For over two decades, a certain philosophy on how to solve homelessness in America has gained ascendance, drawing bipartisan support, garnering billions in government funding and changing the way some cities address their unhoused population.
Known as Housing First, it’s a simple concept:
Give homeless people safe and permanent housing without any strings attached — as in, don’t require them to first undergo treatment for substance use disorders or mental illness, often the very issues that caused their homelessness in the first place. (Studies show addiction and mental health problems, often a co-occurrence of the two, underlie most chronic homelessness.)
Provide residents with quick and easy access to supportive services — free counseling, medical care, alcohol and drug treatment, along with free meals and other amenities — but don’t mandate that they avail themselves of same before earning a roof over their heads.
The idea is that once residents get settled in and accustomed to regular food, showers and a safe environment — once they’re free of the dangers of the streets — they will voluntarily began reaching out for life-transforming assistance on their own.
There’s a good bit of evidence and a prevailing belief among many advocates that Housing First is a more humane, less costly and more effective way to address homelessness than traditional models, which typically require clients to jump through various hoops — become sober, get stabilized on psychiatric medications, find a job and so on — before being provided permanent housing.
Usually, it’s a stair-step process: The more success a homeless person has in achieving program goals, the closer they get to a place of their own.
But even as Housing First has gained preeminence, the data on its success is somewhat mixed. (More on that in a moment.)
And now a backlash is brewing against the paradigm.
Its critics argue that the Housing First philosophy is a failed model that keeps homeless people mired in their dysfunctions, while simultaneously destroying quality of life in cities struggling with metastasizing homelessness.
They say it pours money toward costly permanent housing instead of less-expensive shelters that could serve more people. And the lack of expectations stymies homeless folks in their quest to become functioning citizens, critics say.
I thought I’d bring the debate to Edward Gonzales, executive director of Towne Twin Village, the largest and most organized foray into Housing First in San Antonio’s history.
Spearheaded by the Housing First Community Coalition and located on the city’s East Side, Towne Twin is a 17-acre complex dotted with small, pastel-colored houses, shiny new RV trailers and (one day) apartments. Opened in April, it will house around 200 chronically homeless clients once it’s finished by the end of 2025.
At the site, residents can receive services such as daily meals, medical visits, mental health counseling and substance abuse treatment along with a case manager who checks in with them every day.
But it’s up to them which — or any — services they might use.
The site is designed to serve only the most vulnerable, Gonzales said.
Potential residents are carefully screened and must be 50 years or older, have been homeless for one year or more and have some disability, be it a chronic medical or mental health challenge or substance abuse issue.
Residents tend to be “frequent flyers,” Gonzales said — homeless people who consume lots of expensive services like EMS, hospital emergency rooms, acute crisis centers and jails.
Those who receive regular income, usually in the form of a government disability check, will pay no more than 30% of that income toward their monthly rent. Some pay nothing.
Gonzales said the Housing First philosophy flows from a common-sense understanding of human nature, one that may be even more exacerbated among the chronically homeless population.
“You simply can’t make people do things they don’t want to do,” he said. “The prescriptive model is something I’m very much against. That approach hardly works for these folks, or when it does, it takes a very long time.”
He said demanding people who have been homeless for years — at Towne Twin, the average length of homelessness among the 50 current residents was eight years — to become sober or compliant with a mental illness regimen right off the bat is unrealistic.
“Someone who has never experienced that kind of life might not understand it,” he said.
People who are chronically homeless are so used to worrying about where they’re going to sleep or find their next meal — about survival — that they’re not focused on making their next doctor’s appointment or refilling a medication prescription or going to an Alcoholics Anonymous meeting.
But give them peace and quiet, support and time, and almost organically they begin to want to heal, he argued.
That’s what’s happening with the residents who’ve already moved in, Gonzales said. They’re reaching out. They’re accepting help.
But those who doubt Housing First — which includes directors of traditional homelessness programs who’ve seen their funding slashed since the advent of the no-strings approach — point to research suggesting less-than-stellar results.
For example, one study by the National Academies of Sciences, Engineering and Medicine in 2018 noted a paucity of published studies confirming the benefits of Housing First, found there was “no substantial evidence” that such programs improved clients’ health or saved money.
Another study, published in the prestigious medical journal The Lancet, found that while Housing First programs helped stabilize housing among formerly homeless residents, they had “no measurable effect” on the severity of their psychiatric problems, addiction or employment issues.
Then again, another study found that 88% of residents in a New York Housing First program were still housed five years later, versus just 47% in a traditional program.
A two-year study of Housing First programs in five Canadian cities found the model brought stable housing and improved quality of life for residents, along with cost savings and other impressive benefits.
Other studies show reduced alcohol and drug use among residents in Housing First programs.
Clearly, more data on the benefits — and drawbacks — of Housing First, which the Biden administration has gone all in on, would be helpful.
As for Towne Twin Village, Gonzales said he’s not running a “Wild West” environment. Residents are expected to follow rules and obey the law. Those who don’t are dealt with via an “escalating process” that includes “progressive discipline,” he said.
Gonzales added that all staff are trained in crisis intervention. Should someone decompensate and have a mental health crisis, such as a psychotic episode, employees are trained in how to handle it.
Jerry Hicks, 57, moved into one of the shiny RV trailers a month ago.
On a recent sweltering afternoon, he sat inside its dark and cool comfort, a veritable sanctuary (complete with widescreen flat TV) compared to the outdoor courtyard at Haven for Hope, which is where his mental health issues and methamphetamine addiction landed him about a year and a half ago.
Hicks went through an addiction treatment program at Haven and was clean before he moved into his current digs. But the bevy of prescription pill bottles lined up on his kitchen counter attests to the medical and mental health treatment he’s willingly receiving at Towne Twin.
“It’s very rewarding here,” he said. “I’m ecstatic. [The staff] give you a push to make you want to act better. People care about you and they don’t even know you.”
Kim Jeffries, CEO of Haven for Hope, the behemoth of homeless shelters in San Antonio, said Housing First principles are also part of the organization’s “toolkit” in the form of 124 permanent supportive housing units scattered throughout the city in different apartment complexes.
A small percentage of Haven’s clients go into housing right away; they don’t have to be sober or involved in program requirements to be placed in a unit, said Jeffries, although supportive services are offered.
Clients staying on the outdoor courtyard are eligible for permanent housing and don’t have to be sober or working on program goals, but those living on the main campus must first achieve both those things.
“The average length of stay at Haven is four months, and most of that time is spent on clients getting identification and other documents together for housing,” Jeffries said.
Like it or not, the city of San Antonio has also gone “all in” for Housing First. Its strategic housing plan includes a stated goal of adding 1,000 such site-based permanent supportive housing units for homeless people by 2031.
The cost of Towne Twin, when it’s finally finished, will reach nearly $41 million, paid for through private donations, city and county money and resident rent payments.
The need for some kind of innovative approach to this thornily intractable problem is blindingly obvious.
Chronic homelessness is a blight on too many major metropolitan areas; San Antonio is far from exempt. While the 2023 point-in-time count found that the overall number of chronically homeless people (those who’ve been homeless for a year or more and are disabled) actually declined 33% from the previous year, there are still far too many folks living on the streets and under the overpasses of this city.
This state of affairs is not good for tourism, not good for business, not good for quality of life and certainly not good for the estimated 400 to 500 people who comprise the most vulnerable subset among the homeless, battered souls who live in squalid encampments and often refuse the kind of help that would relieve their very public suffering.
As a result, Gonzales said there’s no need for a debate over Housing First.
The homelessness problem is so vast and deep and complex that we do better with “a wide toolbox” to address it — both alternative and traditional models.
“There’s a misunderstanding that one intervention works for everyone,” he said. “I think you need both interventions.”
It’s a quintessential moral ethics question: Doesn’t everyone deserve a home?
