Housing Ends Homelessness

According to the annual Point in Time Count, the number of veterans experiencing homelessness in the United States has declined by more than 50% since 2010. Over that same period in the United States, there has been an increase in the total number of adults experiencing homelessness.¹

Housing ends homelessness. While the prevalence of mental illness and substance use is higher among people who experience homelessness than in the general population, housing will always be the foundation necessary to end the homelessness epidemic in the United States.

REDUCTIONS IN VETERAN HOMELESSNESS

At present, 12 communities across the United States have effectively and sustainably ended homelessness for veterans.² Since 2008, more than 144 000 veterans have been assisted into permanent housing with the help of our nation’s most effective program to reduce and end homelessness, the Housing and Urban Development VA Supportive Housing (HUD VASH) program.³ HUD VASH provides the funding to bridge the gap between what a veteran can contribute in rent and the market rate rent in a community. In addition, the VA is our nation’s largest single-payer health care system and provides care and treatment of veterans who suffer from the chronic medical and behavioral health conditions that can lead to or result from living on the streets.

While a combination of state, federal, and local programs make similar investments in permanent housing in some communities, no other subpopulation has seen such progress in reducing and ending homelessness. One reason why there has been such progress among veterans in the United States is that in addition to robust funding for permanent housing, the VA has also funded Supportive Services for Veteran Families (SSVF), a veteran-centric program that provides flexible funding to overcome the myriad impediments that get in the way of helping individuals and families move from homelessness to housing or to prevent homelessness in the first place.

In this issue of AJPH, Wilkinson et al. (p. 610) provide an overview of the first 10 years of SSVF and describe how it has been an essential component of improved outcomes for veterans experiencing homelessness. Funding for SSVF successfully escapes the constraints of the heavily bureaucratic VA system of care by pushing funding out to community-based organizations. Over the 10 years of its existence, SSVF has grown dramatically and been used for an array of services from assisting people to reunite with loved ones in their community to paying for rental gaps that could lead to homelessness and even sometimes paying for car repairs so veterans can get to the appointments necessary to get a job or get a home. No other federal program for people experiencing homelessness is similarly structured, and few local or state programs provide funding that incorporates the flexibility and scale of SSVF. In addition to SSVF and HUD VASH, the VA also funds the Grant and Per Diem Programs that offer residential substance use treatment and rapidly accessible, noncongregate, short-term housing to keep veterans safe and quickly move them off the street while they work with the VA and community-based organizations to obtain permanent housing. These three lines of business within the VA are the cornerstones that have most likely led to the impressive progress in reducing homelessness among veterans.

MORE THAT CAN BE DONE TO HELP END VETERAN HOMELESSNESS

Despite considerable success, more could be done. It is possible that a more flexible program than SSVF such as providing a basic income to veterans experiencing homelessness could be even more effective and simpler to administer than SSVF.⁴ In Los Angeles, California, local housing authorities have issued more than 2500 HUD VASH vouchers that are sitting unused by veterans⁵ while more than 4000 veterans in Los Angeles County experience homelessness.⁶ Inadequate numbers of outreach staff contribute to a system-wide failure to identify the housing needs of homeless veterans while SSVF has struggled to be used to pay for essential housing locator functions to identify landlords who have vacant units and are willing to rent to veterans. The inability to successfully use already allocated funding for HUD VASH is common across many high-rent, low-vacancy communities. Because SSVF must be issued to an individual veteran, there are significant administrative barriers that prevent a master-leasing strategy that could support set-aside blocks of units for veterans to live stably with other veterans.

The VA has been slow to establish a diversity of medical services (such as embedding full-time nurses in housing) across project-based housing programs so that veterans with complex medical and behavioral health needs can be matched with housing with on-site services that meet their needs. This can lead to unnecessary use of high-cost inpatient stays within the VA hospital system. Lastly, the VA has no line of business similar to Medicaid Assisted Living Waivers⁷ that can provide funding for residential care facilities to serve the small but growing subset of veterans with needs too medically complex for independent housing but who do not need or qualify for the institutional-based care of a skilled nursing facility. These unfortunate veterans often cycle between very expensive hospital-based care and inadequate shelter or independent housing until they become sick enough to develop a skilled nursing need. The demand for a program that supports assisted living facilities for veterans will only increase over the next decade as the expected number of homeless veterans aged older than 60 years also increases dramatically.⁸

CONCLUSIONS

Having provided primary care for the past 35 years for adults experiencing homelessness and primary care for veterans for the past 10 years, I see little difference in the clinical presentation between the veterans I serve in the VA and the nonveterans I serve in the general public health system. However, for my patients who happen to have served in the military, their time experiencing homelessness is usually rare, brief, and nonrecurring. Ending homelessness for an individual outside of the VA system of care is sometimes possible but is much more complicated and unpredictable. I have often wondered what it would be like to provide care for adults experiencing homelessness in Northern European countries that have universal health care, truly embrace Housing First,⁹ and provide adequate funding for affordable housing.¹⁰ While the fractured US health care and housing systems have a long way to go to deliver the housing outcomes seen in Europe, what the VA has developed over these past 20 years gets us closer than any other system in the United States. SSVF fills in the gaps in the system and is catalytic in leading to this success. For that, we should all be proud of what this country can do while it serves as a road map of what we have yet to achieve.