” 2017.

Adequate Shelter

Levitt, A., et. al., “Health and Social Characteristics of Homeless Adults in Manhattan Who Were

Chronically or Not Chronically Unsheltered,” Psychiatric Services, 2009.

Montgomery, A., et. al., “Homelessness, Unsheltered Status, and Risk Factors for Mortality:

Findings From the 100,000 Homes Campaign,” Public Health Reports, 131(6), 765-772, 2016.

Roncarati, J., Baggett, T., and O’Connell, J., “Mortality Among Unsheltered Homeless Adults in

Boston, Massachusetts, 2000-2009,” 178(9), 1242-1248, 2018.

Rountree, J., Hess, N., and Lyke, A., “Health Conditions Among Unsheltered Adults in the U.S.,”

California Policy Lab, 2019.

Criminalization

Aidala, A., et. al., “Frequent Users Service Enhancement `Fuse’ Initiative: New York City FUSE II

Evaluation Report,” 2014

Junejo, S., Skinner, S., and Rankin, S., “No Rest for the Weary: Why Cities Should Embrace

Homeless Encampments,” Homeless Rights Advocacy Project, 2016.

National Law Center on Homelessness & Poverty, “Housing Not Handcuffs 2019,” 2019.