Homelessness

 

Trends in Homelessness

  • While all big cities struggle with homelessness, the West Coast cities of the San Francisco Bay Area, Los Angeles, and Seattle struggle more. The change over the last fifteen years has been dramatic.

  • Between 2005 and 2020, the estimated number of homeless people in San Francisco increased from 5,404 to 8,124. The estimated number of unsheltered homeless rose from 2,655 to 5,180.

  • The San Francisco Bay Area as a whole saw sheltered and unsheltered homeless increase by 32 percent between 2015 and 2020, with the share of unsheltered homeless rising from 65 percent to 73 percent. Total homelessness more than doubled in Alameda County, which includes Oakland and Berkeley, between 2015 and 2020.

  • Meanwhile, homelessness declined in the nation as a whole, and in other big cities, over the last decade and a half. Homelessness nationwide declined from 763,000 to 568,000 between 2005 and 2020. In the same fifteen-year period, the homeless populations of Chicago, Greater Miami, and Greater Atlanta declined 19 percent, 32 percent, and 43 percent, respectively.

  • While it is true that New York City saw an increase of 62 percent in its homeless population between 2005 and 2020, over 99 percent of New York’s homeless have access to shelter. In San Francisco, just 43 percent do.

  • The research finds that far more homeless in the San Francisco Bay Area are adults without families than in other parts of the United States. Whereas families make up 32, 53, and 65 percent of the homeless in New York City, Chicago, and Boston, they make up just 9 percent of the Bay Area’s homeless population.

  • San Francisco has a much higher share of unsheltered homeless who are “chronically homeless” than other cities. The US Department of Housing and Urban Development (HUD) defines chronically homeless as those who have been homeless for a year, had four episodes of homelessness totaling twelve months in the last three years, or those who are too disabled to work. Of the roughly 5,200 unsheltered homeless people in San Francisco, 37 percent in 2020 were chronically homeless, in comparison to the 34 percent, 19 percent, 17 percent, and 16 percent chronically homeless in New York City, Greater Phoenix, Greater San Diego, and Boston, respectively.

  • San Francisco’s mild climate alone cannot explain why it has more homeless people than other cities. Miami, Phoenix, and Houston have year-round warm weather and far fewer homeless than San Francisco per capita. Per capita homelessness in San Francisco, Greater Miami, Greater Phoenix, and Greater Houston in 2020 was 9.3, 1.3, 1.6, and 0.8 per 1,000 residents, respectively. And Greater Miami, Greater Phoenix, and Greater Houston saw their per capita homeless population decline from 2005 to 2020 by 39, 17, and 74 percent while San Francisco saw its rise 30 percent.

Causes of Homelessness

  • Housing prices cannot explain the rise in homelessness in San Francisco and other progressive cities. Cities including Chicago, Houston, and the Greater Miami area saw typical rents increase 24 percent, 32 percent, and 35 percent and the number of homeless decline 20 percent, 57 percent, and 9 percent between 2011 and 2019.

  • While the homeless are poor, few poor people live on the street. Nearly 90,000 people in San Francisco live in poverty but just over 8,000 are homeless. The vast majority of people, including very poor people who are priced out of San Francisco’s expensive rental markets, move out of the city or move in with friends or family. Vanishingly few decide to pitch a tent on the filthiest sidewalks in America.

  • For decades researchers have documented much higher levels of mental illness and substance abuse among the homeless than in the rest of the population. It’s true that just 8 and 18 percent of homeless people point to mental illness and substance abuse, respectively, as the primary cause of their homelessness, but researchers have long understood that such self-reports are unreliable due to the socially undesirable nature of substance abuse, and the lack of insight that often accompanies mental illness. Using other methods, San Francisco’s Health Department in 2019 estimated that 4,000 of the city’s 8,035 homeless, sheltered and unsheltered, are both mentally ill and suffering from substance abuse. Of those 4,000, about 1,600 frequently used emergency psychiatric services.

  • In 2019, the Los Angeles Times analyzed government data and found that two-thirds of homeless in Los Angeles struggle with either addiction or mental illness. Against the insistence among some progressives that homelessness is strictly the result of poverty and housing prices, researchers for decades have documented not just the prevalence of mental illness and substance abuse among the homeless, but also their role in creating homelessness in the first place.

  • A large, 5,406-person study of US veterans published in 2021 found that the major personal characteristics of the unsheltered homeless were “unmarried status, criminal justice problems, weak social support, medical diagnoses, drug (but not alcohol) problems, low income, and inability to afford basic needs.” Wrote the authors, “where weather was warmer, or rents were higher, the number of personal risk factors mattered more.”

  • Crack was a major factor behind the emergence of homelessness as a problem in the 1980s. Boona Cheema, a former homeless service provider and advocate in Berkeley, estimated in the early 1990s that 85 percent of the homeless in her Oakland shelter had recently used crack, and that “there are almost no family ties” left among them. Crack radically reduced the price of cocaine, along with the duration of the high, making it available to the poor and working class. The cost of crack declined from $10 to $3 for a single hit between the mid-1980s and early 1990s.

  • “Of the people in supportive housing in San Francisco, 93 percent have a major mental illness that we can name,” said a housing policy maker. “That is very, very high. Eighty percent use cocaine, speed, or heroin every thirty days, or get drunk to the point of unconsciousness.”

  • According to many homelessness researchers, the defining characteristics of chronic homelessness are addiction and “disaffiliation,” or estrangement, from friends and family. “What causes homelessness among these skid row dwellers?” asked a leading researcher in the early 1990s. “Addiction and the lack of a support system.”

  • The term “homeless” itself was invented by advocates to replace terms like “transient” or “indigent.” Advocates used the term to convince the public that the biggest difference between the homeless and the housed was not drug addiction, mental illness, or personal choices, but was instead caused solely by poverty.

Housing First

  • Housing First provides permanent supportive housing without preconditions. There is “no empirical support for the practice of requiring individuals to participate in psychiatric treatment or attain sobriety before being housed,” wrote founder of Housing First Sam Tsemberis. Homelessness researcher Margot Kushel agrees. “You hear people saying things like, ‘You can’t just house people who have addiction problems.’ You can, and you must,” she said in an interview with the New York Times.

  • The George W. Bush administration made Housing First federal policy. It helped cities and states create plans to end chronic homelessness in ten years through permanent supportive housing, and provided money after they had done so. By 2009, more than two hundred cities and states had done so.

  • Utah garnered widespread media attention after state officials claimed a 91 percent decline in chronic homelessness because of its adoption of Housing First.

  • From 2005 to 2020, San Francisco experienced an astonishing 95 percent increase in unsheltered homelessness as the number of permanent supportive housing units offered by the city rose from 6,487 to 10,051.

  • Today, San Francisco has the greatest quantity of permanent supportive housing units per capita of any major city in the United States. It has 11 permanent supportive housing units per 1,000 people, which is nearly three times as much as New York City (4 per 1,000 people) and Chicago (4 per 1,000), and over six times as much as Miami-Dade County (1.7 per 1,000).

  • All of that, and yet the unsheltered homeless population of New York City, Chicago, and Miami fell 11, 10, and 50 percent, respectively, between 2005 and 2020, while San Francisco’s rose 95 percent.

  • After San Francisco started offering free hotel rooms to the homeless during the 2020 coronavirus pandemic, first responders reported that people had come from across the state. “People are coming from all over the place—Sacramento, Lake County, Bakersfield,” said the city’s fire chief. “We have also heard that people are getting released from jail in other counties and being told to go to San Francisco where you will get a tent and then you will get housing.”

  • Los Angeles passed a bond measure in 2016 to build housing for the homeless, and each unit was projected to cost $140,000. Unfortunately, the cost per unit rose to $531,000. As a consequence, by 2025, just 7,000 units will be built for the roughly 41,000 homeless people in the city of Los Angeles.

  • In 2018, San Francisco passed Proposition C, a new tax on businesses that gross over $50 million annually to be spent on homeless services. In mid-2021, city officials announced that $1.1 billion, which include Prop C funds, would be used for 1,000 new shelter beds, 825 new housing units, 650 rental subsidies, 200 tents, and more outreach. As a result, the city’s shelter bed capacity will rise from 2,875 to 3,875, which could reduce San Francisco’s total unsheltered homeless population of 5,180 by 19 percent but only if the newly sheltered aren’t replaced.

  • The study that is the basis for many advocates’ claims around Housing First found that for the duration of two and a half years, 86 percent of the participants who received subsidized housing stayed for nearly the whole time. “It works,” Housing First advocate Margot Kushel told the San Jose Mercury News. “It improves people’s lives. It keeps people housed. . . . It ends homelessness. Full stop.” The newspaper’s headline read, “ ‘It works.’ ” Wrote the reporter, “Groundbreaking data proves success of Santa Clara County homeless housing program.” The Mercury News reported that the “researchers say these findings are groundbreaking because they show that permanent supportive housing—which provides subsidized housing paired with counseling, mental health, addiction and other services—is helping the county’s most difficult cases.” But there was a twist. The Housing First intervention did not reduce the rate of deaths. There were 37 deaths out of 199 participants in the control group and 33 deaths out of 224 in the experimental group. Though the samples weren’t large, it was still a surprising, and sad, finding.

  • The evidence for Housing First turns out to be significantly weaker than its proponents suggest. Despite Utah’s much lauded Housing First program, the state’s legislative auditor general concluded in 2018 that the 91 percent number was wrong, based on a sloppy use of incorrect methodologies. Before 2015, Utah had annualized its homeless count, meaning that researchers counted the homeless at a single point in time and multiplied the data by some factor. But after 2015 the state used raw point-in-time counts, causing a precipitous drop in the official population counts. Over the same period, the state also narrowed its definition of chronic homelessness in several ways, resulting in further apparent reductions. In reality, the homeless population in Utah increased by 12 percent between 2016 and 2020.

  • An experiment with 249 homeless people in San Francisco between 1999 and 2002 found those enrolled in the city’s Housing First program, Direct Access to Housing, used medical services at the same rate as those who were not given housing through the program, suggesting that the Housing First program likely had minimal impact on the participants’ health. Wrote a team of researchers, “obtaining housing does not necessarily resolve other issues that may impede one’s housing success,” pointing to the lack of significant improvements in substance use and psychiatric symptoms over the twelve months that people were housed (the share of patients with severe substance use actually saw a modest increase).

  • The problem with Housing First stems from the fact that it doesn’t require that people address their mental illness and substance abuse, which are often the underlying causes of homelessness. Several studies have found that people in Housing First–type housing showed no improvement in drug use from when they were first housed.

  • In 2018, the National Academies of Sciences, Engineering, and Medicine published a review of the scientific literature of Housing First. “On the basis of currently available research,” the report’s authors wrote, with some surprise, “the committee found no substantial evidence that [permanent supportive housing] contributes to improved health outcomes, notwithstanding the intuitive logic that it should do so and limited data showing that it does do so for persons with HIV/AIDS.”

  • Housing First may even increase addiction and overdose deaths and make quitting drugs more difficult. Warned a multiauthor review in 2009, “One potential risk [of Housing First’s harm reduction approach] would be worsening the addiction itself, as the federal collaborative initiative preliminary evaluation seemed to suggest.” The authors pointed to an experiment that had to be stopped and reorganized after the homeless individuals in the abstinence group complained of being housed with people in the control group, who didn’t stop their drug and alcohol use. “They claimed that they preferred to return to homelessness rather than live near drug users.”

  • There is evidence that privacy and solitude created by Housing First make substance abuse worse. A study in Ottawa found that, while the Housing First group kept people in housing longer, the comparison group saw greater reductions in alcohol consumption and problematic drug use, and greater improvements to mental health, after two years. “One reason for the surprising results,” wrote the authors, “may be that aspects of the Housing First intervention, such as the privacy afforded by Housing First and harm reduction approach, might result in slower improvements around substance use and mental health.”

Advocates Against Shelters

  • Jennifer Friedenbach, who leads the advocacy group Coalition on Homelessness, is arguably the most influential homelessness advocate in San Francisco. She believes that advocates for shelter don’t care about the homeless. In an interview, she said, “There’s this thought that [shelters] are an easy, quick solution and we get people off the streets, and the neighbors stop complaining… It really comes from a perspective of, ‘How do we keep the neighbors happy.’ They don’t want to have to look at homeless people anymore. ‘So, let’s shove them into a shelter so we don’t have to look at them.’”

  • The leading advocates for the homeless often oppose shelters. Housing First advocate Margot Kushel of the University of California, San Francisco is also against shelters. “The problem with New York—and I spend a lot of time with people working in the system in New York—is that they spend an estimated $30,000 for each person per year to keep them in shelter. That’s not what we want to do. Because if you create the shelter and you don’t create the housing, then people are just in shelter forever.”

  • Housing First advocates oppose shelter in Los Angeles. “Why haven’t we solved homelessness?” asked Housing First creator Sam Tsemberis. “Because [Los Angeles mayor] Eric Garcetti [has] Andy Bales [saying,] ‘You need emergency housing.’ ‘These people need to be cleaned up.’ ‘They need to be sober.’ ‘They need Jesus before they’ll be ready for housing.’ I said, ‘People should be housed and then maybe they’ll get sobriety and Jesus and the rest.’ We’re definitely on polar opposites of the whole thing.”

  • But funding permanent supportive housing over shelters has meant that San Francisco lacks shelter capacity and suffers far higher levels of unsheltered homelessness than other cities with more shelter. Greater Phoenix has 700 fewer homeless people than San Francisco but has 500 more shelter beds. Miami, a rare city that has had consistent success at reducing homelessness over the last fifteen years, has 75 percent more shelter beds per homeless person than San Francisco. New York City today shelters 95 percent of its homeless after increasing its shelter population by 31,000 since 2005. In 2020, San Francisco had 3,530 shelter beds for 8,124 people experiencing homelessness. There were more than 1,200 people on the wait list for a shelter bed on any given day in 2019. It took one to two months to reach the top of the list. And a bed is only good for ninety days.

  • Progressives in San Francisco have opposed creating sufficient shelter space for the homeless since at least 2004, when then-mayor Gavin Newsom’s homelessness task force proposed a phaseout of emergency shelters in lieu of permanent supportive housing.

  • Housing First homeless advocates have similarly contributed to the shortage of homelessness shelters in Los Angeles. “The mayor is unwilling to put out bridge shelters because of backlash from some homeless advocates,” said Skid Row shelter provider Rev. Andy Bales, referring to Tsemberis. He added that Housing First activists insisted on building a smaller number of expensive apartments instead of building cheaper temporary shelter units faster, with the $1.2 billion in tax-financed bond funding that voters approved in 2016.

  • In other words, the reason that there are so many homeless people on the streets in San Francisco is that both progressive and moderate Democratic elected officials, and the city’s most influential homelessness experts and advocates, have for two decades opposed building sufficient shelters. And that is unlikely to change even after San Francisco starts spending hundreds of millions more per year on the problem and might even get worse.

Social Spending

  • San Francisco remains significantly more generous in its cash payments to homeless, and other spending to serve them, than other cities. For example, San Francisco’s maximum General Assistance cash welfare monthly benefit for the poor is $588, as compared to $449, $221, and $183 for individuals in San Diego, Los Angeles, and New York City, respectively. While New York City, Chicago, Phoenix, and San Diego spend 3.5, 1.1, 0.9, and 2.5 percent of their budget on homelessness services, San Francisco spends 6 percent. When local, state, and federal funding are accounted for, San Francisco spends $31,985 per homeless person just on housing, not including General Assistance, other cash welfare programs like Temporary Assistance for Needy Families, and other services. By contrast, New York City spends $11,662 and Los Angeles spends $5,001.

  • Even with restrictions on cash welfare payments to some homeless people, San Francisco still gives significantly larger cash benefits to the poor in comparison to other cities. San Francisco gives $709 per capita of total cash welfare payments to the poor as compared to $195, $120, and $0.34 in New York City, Chicago, and Phoenix, respectively. Including overhead, San Francisco spends $15,583 per recipient where New York City spends $7,129 per recipient through its cash welfare program.

Solutions to the Homelessness Crisis

  • In the past, governments and nonprofits had sometimes required homeless people to earn an apartment unit through sobriety, work, and, when appropriate, compliance with taking their psychiatric medicine. This is called the “contingency” approach, linear approach, or staircase approach, since one must earn the next step through good behavior.

  • The contingency approach works. Researchers have found ways to use contingency housing to reduce addiction. Between 1990 and 2006, researchers in Birmingham, Alabama, conducted clinical trials of abstinence-contingent housing with 644 homeless people with crack cocaine addictions. Two-thirds of participants remained abstinent after six months, a very high rate of abstinence, compared to other treatment programs. Other studies found that around 40 percent of homeless in abstinence-contingent housing maintained their abstinence, housing, and jobs.

  • In a randomized controlled trial, homeless people were given furnished apartments and allowed to keep them unless they failed a drug test, at which point they were sent to stay in a shelter. Sixty-five percent of participants completed the program. Three similar randomized controlled trials also found moderate to high rates of completion. And participants in abstinence-contingent housing had better housing and employment outcomes than participants assigned housing for whom abstinence was not required.

  • It turns out that over longer periods of time, Housing First may not even outperform contingency in terms of keeping people housed. In the spring of 2021, a team of Harvard medical experts published the results of a fourteen-year-long study of chronic homeless placed into permanent supportive housing in Boston. Most studies of permanent supportive housing, including the Kushel study conducted in Santa Clara, only study the newly housed homeless for a span of around two years. The study found that 86 percent of the homeless, who were referred based on length of time living on the streets, suffered from “trimorbidity”—a combination of medical illness, mental illness, and substance abuse. The authors found that after ten years, just 12 percent of the homeless remained housed. During the study period, 45 percent died. The authors concluded that, because the chronically homeless had such higher rates of physical and mental illness, “the supportive services, essential to the PSH model, may not have been sufficient to address the needs of this unsheltered population.”

  • California should adopt a right to shelter, not housing, and require the homeless to stay in shelters if they have no other option. The alternative to this policy is dangerous homeless encampments that threaten the health of the homeless and degrade public spaces. New York City has a right to shelter and doesn’t suffer from the same breakdown in order that San Francisco is experiencing.

  • California should enact a new statewide agency that reports directly to the governor and would be responsible for tackling the homelessness, drug deaths, and mental illness crises. Let’s call this new institution “Cal-Psych.” (The use of “psych” is appropriate since a large portion of this agency would be dedicated to universal care for the severely mentally ill. See the tab “mental illness” on this website to learn more.)

  • Cal-Psych would rectify the homelessness crisis through implementing evidence-based solutions like right to shelter and contingency management. Because it would be a statewide agency, Cal-Psych would have the capacity to create numerous shelters across the state, which is much easier than expecting every locality to acquire shelters themselves. Crucially, Cal-Psych’s statewide nature would allow the creation of shelters away from open air drug scenes.