Housing as Healthcare: How the Housing First model improves healthcare access amongst individuals experiencing homelessness

Lauren Choy

ABSTRACT:

The Housing First model is an approach that believes housing is necessary for proper health and wellbeing by providing stable housing to individuals experiencing homelessness. The approach lacks many of the prerequisites associated with other treatment-first programs that often require individuals to prove sobriety or a lack of health issues. As a result, the Housing First model has shown substantial benefits including reduced hospital visits and generated economic profit. On the other hand, the model’s direct impact on health outcomes remains contested, with studies showing limited improvements in physical health, housing stability, or substance use disorders in populations of individuals enrolled in the program. Nevertheless, due to the United States’ continued battles with high rates of poor health, especially amongst unhoused and economically-disadvantaged individuals, there is a critical need to adjust current health policy to better support individuals experiencing homelessness. At this point, a critical question emerges: should the United States further invest in the Housing First approach as a health care policy, or should it look toward alternative options that address healthcare separate from housing?

INTRODUCTION TO THE HOUSING FIRST MODEL:

In January 2024, the US Department of Housing and Urban Development (HUD) reported to Congress that there were 771,480 individuals experiencing homelessness, rising 18.1% from the previous year.¹ This ultimately reflects the United States’ continued struggles with issues of housing, large wealth gaps, and overall life conditions. The Housing First approach, introduced in the 1990s, acknowledges this critical need for housing and positions it as a first-step in addressing barriers to health care in low-income individuals.² Housing First is an approach that views homelessness and healthcare as interrelated. This model asserts that proper health and healthcare require the basic necessities that come with stable housing. Thus, the Housing First approach focuses on providing individuals faced with homelessness with permanent housing, free of any prerequisites or conditions. Often referred to as a Treatment First model, approaches like these focus on improved health outcomes before considering housing. Individuals seeking housing are often expected to first resolve behavioral health issues, participate in treatment programs, or demonstrate complete sobriety. The Housing First approach, however, recognizes that these conditions are difficult to meet without permanent housing. Supporters of the Housing First model believe that permanent housing will follow with increased overall life and health-related outcomes as well.³

BENEFITS OF THE HOUSING FIRST MODEL

1.1: Health benefits
The use of housing as a public health intervention has health and substance-use benefits. When compared to Treatment First approaches, implementation of Housing First programs were shown to not only decrease homelessness by 88%, but also to decrease health-related factors as well.⁴ Housing First programs reduced emergency department use by 41%, hospitalization by 36%, and mortality by 37% in individuals with HIV.⁴ Another study found that individuals under a Housing First program demonstrated reduced psychological distress scores, showing that the Housing First approach has not only physical but mental health benefits as well.⁵ Individuals under the Housing First approach also report significantly lower rates of substance use and substance abuse treatment utilization.⁶ This research illustrates that there is a strong association between Housing First programs and increased health outcomes, supporting the push for its increased implementation as a health intervention strategy.

1.2: Economic benefits
Housing First approaches also reap economic rewards. Economic benefits have been found to exceed the costs associated with Housing First programs, reporting a 1.8:1 benefit-to-cost ratio in the United States.⁷ This means that the economic returns of the Housing First model are nearly two times as great as the economic costs—for every $1 put into the Housing First program, there is about $1.80 returned in economic benefits. Further studies also report that a Housing First approach was associated with decreased private and public health-related costs.⁸ This ultimately implies that not only does a Housing First approach improve health outcomes of the individuals using the program but it is also cost-effective, limiting the healthcare expenditures spent on individuals with little access to healthcare or shelter. Given that the United States economic burden of homelessness is nearly $3.4 billion yearly, reduced costs are critical.⁷

LIMITATIONS OF THE HOUSING FIRST MODEL

Although the Housing First approach has been shown to lead to significantly fewer instances of inpatient and emergency department service use by its users, its direct impact on the clinical, social, and long-term health-related aspects of an individual’s life remain more uncertain, putting to question the efficacy of the Housing First model. Even if the Housing First model can have a temporary and short-lived impact on an individual’s interactions with health care systems, there is limited potential to help if it does not actually change their long-term clinical interactions and health.

2.1: Subjective physical health
Individuals reported increases in subjective physical health, irrespective of whether they were in the intervention group experiencing a treatment similar to the Housing First model or the control group exposed to customary housing services with case management.⁹ However, subjective health is just one measurement of well-being and so the Housing First model’s inability to significantly improve its users’ subjective physical health reports compared to other healthcare approaches does not mean it lacks any impact on the health of its users. Additionally, it is still important to acknowledge that the Housing First model improved subjective physical health. Even if it did not improve health significantly more than other approaches, this finding indicates that the Housing First model is able to induce positive effects in its users to an extent similar to many other traditional and well-established approaches.

2.2: Housing stability
A meta-analysis of housing models for individuals with mental illnesses also found that all housing models—residential care and treatment, residential continuum, and permanent supported housing—were associated with improved housing stability—regardless of the specific model.¹⁰ Therefore, the Housing First model does not necessarily stand out as the dominant option for improving housing stability and, following the logic that housing allows for improved health, consequently, the Housing First model might not have the strongest effects on health as well.

2.3: Substance disorders
Additionally, the proposition of a Housing First model which does not require proof of sobriety does not mean that individuals’ substance use disorders will automatically diminish. Even under a model like Housing First, individuals will require certain abstinence-based programs or health-related support services, and the Housing First model does not guarantee these resources. This is evidenced by findings that individuals who received immediate housing without prerequisites did not demonstrate significant improvements in substance use than those who experienced the typical challenges associated with obtaining housing.¹¹

CURRENT LEGISLATION

3.1: American Rescue Plan Act of 2021
In response to the economic struggles brought on by the COVID-19 pandemic, Congress passed the American Rescue Plan Act of 2021, introduced by the Biden-Harris administration.^1,12 This introduced a plan for the HUD to provide immediate and direct assistance to individuals struggling to maintain stable housing. This legislation included $5 billion in Emergency Housing Vouchers and $5 billion for the HOME Investment Partnerships Program, both of which were introduced to provide greater aid and support to those without stable housing.^12,13

3.2: The “ALL IN” Plan
In December 2022, the Biden-Harris administration built on its mission of addressing homelessness by introducing its “ALL IN: Federal Strategic Plan to Prevent and End Homelessness”.¹⁴ This added further support to Biden’s American Rescue Plan Act of 2021 and emphasized the importance of housing as a public health intervention by demonstrating the significant associations between health issues and homelessness.¹⁴ Biden and Harris directly addressed the Housing First approach, explaining that the main goal of their federal plan was to emphasize the importance of Housing First and provide proper support in order to allow the model to thrive.

3.3: Failed outcomes
Perhaps most notable and discussed was the Biden-Harris administration’s goals to reduce homelessness by 25% by January 2025.¹⁴ Unfortunately, since 2022 when the Biden administration enacted its “All In” plan, homelessness has continued to rise, reaching unprecedentedly high levels.¹ Therefore, the Biden-Harris administration’s plans of significantly reducing homelessness and utilizing Housing First as a means of addressing health care were not fully accomplished.

CONCLUSION AND NEXT STEPS:

Therefore, as the country looks to future directions and next steps forward, this serves as a critical moment for the Housing First model. Legislators and policymakers need to decide whether the benefits or limitations of the Housing First model are favored.

If it is decided that the Housing First approach has a weaker and less significant impact than originally anticipated, this might indicate the need for a shift towards a new strategy to address healthcare amongst unhoused individuals. Policymakers need to reconsider whether housing and healthcare should be addressed jointly or separately from their healthcare. Alternatively, for those who believe that the benefits of the Housing First approach are stronger than its potential limitations, specific changes to the current Housing First model will need to be employed. After all, one fact is indisputable—the current Housing First model being used to address health care for individuals experiencing homelessness is not doing enough. The real question is whether the Housing First model should be adjusted or if we should look to the support of completely new strategies for addressing healthcare of individuals experiencing homelessness.

References

1. U.S. Department of Housing and Urban Development. The 2024 Annual Homelessness Assessment Report (AHAR) to Congress: Part 1: Point-In-Time Estimates of Homelessness. December 2024. https://www.huduser.gov/portal/sites/default/files/pdf/2024-AHAR-Part-1.pdf.
2. Tsemberis, Sam. Housing First: An Interview with Sam Tsemberis. Nassau County Department of Human Services. Accessed May 11, 2025. https://nassauda.org/DocumentCenter/View/664/Housing-First-an-Interview-with-Sam-Tsemberis-Dr-Sam-Tsemberis-Is-the-Founder-of-Pathways-to-Housing-Inc-PDF.
3. National Alliance to End Homelessness. Housing First. Accessed May 11, 2025. https://endhomelessness.org/resources/toolkits-and-training-materials/housing-first/.
4. Peng, Yinan, Robert A. Hahn, Ramona K.C. Finnie, Jamaicia Cobb, Samantha P. Williams, Jonathan E. Fielding, Robert L. Johnson, Ann Elizabeth Montgomery, Alex Schwartz, Carles Muntaner, Veronica Helms Garrison, Beda Jean-Francois, Benedict I. Truman, and Mindy T. Fullilove. "Permanent Supportive Housing with Housing First to Reduce Homelessness and Promote Health among Homeless Populations with Disability: A Community Guide Systematic Review." Journal of Public Health Management and Practice 26, no. 5 (2020): 404–411. https://doi.org/10.1097/PHH.0000000000001219.
5. Tsemberis, Sam, Douglas Kent, and Christy Respress. "Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occurring Disorders in Washington, DC." American Journal of Public Health 102, no. 1 (January 2012): 13–16. https://doi.org/10.2105/AJPH.2011.300320.
6. Padgett, Deborah K., Victoria Stanhope, Ben F. Henwood, and Ana Stefancic. "Substance Use Outcomes Among Homeless Clients with Serious Mental Illness: Comparing Housing First with Treatment First Programs." Community Mental Health Journal 47, no. 2 (2011): 227–232. https://doi.org/10.1007/s10597-009-9283-7.
7. Jacob, Verughese, Sajal K. Chattopadhyay, Sharon Attipoe-Dorcoo, Yinan Peng, and the Community Preventive Services Task Force. "Permanent Supportive Housing With Housing First: Findings From a Community Guide Systematic Economic Review." American Journal of Preventive Medicine 61, no. 6 (2021): 871–880. https://doi.org/10.1016/j.amepre.2021.06.021.
8. Larimer, Mary E., Daniel K. Malone, Michelle D. Garner, David C. Atkins, Bonnie Burlingham, Heather S. Lonczak, Kenneth Tanzer, Joshua Ginzler, Seema L. Clifasefi, William G. Hobson, and G. Alan Marlatt. "Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons With Severe Alcohol Problems." JAMA 301, no. 13 (2009): 1349–1357. https://doi.org/10.1001/jama.2009.414.
9. Wolitski, Richard J., Daniel P. Kidder, Sherri L. Pals, Scott Royal, Angela Aidala, Ron Stall, David R. Holtgrave, David Harre, and Cari Courtenay-Quirk. "Randomized Trial of the Effects of Housing Assistance on the Health and Risk Behaviors of Homeless and Unstably Housed People Living with HIV." AIDS and Behavior 14, no. 3 (2010): 493–503. https://doi.org/10.1007/s10461-009-9643-x.
10. Leff, H. Stephen, Clifton M. Chow, Renee Pepin, Jeremy Conley, I. Elaine Allen, and Christopher A. Seaman. "Does One Size Fit All? What We Can and Can't Learn From a Meta-analysis of Housing Models for Persons With Mental Illness." Psychiatric Services 60, no. 4 (2009): 473–481. https://doi.org/10.1176/ps.2009.60.4.473.
11. Tsemberis, Sam, Leyla Gulcur, and Maria Nakae. "Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis." American Journal of Public Health 94, no. 4 (2004): 651–656. https://doi.org/10.2105/AJPH.94.4.651.
12. Results for America. RFA ARP One-Pager: Housing. April 2021. https://results4america.org/wp-content/uploads/2021/04/RFA-ARP-One-Pager_Housing.pdf.
13. U.S. Department of Housing and Urban Development. Factsheet: Housing Provisions in the American Rescue Plan Act of 2021. March 2021. https://www.hud.gov/sites/dfiles/Main/documents/Factsheet_Housing_Provisions_American_Rescue_Plan_Act-2021.pdf.
14. U.S. Interagency Council on Homelessness. All In: The Federal Strategic Plan to Prevent and End Homelessness. December 2022. https://www.usich.gov/sites/default/files/document/All_In.pdf.