Time for some tough love?

SAM TSEMBERIS TRACES Housing First’s beginnings to his daily commute to and from the psychiatric wing at Bellevue, New York City’s oldest public hospital. The soft-spoken clinical psychologist began noticing former patients loitering on street corners with nowhere to go, discharged to a life of unsheltered homelessness. “It was incomprehensible,” he said. “So I changed my job.”

Tsemberis joined a street outreach team in the 1980s as cities across the nation began reckoning with this new kind of visible street homelessness. He winced as he recalled the incident that convinced him something needed to change. A 62-year-old woman froze to death on the street. “She was sleeping in a cardboard box outside an office building in the Wall Street area of New York City,” he said. “And overnight, the temperature dropped.”

So, in 1992, Tsemberis created the organization Pathways to Housing and acquired a government grant. The group placed individuals living on the streets directly into subsidized apartments for as long as they wanted to stay without sobering them up or requiring them to engage in treatment.

His approach became known as Housing First. Along with its sister policy, permanent supportive housing, Housing First has shaped most federal and state agencies and the community nonprofits they fund for more than a decade.

But critics assert it has failed massively. Homelessness in America has only continued to rise since the Department of Housing and Urban Development started its annual tally in 2005. An estimated 771,480 people—the most since the government started counting—needed a place to live at some point in 2024, and more than a third experienced unsheltered homelessness, living under bridges, in their cars, or in other places not meant for human habitation.

The Trump administration says it’s time for a new approach. In November, HUD announced plans to cap spending on permanent supportive housing at 30% of its budget, funneling billions of dollars back into substance abuse treatment programs and transitional housing.

“We will no longer warehouse homelessness through the Housing First model that neglected to treat the root causes of homelessness, including drug addiction and mental illness,” HUD Secretary Scott Turner told WORLD in a statement. “Instead, we will support providers, including faith-based organizations, that take a holistic approach to homelessness.”

Housing First adherents hit back hard. Twenty states and the District of Columbia filed a lawsuit against the funding changes, warning they could send up to 170,000 permanent supportive housing recipients back to the streets. A group of 11 local governments and nonprofits filed another legal challenge.

But amid the political tug-of-war, a growing number of experts, advocates, and ministry leaders are building consensus around the idea that there’s no silver-bullet approach to solving our country’s homelessness problem. Americans end up on the streets due to all kinds of problems the government’s blanket approach can’t solve.

TODAY, UNSHELTERED street living is a familiar feature in most major American cities. But four decades ago, the sight shocked Tsemberis and his team of social workers. Most historians agree a toxic convergence drove Americans to the street toward the end of the 20th century: economic volatility, the deinstitutionalization of the mental healthcare system, and urban renewal movements that diminished the country’s stock of cheap, low-quality housing.

Tsemberis struck up conversations with New York City’s chronic street dwellers. People told him they needed housing, but the available programs—typically community rescue missions and transitional housing programs—operated according to the idea that people should receive treatment for their mental illness or addiction before they could live independently. This approach alienated many individuals who weren’t interested in treatment or would quickly lose their housing once they relapsed, Tsemberis said.

Pathways to Housing moved chronically homeless individuals into apartments straight from the streets. Service support teams visited them and provided help whenever someone asked. But the client’s housing wasn’t tied to accepting that help.

Tsemberis knew it was risky. But a randomized controlled study of his experiment showed 88% remained stably housed after five years. A systematic review of Housing First studies published in 2020 showed the model increased housing stability by 41% when compared with treatment-first programs, though most of the studies analyzed only tracked the individual’s housing status for two years or less.

“People who get housed start to care about themselves more,” Tsemberis said. “When they’re on the streets all they can think about is a safe place to stay.”

In other words, permanent housing without conditions gives people the stability and bandwidth they need to make other essential life changes.

Tsemberis’ novel program went mainstream when Philip Mangano, the executive director of the U.S. Interagency Council on Homelessness under President George W. Bush, threw himself into replicating Tsemberis’ success across the country. The self-proclaimed homelessness “abolitionist” urged communities to develop 10-year plans for ending chronic homelessness using the Housing First model, and more than 350 followed suit before Mangano left his role in 2009.

Under President Barack Obama, HUD doubled down on the policy, mandating grant recipients adopt a Housing First approach or lose their government funding. HUD spent about 87% of its budget on services and transitional housing when Mangano arrived in Washington, D.C. When President Joe Biden left office, the funding priorities had flipped: The agency allocated about 90% of its homelessness funding toward permanent supportive housing.

Housing First devotees argue that a rise in chronic homelessness doesn’t mean their model is failing to keep individuals stably housed. They say it just can’t keep up. “The inflow into homelessness is crushing communities,” said Marcy Thompson, the vice president of programs and policy at the National Alliance to End Homelessness, one of the groups suing to block the Trump administration’s change.

Thompson also argued permanent supportive housing saves taxpayers money since it prevents individuals from cycling through treatment programs, jail, or transitional housing. Some data shows Housing First programs may reduce emergency room visits and hospitalizations, but there is little published data showing the model improves criminal justice outcomes or reduces healthcare costs as a whole.

Tsemberis called the Trump administration’s push for a treatment-first approach “frightening.”

“That’s exactly what we were doing 30 or 40 years ago,” he said. “And it wasn’t getting us anywhere.”

CRITICS OF HOUSING FIRST argue the model routinely fails the chronically homeless—the very people its creators intended to help. Devon Kurtz is one of Housing First’s fiercest opponents. The youthful, bespectacled researcher serves as public safety policy director at the Cicero Institute, a conservative think tank that has the ear of the Trump administration.

The people who struggle the most to find housing due to complicated behavioral health needs or to becoming entangled in the criminal justice system will also struggle the most in a Housing First program, Kurtz said. He pointed to data estimating more than two-thirds of the unsheltered homeless live with an untreated mental health condition or substance abuse disorder, often both. That makes it difficult for them to maintain their housing or find steady employment without intensive interventions.

Individuals deep in the throes of addiction or an untreated mental health condition might not have the capacity to make the choice to accept essential help, Kurtz argued. “There’s a really perverse framing around voluntary treatment where we almost frame it as a moral failing of homeless people not to choose it,” he added.

Randomized controlled studies of Housing First programs show people tend to hold onto their housing for one to two years even with severe mental illness and a history of addiction. But as Stephen Eide, a senior fellow at the Manhattan Institute, points out in his book Homelessness in America, there’s little evidence that Housing First increases social integration or helps people overcome their behavioral health challenges and addictions in the long run. Data showing Housing First improves housing stability for individuals in active addiction is also scarce.

Most individuals experiencing chronic homelessness don’t meet the standards for involuntary hospitalization, but they need more rigorous engagement than a locked apartment and completely voluntary services, Kurtz said. But the federal government’s continuum of care—the bureaucratic structure that awards grants to organizations through local governments—has discouraged communities from creating middle-of-the-road options, like transitional housing facilities with service and sobriety requirements, since they don’t adhere to the Housing First model.

Door of Hope, a transitional housing program for homeless families in Los Angeles, received government funding until regulatory changes enshrining Housing First as official policy at the state and federal level would have forced it to scrap its service participation requirements and stop drug testing. That would have put some of its families in danger, said CEO Megan Katerjian: “When you’re a mom or dad trying to keep your babies safe and people around you are expressing volatile or unsafe behaviors … that is just a very toxic, dangerous-feeling environment to live in.”

Serna Village, once a sober living apartment community for the homeless in Sacramento County, Calif., can no longer require its residents to maintain sobriety. Now, the permanent supportive housing facility must accept whoever is next in line. Kris Martin is the CEO of Sacramento Cottage Housing, the group providing optional recovery services to Serna Village and another tiny home community. She estimates about 99% of residents use some type of substance.

The fiery 82-year-old questions the government’s one-size-fits all commitment to Housing First’s foundational premise: that people will voluntarily seek out sobriety and services once they’re provided a clean, dry place to live. “It takes a lot of work and a lot of time to get clean and sober,” she said. And the right incentives are key.

“The approach of Housing First, as far as I’m concerned, is simply a new title for warehousing people,” Martin said.

Critics also highlight economic concerns. “We have a limited number of subsidized housing apartments, and people stay in them for an extremely long time,” said Howard Husock, a senior fellow in domestic policy studies at the American Enterprise Institute. HUD data for fiscal year 2022 showed less than 14% of households exit permanent supportive housing units each year. In fiscal year 2024, federal funding for permanent supportive housing and rapid rehousing, the federal government’s two Housing First programs, totaled about $5.4 billion. The National Alliance to End Homelessness estimated it would cost an additional $9.6 billion per year to provide these programs to every person living in a homeless shelter.

Still, some of Housing First’s most staunch critics told me they worry the Trump administration might swing the pendulum back too aggressively. Andy Bales served as CEO of the Union Rescue Mission in downtown Los Angeles for nearly 20 years. The mission sits in the heart of Skid Row, a 50-block neighborhood home to about 3,800 homeless individuals, 2,112 of whom are unsheltered. Bales is hopeful the administration’s changes will give faith-based groups more opportunities to provide individuals with essential treatment and accountability.

But he warned that mandating a treatment-first approach without explaining how the administration will transition individuals currently living in permanent supportive housing into more treatment-focused programs will only bolster opposition to the shift. “You can talk about things, and then you can roll it out in a way that doesn’t get it accomplished,” Bales noted.

In April, a federal appeals court blocked the funding changes, but Trump officials say they remain committed to reforms.

AMID THE POLITICAL GRAPPLING, an unlikely group gathered around a long wooden table in the administrative building of the Denver Rescue Mission in December, about a month after the administration announced its new paradigm shift.

Dennis Van Kampen, the mission’s president and CEO, sat next to Sam Tsemberis, the graying clinical psychologist who created the original Housing First program. On the other side of the table, Tom De Vries, CEO and president of Citygate Network, a community of gospel rescue missions across the country, sat next to another rescue mission leader. Philip Mangano, George W. Bush’s former homelessness czar who promoted Housing First in communities across the country, joined over Zoom.

The men met for about five hours. They sipped on soda, coffee, or water while they talked. The mission statement of the 134-year-old organization hung on the wall: Changing lives in the name of Christ by meeting people at their physical and spiritual points of need with the goal of returning them to society as productive, self-­sufficient citizens.

“I was really excited for that meeting,” Van Kampen said, noting Housing First advocates often have negative views of rescue missions. “We need to have open and honest, respectful dialogue and figure out where we align.”

The Denver Rescue Mission provides emergency, temporary shelter recovery programs for individuals addicted to drugs or alcohol, and a transitional housing program. But in some cases, the mission has connected clients to Housing First programs. Permanent supportive housing may be the right approach for clients with a physical disability that may prevent them from ever holding a stable job and becoming self-sufficient, Van Kampen said. Many homeless families the mission serves ended up on the streets because of unpaid medical bills or another life-altering tragedy, not as the result of addiction or other behavioral health issues.

But for about half the people the mission works with, those dealing with addictions and mental health issues, often at the same time, Housing First is not the solution, Van Kampen argued: “I know people … who went through the Housing First model six times, and they never stayed housed more than three months.”

Mangano, who is now the president of the American Round Table to Abolish Homelessness, acknowledged that Housing First often fails individuals with substance use disorders for whom isolation and a locked door tend to exacerbate the addiction spiral. That’s where a structured rescue mission recovery program might make more headway, Mangano agreed.

But rather than reallocate housing funding toward recovery services, Mangano argued, the Department of Health and Human Services should provide funding for treatment opportunities in addition to HUD’s permanent supportive housing budget. He’s hopeful HHS has already started to play a larger role. In February, the agency announced it is setting aside $100 million to connect homeless individuals struggling with addiction to stable housing focused on long-term recovery and independence.

Still, Mangano told me he believes the Trump administration is right to reassess the government’s exclusive allegiance to the Housing First model. Though he’s still a firm believer in the strategy as a solution for most people—especially for the chronically homeless suffering from mental illness—Mangano argued the federal government should not have mandated that every homelessness program adopt the approach.

“They felt this was the policy for every single person,” he said. But HUD’s broad application of what was created to be a very targeted approach was not evidence-­based, Mangano added.

TSEMBERIS TOLD ME the government’s one-size-fits-all approach incentivized programs to adopt the language of Housing First without actually sticking to the original model. Studies demonstrating Housing First’s success followed individuals who were placed in apartments throughout the community and regularly offered intensive services. But that’s not always how it’s applied.

Some permanent supportive housing programs in California tend to put many chronically homeless people struggling with addiction together in one apartment building, Tsemberis pointed out, without providing enough supportive services. California enshrined Housing First into law at the state level in 2016, shortly after HUD mandated the approach for most housing programs receiving federal funding. Unsheltered homelessness climbed 47.1% between 2016 and 2019 even as the Golden State increased permanent housing units by 33% and overall homelessness funding by 101%.

A few months after the December meeting in Denver, Sam Tsemberis and Phillip Mangano presented on Housing First at Citygate Network’s DC Forum in the nation’s capital. They discussed ways to integrate the two approaches and took questions from a room full of mission leaders. Mangano told me while the two camps still have significant disagreements, they agree that the days of doing it one way are over.

For the Denver Rescue Mission’s Van Kampen, that’s a welcome change. “There’s dozens of reasons and pathways that led them to homelessness. And there have to be multiple approaches to get them out of homelessness,” Van Kampen said. “Housing First is an important tool for us to have in our tool belt. But it can’t be the only tool.”