February 17, 2021

Homelessness in America: An Overview

by Christopher F. Rufo

Although homelessness decreased 10 percent nationwide from 2009 to 2019,[mfn]U.S. Department of Housing and Urban Development, Office of Community Planning and Development, The 2019 Annual Homeless Assessment Report (AHAR) to Congress, Part 1: Point-in-Time Estimates of Homelessness, January 2020, (accessed January 27, 2021).[/mfn] it is a growing problem in some neighborhoods of such U.S. cities as San Francisco, Seattle, and Los Angeles, where the streets are lined with tents,[mfn]Christopher F. Rufo, “The Moral Crisis of Skid Row,” City Journal, Winter 2020, (accessed January 27, 2021).[/mfn] homelessness-related crime has exploded,[mfn]Christopher F. Rufo, “Seattle Under Siege,” City Journal, Autumn 2018, (accessed January 27, 2021).[/mfn] and residents are exasperated by persistent public disorder. Since 2011, these cities have spent billions on homelessness, yet the number of homeless has increased 15 percent in Los Angeles, 24 percent in San Francisco, and 25 percent in Seattle.[mfn]U.S. Department of Housing and Urban Development, Office of Community Planning and Development, The 2011 Annual Homeless Assessment Report to Congress, November 2012, Revised, (accessed January 27, 2021).[/mfn]

Local leaders have the primary responsibility for homelessness policy. Those in cities who have failed to solve the problem have failed because they have failed to understand the problem—with perilous consequences not only for average citizens, but also for the homeless themselves, who have been left in the streets where they suffer from addiction, mental illness, and threats of violence and in many case pass away.

A Human Problem, Not a Housing Problem

While it is tempting to think of homelessness in terms of housing—it is embedded in the very term “homeless”—this conceptualization obscures important dynamics. For most of the homeless, lack of housing is the result of a series of misfortunes, including job loss, domestic violence, family crisis, and health emergencies.[mfn]San Francisco Department of Homelessness and Supportive Housing, “San Francisco Homeless Count & Survey, 2019 Executive Summary,” (accessed January 27, 2021). Los Angeles Homeless Services Authority, “2019 Greater Los Angeles Homeless Count Summary and Key Messages,” (accessed February 16, 2021).[/mfn]

Furthermore, despite the political rhetoric that attempts to avoid it, two of the primary drivers of homelessness are drug addiction and mental illness. According to the latest data, approximately three-quarters of the unsheltered homeless—people living in cars, tents, and on the streets—suffer from serious mental illness and drug addiction.[mfn]Janey Rountree, Nathan Hess, and Austin Lyke, “Health Conditions Among Unsheltered Adults in the U.S.,” California Policy Lab Policy Brief, October 2019, (accessed January 27, 2021).[/mfn] Ultimately, as we have known since the 1990s when street homelessness first became prevalent in major cities, homelessness is the result of the loss of human relationships, including those with family and community.[mfn]Alice S. Baum and Donald W. Burnes, A Nation in Denial: The Truth About Homelessness (Avalon Publishing, May 4, 1993), (accessed January 27, 2021).[/mfn]

Currently, the dominant policy prescription in many progressive cities is “Housing First” combined with “harm reduction.” Housing First, which has become the default policy in hundreds of American cities and is widely subsidized by the federal government,[mfn]For a more detailed discussion of the federal role in Housing First, see Christopher F. Rufo, “The ‘Housing First’ Approach Has Failed: Time to Reform Federal Policy and Make It Work for Homeless Americans,” Heritage Foundation Backgrounder No. 3513, August 4, 2020,[/mfn] is the idea of providing permanent housing to the homeless with no requirement for sobriety or participation in addiction and mental health services. This model assumes that many, if not most, of the homeless will never be able to overcome their addictions and that programs should therefore focus on “harm reduction,” which means preventing overdose deaths and managing the most negative aspects of addiction, not promoting drug recovery or abstinence. Unfortunately, neither Housing First nor harm reduction has lived up to its promises.

Housing First programs, which have cost the local, state, and federal governments billions of dollars over the past decade, have failed even to keep pace with homelessness.[mfn]Table of “funding and staffing requests for fiscal years 2018 through 2020,” in U.S. Department of Housing and Urban Development, FY 2020 Congressional Justifications, p. 1-1, (accessed January 28, 2021).[/mfn] Some projects have cost up to $700,000 for a simple apartment unit,[mfn]Chris Woodyard, “$700K for an Apartment? The Cost to Solve the Homeless Crisis Is Soaring in Los Angeles,” USA TODAY, August 20, 2019, (accessed January 27, 2021).[/mfn] and taxpayers in Los Angeles voted for a $1.2 billion bond that will likely provide fewer than 5,000 Housing First units for a total homeless population of 59,000.[mfn]Los Angeles Housing + Community Investment Department, “City of Los Angeles Prop HHH Progress Report,” January 26, 2021, (accessed February 5, 2021); Jason Henry, “”Prop. HHH Projects in LA Cost up to $700,000 a Unit to House Homeless. Here’s Why,” Los Angeles Daily News, February 21, 2020, (accessed February 5, 2021); Los Angeles Homeless Services Authority, “Greater Los Angeles Homeless Count Shows 12% Rise in Homelessness,” updated December 4, 2019, (accessed February 5, 2021); Los Angeles Homeless Services Authority, “2019 Greater Los Angeles Homeless Count Summary and Key Messages,” (accessed February 5, 2021).[/mfn] Moreover, as a large body of evidence demonstrates, Housing First programs generally do not reduce substance abuse, psychiatric symptoms, and (in some studies) even the rate of death—the very human factors that are central to the experience of homelessness.[mfn]Union Rescue Mission, “State of Homelessness & Impact of Housing First Only, Harm Reduction Model on Homelessness, Specifically Street Homelessness, from Reputable and High-Level Sources,” chart source from United States Interagency Council on Homelessness and interpretation from Andy Bales, (accessed January 28, 2021); Angela Ly and Eric Latimer, “Housing First Impact on Costs and Associated Cost Offsets: A Review of the Literature,” Canadian Journal of Psychiatry, Vol. 60, No. 11 (November 2015), pp. 475–487, (accessed January 28, 2021); Jennifer Perlman and John Parvensky, “Denver Housing First Collaborative: Cost Benefit Analysis and Program Outcomes Report,” Colorado Coalition for the Homeless, December 11, 2006, https://shnny. org/uploads/Supportive_Housing_in_Denver.pdf (accessed January 28, 2021); Mary E. Larimer, 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,” Journal of the American Medical Association, Vol. 301, No. 13 (April 1, 2009), pp. 1349–1357, (accessed January 28, 2021); Rebecca A. Cherner, Tim Aubry, John Sylvestre, Rob Boyd, and Donna Pettey, “Housing First for Adults with Problematic Substance Use,” Journal of Dual Diagnoses, Vol. 13, No. 3 (April 2017), pp. 219–229, (accessed January 28, 2021); Stefan G. Kertesz and Saul J. Weiner, “Housing the Chronically Homeless: High Hopes, Complex Realities,” Journal of American Medical Association, Vol. 301, No. 17 (May 6, 2009), pp. 1822–1824, (accessed January 28, 2021); Stefan G. Kertesz, Kimberly Crouch, Jesse B. Milby, Robert E. Cusimano, and Joseph E. Schumacher, “Housing First for Homeless Persons with Active Addiction: Are We Overreaching?” The Milbank Quarterly, Vol. 87, No. 2 (June 2009), pp. 495–534, (accessed January 28, 2021).[/mfn] Many Housing First programs simply transfer the dysfunction of the street to subsidized apartment complexes.

Seattle, Philadelphia, San Francisco, Denver, and other cities[mfn]For example, in “cities such as Philadelphia, Denver and San Francisco, drug legalization activists have launched a campaign to create” safe injection cites. For more, see Chris Rufo, “‘Safe Injection Sites’ Aren’t Safe, Effective or Wise. Just Ask Canadians,” Heritage Foundation Commentary, September 29, 2020, (accessed January 27, 2021).[/mfn] have argued recently that policymakers should move further in the direction of “harm reduction” and follow the model of Vancouver, Canada, which has adopted the most progressive homelessness and addiction policies in North America. Fifteen years ago, Vancouver opened a series of “safe injection sites” in which predominantly homeless addicts can inject heroin, methamphetamine, and other drugs under the supervision of support workers, who can administer overdose-reversal drugs if necessary. Although no one has overdosed within these facilities, the surrounding neighborhood has seen more overdose deaths than ever.[mfn]Christopher F. Rufo, “The Harm in ‘Harm Reduction,’” City Journal, Spring 2020, (accessed January 27, 2021).[/mfn] Even worse, the injection sites have created a neighborhood-wide haven for drug dealers, drug users, and criminal gangs, which has led to increased rates of overdose deaths, crime, and violence.

Despite these negative outcomes, political leaders have continued to centralize services, including safe injection sites, in the neighborhood, which only compounds the social dysfunction.[mfn]Ibid.[/mfn] In other words, the policy that seeks to reduce harm ends up enabling it.

Another policy is needed. The approach of progressive West Coast cities has not succeeded in reducing homelessness, but there are other models in the United States that show the potential for positive results.

Balancing Services with Enforcement to Reduce Homelessness Successfully

Houston, Texas, is the untold homelessness success story. Democratic mayor Sylvester Turner has argued that the city must balance the provision of services with enforcement of the law against street camping—a combination he refers to as “tough love.”[mfn]ABC 13, Houston, “Mayor Turner Reveals Plan to Deal with Homelessness,” March 2, 2017, (accessed January 27, 2021).[/mfn]

This approach has paid dividends. Between 2011 and 2019, the city reduced homelessness by a remarkable 54 percent as it continued to skyrocket in cities like Los Angeles, San Francisco, and Seattle.[mfn]Janelle Bludau, “Houston Homeless Population Drops by 54% since 2011,” KHOU 11, Houston, August 2, 2019, (accessed January 27, 2021).[/mfn] The mayor consistently enforced the law against camping and drug consumption, even fighting and winning a lawsuit against the American Civil Liberties Union, which had attempted to hamstring enforcement efforts.[mfn]NBC 5, Dallas-Fort Worth, “Houston Can Clear Out Homeless Tent Cities: Federal Judge,” December 29, 2017, (accessed January 27, 2021).[/mfn]

Mayor Turner demonstrated an important lesson: City governments cannot and should not tolerate rampant street disorder, which is common in the major West Coast cities. This only incentivizes more homelessness and disorder, including large numbers of transient homeless who migrate to permissive jurisdictions. This so-called magnet effect can profoundly impact the composition of a city or county’s homeless population: In Los Angeles County, for example, 35 percent of the homeless migrated to the county after becoming homeless outside the county;[mfn]Los Angeles Homeless Services Authority, “2019 Greater Los Angeles Homeless Count Presentation,” updated June 17, 2020, (accessed January 28, 2021).[/mfn] in King County, which is home to Seattle, 23 percent of the homeless migrated to the county after becoming homeless in another state.[mfn]Christopher F. Rufo, “Hiding the Homeless: King County Hides the Statistics About Homeless Migration—Until I Threatened a Lawsuit,” Christopher F. Rufo blog, August 5, 2020, (accessed January 27, 2021).[/mfn]

Next, in order to address the human challenges associated with homelessness, particularly addiction and mental illness, cities must provide effective services and treatment programs. Fortunately, gold standard “Treatment First” programs have demonstrated robust results. The University of Alabama at Birmingham has run a multi-decade study on intensive housing and treatment programs for the homeless that get people off the streets, into recovery, connected with employment, and eventually on to independent living.[mfn]Joseph E. Schumacher, Jesse B. Milby, Dawna-Cricket Meehan, Stefan Kertesz, Rudy Vuchinich, Dennis Wallace, Jonathan Dunning, and Stuart Usdan, “Meta-Analysis of Day Treatment and Contingency-Management Dismantling Research: Birmingham Homeless Cocaine Studies (1990–2006),” Journal of Consulting and Clinical Psychology, Vol. 75, No. 5 (October 2007), pp. 823–828, (accessed January 28, 2021).[/mfn] In one of the program’s most successful cohorts, 44 percent of men were stably housed and 53 percent were stably employed after 12 months—an incredible outcome, given the severe social, psychological, and medical challenges of this population.


As American policymakers grapple with rising homelessness, they should first recognize that current approaches are not working. Housing First and harm reduction made outsized promises but failed to deliver commensurate results. Cities must recognize that a new approach is needed to address the full nature of human challenges facing the homeless.

First, policymakers must ensure a baseline of public order—in short, enforce the laws against public camping, drug consumption, and homelessness-related property crimes—which is a prerequisite for any successful intervention. Next, cities must shift funds from failing Housing First programs into so-called Treatment First programs that address the human problems of addiction and mental illness and create a series of incentives to move the homeless from the streets into treatment programs and, ultimately, to self-sufficiency.[mfn]Christopher F. Rufo, “‘Housing First’: Homing In on the Problem,” Heritage Foundation Commentary, August 24, 2020,[/mfn] Compassionate leadership, combined with a proper sense of limits and public order, can make all the difference.

Originally published at The Heritage Foundation.

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