Housing First and the Thirty Years of Evidence Behind It

In 1992, a psychologist named Sam Tsemberis was working with people who lived on the streets of New York City, many of them with serious mental illness. The system he worked within had a logic that seemed sensible on paper. A person had to get sober, accept psychiatric treatment and prove themselves in a shelter or transitional program before they were judged ready for an apartment of their own. Tsemberis noticed that many of the people he met never got through that ladder. They dropped off at one rung or another and landed back on the sidewalk. So he asked them what they wanted. Most said, in one form or another, a place to live. He founded an organization called Pathways to Housing and turned the ladder upside down: an apartment first, with support offered and never required. Three decades later, that inversion has been tested in more trials, in more countries, than almost any idea in social policy, and it has become the target of a federal government that wants to go back.

In short: Housing First gives people experiencing chronic homelessness a permanent home without requiring sobriety or treatment first, then offers services. Rigorous studies in the United States, Canada and Europe consistently find that most participants stay housed. It is not a cure for addiction or a substitute for building more homes, and its critics have real points, but abandoning it means abandoning what works best at the thing it was built to do.

The staircase and its missing steps

The older approach is often called treatment first, or the staircase model. Its premise is that a person living on the street needs to be stabilized before they can succeed as a tenant. That premise has an intuitive appeal. Many people living outside do struggle with addiction or mental illness, and a landlord wants rent paid and neighbors left in peace.

The problem was in the practice. Each step on the staircase was a chance to fail. A person who drank once in a transitional program could be thrown out and sent back to the start. Shelters were crowded and often dangerous, with rules that broke up couples or barred pets or possessions. For someone with paranoid schizophrenia or deep trauma, a congregate shelter could be the worst possible place to try to recover. The people with the greatest needs were the ones most likely to be screened out, which meant the system served those easiest to serve and left the rest outside for years.

Tsemberis's model kept the services and threw away the conditions. Participants were placed in ordinary apartments scattered across the city, rented from private landlords, with a portion of their income going to rent. A team of clinicians, social workers, nurses, peer counselors and others visited regularly and was available around the clock. Participants were expected to follow a standard lease, just like any tenant. They were not required to stay sober or take medication. If they lost an apartment, the team helped them find another.

What the first trials found

A model is only as good as its evidence, and Housing First was unusual in subjecting itself to randomized trials early. In New York, researchers compared participants in the Pathways program with people in the existing continuum of care. The results, published in the early 2000s, found that people in the Housing First group got housed faster and stayed housed at much higher rates, with housing retention around four in five over the study period. They did not use drugs or alcohol more than the comparison group, which had been the central fear.

The most ambitious test came from Canada. From 2009 to 2013, the federally funded At Home/Chez Soi project enrolled about 2,000 people experiencing homelessness and mental illness in five cities: Vancouver, Winnipeg, Toronto, Montreal and Moncton. Half were randomly assigned to Housing First and half to usual services. Participants in Housing First spent far more of their time stably housed than those receiving usual care, and they reported better quality of life and community functioning. The effects held across cities with very different housing markets and populations, including large Indigenous communities in Winnipeg.

Europe produced its own evidence. Finland adopted Housing First as national policy in 2008, converting shelters into permanent supported housing and building new units through a nonprofit, the Y-Foundation, and other partners. Finland is now often cited as the one European country where long-term homelessness has fallen steadily for years. Its approach combined Housing First practice with a commitment to build or buy the homes, which is a point worth holding onto.

Why it spread through both parties

Housing First did not become federal policy because of a single administration. It rose under George W. Bush, whose homelessness czar, Philip Mangano, promoted it alongside a focus on ending chronic homelessness and encouraged cities to adopt ten-year plans. It was deepened under Barack Obama, whose administration's federal strategy, Opening Doors, made it a central principle. It carried on through Trump's first term, though not without debate.

The most visible success came with veterans. A joint program between the Department of Housing and Urban Development and the Department of Veterans Affairs, known as HUD-VASH, pairs housing vouchers with VA case management. Combined with other efforts, it helped cut veteran homelessness roughly in half from 2010 onward, according to the government's own annual counts. Republican and Democratic members of Congress have both backed it. Few social programs can claim that kind of bipartisan, measurable result.

Part of the appeal across party lines was economic. People who are chronically homeless often cycle through emergency rooms, jails, detox centers and psychiatric wards, all of which cost public money. Several studies found that housing people reduced those costs substantially, offsetting some or much of the cost of the housing itself. The evidence on cost savings is mixed and depends heavily on how sick the people served are. But for the highest-need individuals, housing is often not much more expensive than leaving them outside.

The critics' strongest points

The case against Housing First has grown louder in recent years, and parts of it deserve a straight answer.

First, critics argue that Housing First keeps people housed but does not do enough to improve their health, reduce addiction or get them working. That is partly correct. A 2018 review by the National Academies of Sciences, Engineering, and Medicine found limited evidence that permanent supportive housing, on its own, improves health outcomes, even as it keeps people housed. Some trials found modest improvements in some measures and none in others.

Second, critics point to cities that adopted Housing First as policy and still saw homelessness rise, especially on the West Coast. If the model works, they ask, why are the tents still there?

Third, some argue that removing all requirements sends the wrong message and that a sober environment helps people in recovery, who may not want to live next to active drug use.

Here are the answers. On health, Housing First was designed to end homelessness, not to cure illness. Expecting a lease to cure schizophrenia or addiction sets up a test no program would pass; stable housing is the platform from which treatment becomes possible, and the services must be funded well enough to deliver it. On rising homelessness, the West Coast's numbers track housing costs far more closely than program design. Researchers who compared cities have found that rents and vacancy rates explain much more of the variation in homelessness than drug use or mental illness rates, which are high in many places with little homelessness. A program that places people into apartments cannot work where there are no apartments to place them in. And on sobriety, nothing in Housing First forbids recovery housing for people who want it. The model's claim is narrower: no one should have to earn a home by passing a test that the sickest people are least likely to pass.

Progressives should concede one thing. Some cities embraced Housing First as a slogan while failing to fund the services that make it work or to build the homes it depends on. When a city adopts the language but not the budget, the failure that follows is real, and critics are right to name it.

The federal reversal

In July 2025, President Trump signed an executive order on homelessness that directed federal agencies to end support for Housing First policies, emphasized treatment requirements and encouraged the use of civil commitment for people with serious mental illness living on the streets. HUD later moved to shift homelessness grant money away from permanent housing and toward programs with treatment and work requirements, prompting lawsuits from housing providers and local governments. How those disputes end will shape the program for years, and readers can follow the court fights as they develop.

Supporters of the change argue that the status quo has failed visibly in America's cities and that compassion requires insisting on treatment. Opponents argue that the evidence points the other way and that taking people out of permanent housing will put many of them back on the street. Both sides want fewer people living outside. The disagreement is about what the record shows, and the record of randomized trials points strongly in one direction.

What it will take to make it work at scale

If there is a single lesson from thirty years of Housing First, it is that the model is a method, not a magic. It works when three things are present: enough homes, enough money for the support teams and enough patience to stick with people through relapses. Finland had all three. New York in 1992 had a small program and a willing landlord market. Cities with severe shortages of rentals have struggled to place people quickly, no matter what philosophy they hold.

That brings the story back to housing supply. Homelessness policy and zoning policy are the same subject seen from opposite ends. A country that does not build enough homes will see its tightest markets push the most vulnerable people outside, and no services model, whether treatment first or housing first, can house people in apartments that do not exist.

What a day in the program looks like

Statistics can make Housing First sound abstract, so consider how it works on the ground. A team member meets someone sleeping in a park and gets to know them over weeks, sometimes months. When the person agrees, the team helps gather identification and benefits paperwork, finds a landlord with a vacancy and helps furnish the apartment. The tenant signs a lease. Rent is usually set at about 30 percent of whatever income the person has, with a subsidy covering the rest.

Then the real work starts. The team visits, often several times a week at first. It helps with groceries, doctor appointments, medication if the person wants it, conflicts with neighbors and the ordinary chores of keeping a home that someone may not have done in years. Peer specialists, people who have been homeless themselves, are often part of the team. If the tenant drinks, the team works on reducing harm rather than issuing an eviction notice. If the tenant is evicted anyway, the team helps find a new place.

That model has a cost, and programs that try to save money by cutting the support side tend to get worse results. The intensive team approach in the original trials is not cheap. But neither are repeated emergency room visits, ambulance rides and nights in jail, which is where many of the same people were before.

Why the strongest critics still keep some of it

It is telling that even many critics of Housing First do not want to abolish permanent supportive housing. They argue for adding expectations, such as treatment participation or employment services, or for funding more recovery-oriented options alongside it. Some cities with conservative leadership have kept Housing First programs for veterans and for people with the most serious disabilities while trying other models for different groups.

That points toward a middle ground worth naming. A system can offer several paths: Housing First for people with long histories on the street and serious disabilities, recovery housing for people who want a sober environment, rapid rehousing with short-term help for families who lost a home after a job loss or a rent spike. The mistake is pretending one approach fits everyone, or cutting off the one approach with the strongest evidence for the group it was built to serve.

What you can do

• Learn what your community actually funds. Every region has a Continuum of Care, the local body that applies for federal homelessness money and sets priorities. Its meetings and plans are usually public. Get background and news on the housing and homelessness page.
• Contact your members of Congress about homelessness funding. HUD's homelessness grants and HUD-VASH depend on annual appropriations. Look up your representative and senators and their latest votes, then call about keeping proven programs funded.
• Respond to federal rule changes. When HUD or other agencies propose rules affecting homelessness programs, the proposals open for public comment. The comment page shows rules open right now, soonest deadline first, and explains how to write a useful comment.
• Support the providers doing the work. Supportive housing nonprofits, outreach teams and food banks need volunteers and donors. Find them near you in the organizations directory.
• Meet your unhoused neighbors as neighbors. Ask outreach workers how you can help; learn names. The people Housing First serves are not a policy problem. They are members of your community who need a door that locks.