Homelessness: A Solvable Crisis

Homelessness: A Solvable Crisis

Most Californians report homelessness as one of the top issues facing our state. The proliferation of people living in tents, on the sidewalk, or whole families living in cars—in the fifth-largest economy in world—is jarring. California, which comprises only 12% of the nation’s population, accounts for 28% of its homeless population, with half experiencing unsheltered homelessness (i.e. sleeping outside or in places not meant for human habitation).

As healthcare professionals, we have an inside view into the havoc wreaked by homelessness on every aspect of health. Individuals facing homelessness are forced to focus on day-to-day survival rather than on their long-term healthcare. Providers become inaccessible, medication is lost or ruined, and belongings are stolen while enroute to a clinic. People face dangers from violence, unintentional injuries, and punishing environmental conditions. They miss screening tests, abandon treatment plans, and wounds and disease fester. Our ability to practice evidence-based medicine falls by the wayside and patients miss out on the remarkable advances we routinely offer others. To paraphrase the sociologist Matthew Desmond, without stable housing, everything else falls apart.

It doesn’t have to be this way. Unlike many of the worst health crises we face daily, we know how to end homelessness. As in medicine, the first step toward a solution is to accurately diagnose the problem.

What causes homelessness?
The rate of homelessness in a community correlates with the availability of affordable housing for the lowest-income households. Regions with a greater supply of housing for extremely low-income households have less homelessness, while areas with a larger deficit—like California—have more. To give a sense of scale, California currently has 24 units of housing available and affordable for every 100 extremely low-income households. We are short approximately one million units of housing that the poorest households could afford. In other words, the answer to the question “why is there so much homelessness in California?” is straightforward: we simply don’t have enough housing. To resolve the crisis, we need to increase the availability of affordable housing for the lowest-income households.

But if that is the case, why is it that so many people experiencing homelessness also struggle with substance use and mental health problems? Isn’t addressing these problems also crucial to ending the crisis?

Homelessness arises from a combination of structural factors (housing availability), individual factors (risk factors like substance use and mental health issues), and the availability of a safety net (resources such as income support if one loses a job). When structural factors and the safety net are weaker, fewer individual risk factors are needed to become homeless. This is evident in California today. Nearly half of all single homeless adults (aged 25 and over who don’t live with children) are 50 and over, with over 40% first becoming homeless after the age of 50. Many of these individuals are low-wage workers who, at some point after the age of 50, experienced a crisis such as the death of their partner or their own illness and couldn’t keep up with their rent.

It's true that people experiencing homelessness are more likely to have substance use and mental health problems than the general population. The UCSF Benioff Homelessness and Housing Initiative’s recent California Statewide Study of People Experiencing Homelessness found that one-third of adults experiencing homelessness in California regularly used illicit substances (40% either regularly use illicit substances or drink heavily at least once a week). Over a quarter had experienced a psychiatric hospitalization, 56% of whom had been hospitalized before their first episode of homelessness.

What is the connection? Substance use and mental health problems can impair social, legal, and economic functioning, increasing an individual's risk of homelessness by reducing income potential and rupturing relationships with family or friends who might otherwise provide support. While overall homelessness rates are determined by housing availability, within any community, disabilities that affect one’s ability to secure housing also increase the likelihood of becoming homeless.

But once homeless, substance use and mental health problems often worsen. Among homeless adults in California, one-third of those who used drugs regularly began doing so after becoming homeless. Homeless individuals face high rates of violence, insufficient sleep, and constant stress, which exacerbate substance use and mental health issues. Accessing treatment becomes more challenging while homeless; our research found that a quarter of those with substance use problems had tried but had been unable to obtain treatment.

How to solve homelessness?
In essence, housing ends homelessness. Addressing homelessness requires increasing the availability and affordability of housing for the lowest-income households. The most significant barrier individuals face is the high cost of housing. Increasing the availability of affordable housing would have an immediate impact on ending homelessness.

For those with severe individual risk factors, our research shows that even those with behavioral health issues and long-term homelessness can be durably housed using a strategy called Housing First. This approach provides subsidized housing, along with necessary services and supports needed to thrive such as case management, medical care, and substance use treatment. The key is that engagement in these services is not a condition for housing. Housing First has a strong evidence base from randomized controlled trials and practice. For example, the Veterans Administration, in collaboration with the Department of Housing and Urban Development, has relied on Housing First principles to reduce Veteran homelessness by over 50% since 2010. They achieved this by relying on evidence-based strategies, securing bipartisan support (which allowed them to scale resources appropriately), and leveraging existing systems to identify and match veterans with appropriate resources. Homelessness is solvable—if we have the political will to scale what works and to create the housing we need.

What is the role of Physicians and other healthcare professionals?
Although homelessness has severe deleterious impacts on health, and certain conditions increase an individual’s risk of homelessness, the solutions extend beyond the purview of healthcare. However, that doesn’t mean that we can’t make a difference.

First, healthcare providers need to speak out on the severe negative impacts of homelessness and push for solutions. Second, providers need to be educated on the true causes and evidence-based solutions for homelessness. Finally, we need to ensure that we do not unintentionally exacerbate the impacts of homelessness by de-stigmatizing it, adapting evidence-based treatments to meet our patients’ unique needs, and partnering with colleagues in housing services to provide the necessary support to end homelessness.

Margot Kushel, MD                                                                 
Professor and Chief, Division of Health Equity and Society