Ending Homelessness and Advancing Health Equity: A Public Health of Consequence, March 2022

Widening sociostructural inequities, especially those arising from homelessness and housing insecurity, are drivers of the growing health inequities in the United States. Continued efforts to understand how homelessness will evolve over the course of the pandemic and beyond to impact adverse health outcomes in rural areas, in suburban communities, and in urban centers will be required. In parallel, pressing questions for public health advocates, policymakers, and community members seeking to end homelessness will include determining which populations to prioritize for intervention and what interventions will yield the most benefit to intervene on this critical driver of health inequity.

HOMELESSNESS INTERVENTIONS—WHO GETS PRIORITY?

Until there are sufficient resources to end homelessness in the United States, communities will struggle with how to allocate limited homeless services.

Thus begins the editorial by Shinn and Richard in this issue of AJPH (p. 378), describing, in the absence of necessary resources, which metrics communities can consider employing to determine how homeless services ought to be allocated. With the widely used tool to assess allocation of homelessness resources, the VI-SPDAT (Vulnerability Index – Service Prioritization Decision Assistance Tool), recognized as “invalid, unreliable and racially biased,” communities require guidance on processes to ensure appropriate and equitable allocation of homeless services. In an effort to account for the inadequacies of the VI-SPDAT and provide a more inclusive allocation framework, the authors offer a more nuanced approach that incorporates assessment of (1) which groups of individuals should be considered at risk, (2) which groups of individuals should be prioritized for intervention, and (3) which services or interventions are appropriate. Shinn and Richard also discuss challenges inherent in applying these risk assessment categories, particularly with respect to identifying priority groups for intervention. Given the discrepancy between needs and availability of resources, the choice of which group to prioritize (e.g., homeless veterans, unsheltered youth, etc.) for housing intervention and support will limit resource availability to other groups in need and likely extend racial inequities in service allocation.

People of color, Indigenous people, and particularly women of color and their families bear the disproportionate burden of homelessness and housing instability in the United States. As per the US Department of Housing and Urban Development’s 2020 Annual Homeless Assessment Report to Congress (https://bit.ly/3e7oIef), 39% of all people experiencing homelessness and 53% of people experiencing homelessness as members of families with children were Black or African American people. In addition, Hispanic/Latino people represented 23% of all persons experiencing homelessness, and American Indian, Alaska Native, Pacific Islander, and Native Hawaiian persons represented 5%. Despite these clear racial and ethnic disparities in homelessness, prioritization of groups by risk status for intervention, as noted by Shinn and Roberts, can heighten racial disparities in homelessness by perpetuating inequitable and opaque systems for allocation of housing resources. Failure to apply a racial equity lens to allocation of homeless interventions will perpetuate structurally racist inequities in access to housing support systems and will continue to entrench people of color and Indigenous people in cycles of poverty.

HOMELESSNESS AND THE PANDEMIC

Layered on top of these existing inequities in homelessness intervention, the COVID-19 pandemic has profoundly exacerbated the homelessness crisis by fueling job loss, medical debt, job insecurity, reduction in homeless shelter capacity, and reduction in social services. Each of these underlying drivers of homelessness has been disproportionately shouldered by individuals and their families who earn lower incomes, have less job security, and are disproportionately people of color and Indigenous people.

Although federal, state, and local authorities galvanized a variety of resources to prevent homelessness, including direct financial support and eviction moratoriums, during the pandemic, these stopgap measures are likely to end or be significantly curtailed as the economy rebounds. However, people and families who experienced homelessness during this time will not rebound as easily. Between 2019 (https://bit.ly/3J7fih2) and 2020 (https://bit.ly/3e7oIef), the number of persons experiencing homelessness increased nationwide, from 553 000 to 580 000. A 2021 report by the Economic Roundtable suggests that the recession caused by the pandemic could lead to an increase in homelessness by 49% over the next 4 years (https://bit.ly/3yGUIzg). Individuals who have a record of an eviction during this period, who had to forgo rent to cover unanticipated medical costs, who are unemployed because of the pandemic, who are employed in low-wage or part-time jobs that make it harder to save the funds needed to afford security deposits or encounter landlords unwilling to accept housing vouchers will face significant and often insurmountable hurdles in procuring affordable and stable housing.¹

ENDING HOMELESSNESS— PRIORITIZING ALL

Shinn and Richard present a thoughtful discussion of the opportunities and pitfalls of applying different prioritization assessments to determine allocation of housing support for homeless individuals in the context of limited resources. This approach to allocation of resources may be more inclusive than prior mechanisms for identifying groups for homeless intervention. In addition, individuals who may not fall into the previously identified risk groups who are currently experiencing or likely to experience homelessness associated with the COVID-19 pandemic and pandemic recession should also be included.² Ignoring the needs of those who are newly homeless during this period will likely increase the rate of homelessness and hold back those already experiencing homelessness. Importantly, the absence of guidance on how to ensure that housing support is provided equitably for people of color and Indigenous people, who already shoulder the greatest burdens of sociostructural inequities during the pandemic, will likely lead to growing racial and ethnic disparities in homelessness after the pandemic.

As summarized by Versey,³ the current patchwork of temporary assistance plans and categorizations of priority for housing support will likely be insufficient to meet the growing demand for support. Rather, a comprehensive federal housing policy that provides multilevel solutions to ensure long-term housing support is necessary to narrow the racial and sociostructural inequities in homelessness.³ Long-term and sustainable change requires overhauling local eviction laws in states that have highly punitive eviction policies, enacting rent control in urban neighborhoods where housing prices have increased dramatically and far outpaced low- and middle-income wages and increased tenant protections, and significantly expanding housing vouchers as well as greater investment in affordable housing stock to make housing available for individuals and families. In addition, eliminating background checks for prior evictions during the pandemic and for criminal records will further reduce inequities in homelessness. These are not unattainable goals. At this critical juncture, mobilizing the necessary resources and committing to a vision of affordable housing for all is necessary to achieve a healthier and more equitable society.