research on homelessness in america

How Housing Costs Drive Levels of Homelessness

Data from metro areas highlights strong connection.

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A new analysis of rent prices and homelessness in American cities demonstrates the strong connection between the two: homelessness is high in urban areas where rents are high, and homelessness rises when rents rise.

To identify and illustrate the housing market dynamics driving these trends, The Pew Charitable Trusts compared homelessness and rent data in 2017 and 2022. In recent years, many metro areas in the U.S. have seen stark increases in levels of homelessness along with fast-rising rents. At the same time, some other locales that saw slow rent growth experienced declines in homelessness.

Media reports have highlighted increases in homelessness and the emergence of encampments in numerous cities, including Austin , Texas; Fresno , California; Phoenix , Arizona; Raleigh , North Carolina; Sacramento , California; and Tucson , Arizona. But other urban areas where homelessness declined over the same period—such as in Chicago, Houston, Minneapolis, and Philadelphia—recorded slower growth in rents than in the U.S. overall.

A large body of academic research has consistently found that homelessness in an area is driven by housing costs , whether expressed in terms of rents , rent-to-income ratios , price-to-income ratios , or home prices. Further, changes in rents precipitate changes in rates of homelessness : homelessness increases when rents rise by amounts that low-income households cannot afford . Similarly, interventions to address housing costs by providing housing directly or through subsidies have been effective in reducing homelessness . That makes sense if housing costs are the main driver of homelessness, but not if other reasons are to blame. Studies show that other factors have a much smaller impact on homelessness .

Much of the research looks at the variation in homelessness among geographies and finds that housing costs explain far more of the difference in rates of homelessness than variables such as substance use disorder, mental health, weather, the strength of the social safety net, poverty, or economic conditions. Some vulnerabilities strongly influence which people are susceptible to homelessness, but research has repeatedly concluded that these factors play only a minor role in driving rates of homelessness compared with the role of housing costs.

For its analysis, Pew reviewed the U.S. Department of Housing and Urban Development’s homelessness data from 2017 and 2022 and Apartment List rent data covering the same period. In the six metro areas highlighted where homelessness rose sharply, rents increased faster than the national average. (See Figure 1). Over the same period, the four urban areas featured that experienced declines in homelessness saw low rent growth.

In some areas, the relationship between housing costs and rates of homelessness is less clear, perhaps because of data volatility or the role played by other factors that influence homelessness. But the strength and consistency of researchers’ findings over time indicate that these places are the exception and that the weak relationship may be temporary.

Recent Pew research indicates that cities that added to their housing supply in recent years , typically by reforming their local zoning codes to allow more apartments to be built, succeeded in keeping rent growth low . On the other hand, several areas in which homelessness spiked had added little to their local housing supply. For example, the Fresno and Tucson areas added just 2.7% and 3.2%, respectively, to their housing stock between 2017 and 2021, despite high demand for homes. The Austin area, meanwhile, added 15.8% to its housing stock despite its restrictive zoning code , but that still fell short of its 22.7% growth in households over that time. With so many households seeking too few homes, rents climbed.

Throughout the United States, rents have reached all-time highs . Half of renters nationwide now spend at least 30% of their income on rent, and a quarter spend at least 50%. As recently as the 1970s, when rents as a share of income were far lower, homelessness was rare in the United States and housing was often available in buildings where individuals would rent private rooms but share kitchens, bathrooms, or common spaces. These low-cost units helped stave off homelessness because someone earning low wages or receiving disability benefits could usually afford to rent a private room . In the decades since, zoning or building code restrictions in most cities prevented more of these units from being developed , and city governments encouraged their conversion into other uses.

There are still places in the U.S. where levels of homelessness are low, either because those places have low-cost housing readily available—such as Mississippi , where homelessness is 10 times lower than California—or because they have rapidly added housing and made a concerted effort to reduce the ranks of residents without homes. In Houston, the rate of homelessness is 19 times lower than it is in San Francisco, even though Houston’s population has grown more than San Francisco’s in the past decade. (See Figure 2.)

Looking at these markets helps to show how population growth generally does not explain growth in homelessness, except in instances where there is not a sufficient increase in the housing supply. Examples of that include Vermont and Maine , both of which until recently have had very restrictive zoning that limited building more homes. Each saw an influx of residents during the COVID-19 pandemic, and homelessness increased 151% and 110% in those states , respectively, from 2020 to 2022.

The metro areas shown in Figure 1 illustrate how research has found that increases in rents cause increases in homelessness. Those shown in Figure 2 exemplify the related, but distinct, finding from academic research that areas with high rents have high rates of homelessness.

The academic research has consistently found that allowing more homes to be built keeps housing costs down. In tandem with the work showing that housing costs are the primary driver of homelessness, the findings suggest that allowing more housing to be built, whether subsidized or not, can reduce homelessness. What distinguishes places in the U.S. with low levels of homelessness is that housing is more abundant relative to the demand and, therefore, costs less. Recognition of the critical need to make sufficient housing available to those going through or at risk of homelessness—rather than requiring participation in programs focused on vulnerabilities such as substance use or mental health issues—has been bipartisan. Philip Mangano and Barbara Poppe, the leaders of the U.S. Interagency Council on Homelessness under Presidents George W. Bush and Barack Obama, respectively, both reviewed the analysis in this article and have championed this approach.

Homelessness and housing affordability have become high priorities for Americans , according to surveys. The evidence shows that allowing more lower-cost housing, such as apartments or individual rooms with shared facilities, can help solve both problems. As stakeholders work to address these difficult issues, welcoming more housing—especially low-cost housing—will be crucial.

Alex Horowitz is a director and Chase Hatchett and Adam Staveski are senior associates with The Pew Charitable Trusts’ housing policy initiative.

Don’t miss our latest facts, findings, and survey results in The Rundown

Pathways to Homeownership: Housing in America

In this episode, Alex Horowitz and Tara Roche, directors of The Pew Charitable Trusts’ housing policy initiative, join us to discuss some of the challenges—and how to overcome them—for those pursuing homeownership.

NY Housing Shortage Pushes Up Rents and Homelessness

Housing costs have soared in much of the United States over the past decade. In 2022, the median rent-to-income ratio reached 30% for the first time, with a record-high number of Americans exceeding that threshold.

More Flexible Zoning Helps Contain Rising Rents

A national housing shortage has driven up rents, leaving a record share of Americans spending more than 30% of their income on rent and making them what is known as rent-burdened. But in four jurisdictions—Minneapolis; New Rochelle, New York; Portland, Oregon; and Tysons, Virginia—new zoning rules to allow more housing have helped curtail rent growth, saving tenants thousands of dollars annually.

Rigid Zoning Rules Are Helping to Drive Up Rents in Colorado

Like their counterparts in other states, policymakers in Colorado are reconsidering zoning policies in the midst of a national housing shortage that is driving rents up to all-time highs. In Colorado, rents increased 31% between January 2017 and January 2023. Some of the state’s cities and towns saw rents rise even faster during that time, including Castle Rock (53%), Colorado Springs (47%), Loveland (42%), and Fort Collins (37%).

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Why it’s so hard to end homelessness in america.

City of Boston workers clear encampments in the area known as Mass and Cass.

Craig F. Walker/The Boston Globe via Getty Images

Alvin Powell

Harvard Staff Writer

Experts cite complexity of problem, which is rooted in poverty, lack of affordable housing but includes medical, psychiatric, substance-use issues

It took seven years for Abigail Judge to see what success looked like for one Boston homeless woman.

The woman had been sex trafficked since she was young, was a drug user, and had been abused, neglected, or exploited in just about every relationship she’d had. If Judge was going to help her, trust had to come first. Everything else — recovery, healing, employment, rejoining society’s mainstream — might be impossible without it. That meant patience despite the daily urgency of the woman’s situation.

“It’s nonlinear. She gets better, stops, gets re-engaged with the trafficker and pulled back into the lifestyle. She does time because she was literally holding the bag of fentanyl for these guys,” said Judge, a psychology instructor at Harvard Medical School whose outreach program, Boston Human Exploitation and Sex Trafficking (HEAT), is supported by Massachusetts General Hospital and the Boston Police Department. “This is someone who’d been initially trafficked as a kid and when I met her was 23 or 24. She turned 30 last year, and now she’s housed, she’s abstinent, she’s on suboxone. And she’s super involved in her community.”

It’s a success story, but one that illustrates some of the difficulties of finding solutions to the nation’s homeless problem. And it’s not a small problem. A  December 2023 report  by the U.S. Department of Housing and Urban Development said 653,104 Americans experienced homelessness, tallied on a single night in January last year. That figure was the highest since HUD began reporting on the issue to Congress in 2007 .

Abigail Judge of the Medical School (from left) and Sandra Andrade of Massachusetts General Hospital run the outreach program Boston HEAT (Human Exploitation and Sex Trafficking).

Niles Singer/Harvard Staff Photographer

Scholars, healthcare workers, and homeless advocates agree that two major contributing factors are poverty and a lack of affordable housing, both stubbornly intractable societal challenges. But they add that hard-to-treat psychiatric issues and substance-use disorders also often underlie chronic homelessness. All of which explains why those who work with the unhoused refer to what they do as “the long game,” “the long walk,” or “the five-year-plan” as they seek to address the traumas underlying life on the street.

“As a society, we’re looking for a quick fix, but there’s no quick fix for this,” said Stephen Wood, a visiting fellow at Harvard Law School’s Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics and a nurse practitioner in the emergency room at Carney Hospital in the Dorchester neighborhood of Boston. “It takes a lot of time to fix this. There will be relapses; there’ll be problems. It requires an interdisciplinary effort for success.”

A recent study of 60,000 homeless people in Boston found the average age of death was decades earlier than the nation’s 2017 life expectancy of 78.8 years.

Illustration by Liz Zonarich/Harvard Staff

Katherine Koh, an assistant professor of psychiatry at HMS and psychiatrist at MGH on the street team for Boston Health Care for the Homeless Program, traced the rise of homelessness in recent decades to a combination of factors, including funding cuts for community-based care, affordable housing, and social services in the 1980s as well as deinstitutionalization of mental hospitals.

“Though we have grown anesthetized to seeing people living on the street in the U.S., homelessness is not inevitable,” said Koh, who sees patients where they feel most comfortable — on the street, in church basements, public libraries. “For most of U.S. history, it has not been nearly as visible as it is now. There are a number of countries with more robust social services but similar prevalence of mental illness, for example, where homelessness rates are significantly lower. We do not have to accept current rates of homelessness as the way it has to be.”

“As a society, we’re looking for a quick fix, but there’s no quick fix for this.” Stephen Wood, visiting fellow, Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics

Success stories exist and illustrate that strong leadership, multidisciplinary collaboration, and adequate resources can significantly reduce the problem. Prevention, meanwhile, in the form of interventions focused on transition periods like military discharge, aging out of foster care, and release from prison, has the potential to vastly reduce the numbers of the newly homeless.

Recognition is also growing — at Harvard and elsewhere — that homelessness is not merely a byproduct of other issues, like drug use or high housing costs, but is itself one of the most difficult problems facing the nation’s cities. Experts say that means interventions have to be multidisciplinary yet focused on the problem; funding for research has to rise; and education of the next generation of leaders on the issue must improve.

“This is an extremely complex problem that is really the physical and most visible embodiment of a lot of the public health challenges that have been happening in this country,” said Carmel Shachar, faculty director of Harvard Law School’s Center for Health Law and Policy Innovation. “The public health infrastructure has always been the poor Cinderella, compared to the healthcare system, in terms of funding. We need increased investment in public health services, in the public health workforce, such that, for people who are unhoused, are unsheltered, who are struggling with substance use, we have a meaningful answer for them.”

“You can either be admitted to a hospital with a substance-use disorder, or you can be admitted with a psychiatric disorder, but very, very rarely will you be admitted to what’s called a dual-diagnosis bed,” said Wood, a nurse practitioner in the emergency room at Carney Hospital.

Kris Snibbe/Harvard Staff Photographer

Experts say that the nation’s unhoused population not only experiences poverty and exposure to the elements, but also suffers from a lack of basic health care, and so tend to get hit earlier and harder than the general population by various ills — from the flu to opioid dependency to COVID-19.

A recent study of 60,000 homeless people in Boston recorded 7,130 deaths over the 14-year study period. The average age of death was 53.7, decades earlier than the nation’s 2017 life expectancy of 78.8 years. The leading cause of death was drug overdose, which increased 9.35 percent annually, reflecting the track of the nation’s opioid epidemic, though rising more quickly than in the general population.

A closer look at the data shows that impacts vary depending on age, sex, race, and ethnicity. All-cause mortality was highest among white men, age 65 to 79, while suicide was a particular problem among the young. HIV infection and homicide, meanwhile, disproportionately affected Black and Latinx individuals. Together, those results highlight the importance of tailoring interventions to background and circumstances, according to Danielle Fine, instructor in medicine at HMS and MGH and an author of two analyses of the study’s data.

“The takeaway is that the mortality gap between the homeless population and the general population is widening over time,” Fine said. “And this is likely driven in part by a disproportionate number of drug-related overdose deaths in the homeless population compared to the general population.”

Inadequate supplies of housing

Though homelessness has roots in poverty and a lack of affordable housing, it also can be traced to early life issues, Koh said. The journey to the streets often starts in childhood, when neglect and abuse leave their marks, interfering with education, acquisition of work skills, and the ability to maintain healthy relationships.

“A major unaddressed pathway to homelessness, from my vantage point, is childhood trauma. It can ravage people’s lives and minds, until old age,” Koh said. “For example, some of my patients in their 70s still talk about the trauma that their parents inflicted on them. The lack of affordable housing is a key factor, though there are other drivers of homelessness we must also tackle.”

The number was the highest since the U.S. Department of Housing and Urban Development began reporting on the issue to Congress in 2007 .

Most advocates embrace a “housing first” approach, prioritizing it as a first step to obtaining other vital services. But they say the type of housing also matters. Temporary shelters are a key part of the response, but many of the unhoused avoid them because of fears of theft, assault, and sexual assault. Instead, long-term beds, including those designated for people struggling with substance use and mental health issues, are needed.

“You can either be admitted to a hospital with a substance-use disorder, or you can be admitted with a psychiatric disorder, but very, very rarely will you be admitted to what’s called a dual-diagnosis bed,” said Petrie-Flom’s Wood. “The data is pretty solid on this issue: If you have a substance-use disorder there’s likely some underlying, severe trauma. Yet, when we go to treat them, we address one but not the other. You’re never going to find success in the system that we currently have if you don’t recognize that dual diagnosis.”

Services offered to those in housing should avoid what Koh describes as a “one-size-fits-none” approach. Some might need monthly visits from a caseworker to ensure they’re getting the support they need, she said. But others struggle once off the streets. They need weekly — even daily — support from counselors, caseworkers, and other service providers.

“I have seen, sadly, people who get housed and move very quickly back out on the streets or, even more tragically, lose their life from an unwitnessed overdose in housing,” Koh said. “There’s a community that’s formed on the street so if you overdose, somebody can give you Narcan or call 911. If you don’t have the safety of peers around, people can die. We had a patient who literally died just a few days after being housed, from an overdose. We really cannot just house people and expect their problems to be solved. We need to continue to provide the best care we can to help people succeed once in housing.”

“We really cannot just house people and expect their problems to be solved.”  Katherine Koh, Mass. General psychiatrist

Koh works on the street team for Boston Health Care for the Homeless Program.

Photo by Dylan Goodman

The nation’s failure to address the causes of homelessness has led to the rise of informal encampments from Portland, Maine, to the large cities of the West Coast. In Boston, an informal settlement of tents and tarps near the intersection of Massachusetts Avenue and Melnea Cass Boulevard was a point of controversy before it was cleared in November.

In the aftermath, more than 100 former “Mass and Cass” residents have been moved into housing, according to media reports. But experts were cautious in their assessment of the city’s plans. They gave positive marks for features such as a guaranteed place to sleep, “low threshold” shelters that don’t require sobriety, and increased outreach to connect people with services. But they also said it’s clear that unintended consequences have arisen. and the city’s homelessness problem is far from solved.

Examples abound. Judge, who leads Boston HEAT in collaboration with Sandra Andrade of MGH, said that a woman she’d been working with for two years, who had been making positive strides despite fragile health, ongoing sexual exploitation, and severe substance use disorder, disappeared after Mass and Cass was cleared.

Mike Jellison, a peer counselor who works on Boston Health Care for the Homeless Program’s street team, said dismantling the encampment dispersed people around the city and set his team scrambling to find and reconnect people who had been receiving medical care with providers. It’s also clear, he said, that Boston Police are taking a hard line to prevent new encampments from popping up in other neighborhoods, quickly clearing tents and other structures.

“We were out there Wednesday morning on our usual route in Charlesgate,” Jellison said in early December. “And there was a really young couple who had all their stuff packed. And [the police] just told them, ‘You’ve got to leave, you can’t stay here.’ She was crying, ‘Where am I going to go?’ This was a couple who works; they’re employed and work out of a tent. It was like 20 degrees out there. It was heartbreaking.”

Prevention as cure?

Successes in reducing homelessness in the U.S. are scarce, but not unknown. The U.S. Department of Veterans Affairs, for example, has reduced veteran homelessness nationally by more than 50 percent since 2010.

Experts point out, however, that the agency has advantages in dealing with the problem. It is a single, nationwide, administrative entity so medical records follow patients when they move, offering continuity of care often absent for those without insurance or dealing with multiple private providers. Another advantage is that the VA’s push, begun during the Obama administration, benefited from both political will on the part of the White House and Congress and received support and resources from other federal agencies.

The city of Houston is another example. In 2011, Houston had the nation’s fifth-largest homeless population. Then-Mayor Annise Parker began a program that coordinated 100 regional nonprofits to provide needed services and boost the construction of low-cost housing in the relatively inexpensive Houston market.

Neither the VA nor Houston was able to eliminate homelessness, however.

To Koh, that highlights the importance of prevention. In 2022, she published research in which she and a team used an artificial-intelligence-driven model to identify those who could benefit from early intervention before they wound up on the streets. The researchers examined a group of U.S. service members and found that self-reported histories of depression, trauma due to a loved one’s murder, and post-traumatic stress disorder were the three strongest predictors of homelessness after discharge.

In April 2023, Koh, with co-author Benjamin Land Gorman, suggested in the Journal of the American Medical Association that using “Critical Time Intervention,” where help is focused on key transitions, such as military discharge or release from prison or the hospital, has the potential to head off homelessness.

“So much of the clinical research and policy focus is on housing those who are already homeless,” Koh said. “But even if we were to house everybody who’s homeless today, there are many more people coming down the line. We need sustainable policies that address these upstream determinants of homelessness, in order to truly solve this problem.”

The education imperative

Despite the obvious presence of people living and sleeping on city sidewalks, the topic of homelessness has been largely absent from the nation’s colleges and universities. Howard Koh, former Massachusetts commissioner of public health and former U.S. assistant secretary for Health and Human Services, is working to change that.

In 2019, Koh, who is also the Harvey V. Fineberg Professor of the Practice of Public Health Leadership, founded the Harvard T.H Chan School of Public Health’s pilot Initiative on Health and Homelessness. The program seeks to educate tomorrow’s leaders about homelessness and support research and interdisciplinary collaboration to create new knowledge on the topic. The Chan School’s course “Homelessness and Health: Lessons from Health Care, Public Health, and Research” is one of just a handful focused on homelessness offered by schools of public health nationwide.

“The topic remains an orphan,” said Koh. The national public health leader (who also happens to be Katherine’s father) traced his interest in the topic to a bitter winter while he was Massachusetts public health commissioner when 13 homeless people froze to death on Boston’s streets. “I’ve been haunted by this issue for several decades as a public health professional. We now want to motivate courageous and compassionate young leaders to step up and address the crisis, educate students, motivate researchers, and better inform policymakers about evidence-based studies. We want every student who walks through Harvard Yard and sees vulnerable people lying in Harvard Square to not accept their suffering as normal.”

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Federal Homelessness Research Agenda

What would it take to prevent and end homelessness?  

While decades of research have documented effective strategies for helping people exit homelessness (particularly Housing First and Critical Time Intervention),  more research is needed  to better understand how to scale housing and supportive services. And while communities are increasingly focused on homelessness prevention (including guaranteed basic income, flexible funding pools, and shelter diversion),  the research remains limited . 

In November 2023, USICH published From Evidence to Action — the first federal homelessness research agenda in more than a decade —to shape federal investments in homelessness research and offer a roadmap for academic researchers, philanthropy, students, and others committed to understanding what works to prevent and end the crisis of homelessness in the United States.

This agenda—which will evolve over time—was  developed with significant public input  from researchers, people with lived experience of homelessness, national organizations, and experts from federal agencies. 

From Evidence to Action seeks to:

• Strengthen our nation’s collective base of knowledge on what works to prevent and end homelessness through rigorous qualitative and quantitative evidence
• Reinforce existing evidence to combat disinformation
• Align research priorities and prevent fragmentation at both the federal and non-federal levels
• Facilitate meaningful engagement of and collaboration with a diverse group of funders, researchers, people with lived expertise, and partners at every stage of developing and implementing federal research activities
• Promote research to address gaps in policy and practice, and facilitate the uptake of evidence by decision makers and service providers
• Catalyze governmental and non-governmental investment in homelessness research

The agenda focuses on the following topics:

Preventing Homelessness

• Universal Prevention
• Targeted Prevention
• Screening and Identifying Risk
• Cost and Scale

Ending Homelessness 

• Cost  
• Longitudinal Outcomes
• Housing and Services
• Specific Subpopulations
• Unsheltered Homelessness
• Lessons Learned From COVID-19 Response

Click to read From Evidence to Action: A Federal Homelessness Research Agenda .

Please email questions or comments to [email protected] .

Addressing the U.S. homelessness crisis

February 29, 2024 – Between 2022 and 2023, the number of people experiencing homelessness in the U.S. jumped 12 percent—the largest yearly increase since the Department of Housing and Urban Development (HUD) started collecting data in 2007.

“We’re in a crisis right now—let’s make no mistake about that,” said Jeff Olivet, executive director of the U.S. Interagency Council on Homelessness, at February 22 virtual event co-sponsored by Harvard T.H. Chan School of Public Health’s Initiative on Health and Homelessness (IHH) . “Housing is a basic human right, just like food or water or a right to education, a right to health care—people need and should have access to affordable housing. And yet, we know we live in a country and in a world where that’s not always the case.”

Other co-sponsors of the event included the Harvard Joint Center on Housing Studies, the Harvard Kennedy School Government Performance Lab, and the Harvard Advanced Leadership Initiative.

Howard Koh , Harvey V. Fineberg Professor of the Practice of Public Health Leadership and IHH faculty chair, served as moderator.

A multi-system failure

The homelessness crisis is driven by challenges across multiple systems, according to Olivet, who discussed key findings from the HUD 2023 Annual Homeless Assessment Report . Not only is there a shortage of affordable housing, but many people also have trouble accessing physical and mental health care, education, and public transportation.

“When you look at all of those factors, it’s no wonder that we have millions of Americans who experience homelessness,” he said.

Olivet noted that during the first couple of years of the COVID-19 pandemic, the federal government instituted eviction moratoriums and provided emergency housing vouchers, but these protections and resources have since ended.

However, Olivet also highlighted a success: With bipartisan support from Congress, the number of veterans experiencing homelessness has decreased by more than 50 percent over the last decade and a half.

“It gives us a proof point that when we invest in housing and wraparound health care, that we know how to end homelessness,” he said. “The question is, how do we apply that to other populations? That’s going to take additional resources.”

Collaborative efforts

In addition to the factors that Olivet mentioned, the number of people experiencing homelessness is increasing due to an influx of immigrants from the Mexico–U.S. border, according to speaker Beth Horwitz, vice president of strategy and innovation at All Chicago Making Homelessness History. The nonprofit coordinates the efforts of organizations across the city, as well as government resources, to serve the different needs of the homeless population.

“We found that when we centralize and coordinate resources, we have the greatest impact,” she said.

Horwitz said that All Chicago expanded its efforts during the pandemic by leveraging resources from the federal government.

She added, “We’re seeing increased investments from state and local government to help us continue to serve even more people, so that we can become a country where housing is a human right, and everyone has access to safe and affordable housing,” she said.

Photo: iStock/Brett Wiatre

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Solving Homelessness from a Complex Systems Perspective: Insights for Prevention Responses

Patrick j. fowler.

1 The Brown School, Washington University in St. Louis, St. Louis, Missouri 63130, USA; ude.ltsuw@relwofjp , ude.ltsuw@dnamvohp , ude.ltsuw@lacramek

Peter S. Hovmand

Katherine e. marcal.

2 Department of Computer Science and Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, USA; ude.ltsuw@yamnas

Homelessness represents an enduring public health threat facing communities across the developed world. Children, families, and marginalized adults face life course implications of housing insecurity, while communities struggle to address the extensive array of needs within heterogeneous homeless populations. Trends in homelessness remain stubbornly high despite policy initiatives to end homelessness. A complex systems perspective provides insights into the dynamics underlying coordinated responses to homelessness. A constant demand for housing assistance strains service delivery, while prevention efforts remain inconsistently implemented in most countries. Feedback processes challenge efficient service delivery. A system dynamics model tests assumptions of policy interventions for ending homelessness. Simulations suggest that prevention provides a leverage point within the system; small efficiencies in keeping people housed yield disproportionately large reductions in homelessness. A need exists for policies that ensure reliable delivery of coordinated prevention efforts. A complex systems approach identifies capacities and constraints for sustainably solving homelessness.

1. HOMELESSNESS AS A COMPLEX PUBLIC HEALTH THREAT

1.1. scope of homelessness.

Homelessness poses an enduring public health challenge throughout the developed world. Although the Universal Declaration of Human Rights declared housing a basic right in 1991, the United Nations continues to identify homelessness as an urgent human rights crisis ( 109 ). Definitions vary, but homelessness generally refers to the lack of safe accommodations necessary for respite and connection with people and places ( 11 , 47 , 110 ). Homelessness includes living on the streets or in shelters, as well as patterns of housing insecurity such as overcrowding or excessive cost burden. The most recent global survey of countries estimates that more than 1.5% of the world’s population lack basic shelter, while as many as one in five people experience housing insecurity ( 109 ).

Trends of homelessness suggest stubbornly stable or expanding rates. Most of Europe has seen large increases in rooflessness as well as housing instability in recent years ( 80 , 110 ). For instance, the homeless populations of Germany and Ireland have increased by approximately 150% from 2014 to 2016 and from 2014 to 2017, respectively ( 92 ). Point-in-time counts of homeless persons in Australia suggest increases in per capita (PC) rates from 2006 (45 per 10,000) to 2016 (50 PC) ( 3 ). The United States shows decreases in PC rates of homelessness based on annual point-in-time counts of sheltered and unsheltered persons ( 47 ); however, changes have leveled off despite substantial reorganization of homeless assistance.

Housing insecurity represents the much larger problem of hidden homelessness. On average, poor families (earning less than 60% of the median national income) in the European Union spent more than 40% of their income on rent in 2016 ( 92 ). More than 80% of US households below the federal poverty line spent at least 30% of their incomes on rent. Frequent moves and doubling up represent additional common indicators of inadequate housing ( 20 ). Foreclosure and evictions are endemic in certain communities; estimates suggest that nearly one million US households experienced eviction in 2016, while eviction represents a major challenge across Europe ( 23 , 53 ). Trends demonstrate the challenges of solving homelessness and the need for innovations.

1.2. Impact of Homelessness

Homelessness and associated poverty have life course implications for physical and mental health. Many adverse health and socioemotional outcomes are linked to homelessness in children ( 26 , 117 ). Homeless adults face increased mortality from all causes, and those with severe mental illness display significantly worse quality of life compared with nonhomeless individuals with mental illness ( 61 ). Education levels and employment rates among homeless adults are low compared with the general population ( 9 , 16 ). In Europe, average life expectancy of people who experience homelessness is 30 years less than nonhomeless populations ( 11 ).

In addition to human suffering, public expenditures associated with homelessness are substantial. In the United States, estimated costs (all adjusted to 2018 USD) of a homeless shelter can exceed $7,000 per month per family ( 19 , 45 , 98 ) with additional costs attributed to inpatient hospitalization, incarceration, and public assistance ( 36 , 99 ). Cost estimates in Europe are limited but suggest substantial expenditures associated with shelter and outside services such as emergency departments, psychiatric care, and jail or prison ( 78 ). In Australia, the government estimates spending at $30,000 per homeless person per year ( 4 ). Few rigorous studies quantify the additional social losses in productivity and well-being. Communities around the world struggle to manage the human and financial burdens of homelessness.

2. COMPLEXITY IN CAUSES AND RESPONSES TO HOMELESSNESS

2.1. complex causes of homelessness.

Experiences of homelessness depend on a complex interplay between individual, interpersonal, and socioeconomic factors. Research has long identified mental illness and addiction as risk factors for homelessness ( 37 , 47 , 48 ). Personal struggles also strain interpersonal relationships with family, friends, and romantic partners; in a vicious cycle, conflict undermines well-being as well as erodes potential housing supports ( 21 , 77 ). However, socioeconomic factors often dictate the likelihood of displacement.

Globally, marginalized communities disproportionately experience homelessness. Homelessness is much more common among the poor and minorities in terms of race/ethnicity, sexual orientation and identity, and institutionalization and among those with physical and mental disabilities compared with the general population ( 105 ). For instance, members of Aboriginal communities in Australia comprise a quarter of people receiving homeless services, while representing less than 3% of the total population ( 3 ). A similar disparity exists in Canada, with Indigenous people 10 times more likely to use homeless shelters than non-Indigenous ( 37 , 91 ). Due to structural inequalities associated with marginalization, the accessibility of jobs and affordable housing remains constrained; availability of appropriate accommodations is more or less random ( 11 , 74 ). Household-level shocks to housing stability such as job loss, termination of assistance, or eviction require a scramble for housing that may or may not be available, given market constraints. Homelessness results when other formal or informal housing supports remain inaccessible; lack of supports can reinforce vulnerability to crises that threaten stable housing. Thus, entries as well as exits into homelessness among vulnerable populations become a matter of bad timing and bad luck. The presence of personal and interpersonal barriers exacerbates vulnerabilities but fails to explain homelessness.

2.2. Implications of Complexity for Homeless Responses

Complexity underlying housing insecurity carries important implications for systematic responses to homelessness. First, extensive heterogeneity exists in homeless populations and in the types of services needed to address housing instability. Individuals with severe mental illness, for example, may require ongoing intensive supports to avoid falling back into homelessness, whereas pregnant teens with few connections to supportive adults have a different set of needs. This variation requires considerable flexibility and tailoring of resources to promote stability.

A related implication concerns variation in the timing and patterns of homelessness. Some households experience single episodes of homelessness, while chronic homelessness refers to instability for more than two years (one year for families with children) with ongoing barriers to stability [HEARTH Act of 2009 (Pub. L. 112–141)]. Research that investigates patterns of housing insecurity reveals distinct subpopulations based on housing trajectories ( 18 , 31 , 33 , 106 ). For instance, studies show that chronic patterns of homelessness affect a relatively small number of persons ( 33 , 34 ). Homeless assistance continuously interacts with households at different stages of different trajectories, which makes accurate prediction of risk as well as response to interventions exceedingly difficult ( 5 , 38 , 44 , 58 , 95 ).

The complex causes of homelessness require complex solutions. Homeless assistance typically requires the provision of multifaceted supports that adapt in response to shifting household demands and often includes unique combinations of residential and nonresidential supports. Recurrent constraints on the availability of supports often require further tailoring of homeless assistance on the basis of resource accessibility. The resulting combinatorial complexity of housing interventions challenges sustained, systematic responses to homelessness ( 35 ).

Finally, the complex causes of and responses to homelessness present substantial challenges for screening and resource allocation. Efficient service provision depends on accurate assessments of risk and potential responses to interventions ( 10 , 58 , 72 ). Tools, such as the Vulnerability Index—Service Prioritization Decision Assistance Tool (VI SPDAT), purport to categorize households seeking homeless assistance for appropriate interventions from responses to screening questions; high vulnerability requires supportive housing, moderate requires temporary housing with less intensive supports, and households with low risk are diverted from the system ( 22 ). VI SPDAT developers report item reliability and claim use in communities around the world ( 75 ). However, little evidence exists on the tool’s accuracy, and available research suggests poor sensitivity and specificity with common scoring procedures ( 7 , 15 ). The VI SPDAT intervention assignments poorly differentiate households, resulting in extensive false positives (false alarms) and false negatives (missed hits) ( 6 , 108 ). Other screening tools show similar challenges for targeting preventive services ( 13 , 28 , 44 , 94 ). The difficulty in prediction reflects the complexity that underlies homelessness ( 5 , 38 , 58 ).

2.3. Complex Systems and Coordinated Responses to Homelessness

Nations have adopted various strategies to address homelessness. Responsibility for serving homeless populations in European Union nations generally falls under common social welfare policies, while federal policies and funding structure local responses to homelessness in Australia, Canada, and the United States (11, 116; Pub. L. 112–141). Although communities differ in how supports are organized, a common structure connects the delivery of homeless assistance. Delivery of housing plus supports leverages interorganizational networks composed of governmental and nongovernmental agencies ( 10 , 41 , 81 , 87 ). Formal and informal partnerships work together to screen and respond to individuals and families experiencing housing crises.

Figure 1 illustrates the underlying framework for homeless services from a complex systems perspective. In the center, households experience countervailing supports and strains that influence stability, represented as virtuous and vicious cycles. When strains exceed supports, a need for housing triggers the demand for homeless assistance. Access to homeless services depends on local and national contexts; formal and informal policies determine eligibility, timing, and funding of resources, while socioeconomic conditions influence demand chains for services ( 27 , 74 ). The resulting dynamics allow homeless services to adapt and evolve over time.

Coordinated responses to homelessness as a complex system. Solid lines reflect a treatment first approach, whereas dashed lines represent housing first philosophy. Circular nodes represent examples of key supports in keeping people housed; ties between nodes generally refer to information exchanges, such as communications, service referrals, or funds. The + and − signs indicate the direction of correlation between variables.

The top layer in Figure 1 represents the general structure of homeless or residential services. Although heavily based on a North American perspective, the model captures a number of common elements in local and national responses to homelessness ( 10 , 11 , 25 ). Screening aims to identify need and allocate households to the most appropriate and available service. Emergency responses address immediate housing crises; in many countries, this represents homeless shelters that provide short-term accommodations. Temporary housing provides time-limited accommodations with case management and other nonresidential services. Supportive housing refers to permanent connection to housing plus case management to address substantial barriers to stability. Rapid rehousing and homelessness prevention represent efforts to provide immediate access to stable accommodations.

Movement through the system depends on organizing philosophies for solving homelessness. Screening attempts to forecast the level of need, ranging from low (prevention), moderate (rapid rehousing), and high (supportive housing) risk for ongoing homelessness ( 75 ). Treatment first assumes people need services to address the underlying barriers that led to homelessness ( 88 , 107 ). A staircase model structures services so that households progress from shelters to temporary housing in addition to the provision of services to permanent supportive housing. Transitions expose people to higher levels of supports that make them more prepared for stable housing. In contrast, housing first considers stable accommodations as a precondition for any treatment needed to reduce homelessness ( 107 ). The structure of residential services attempts to place people in stable housing as quickly as possible.

The bottom layer in Figure 1 illustrates the extensive networks of formal and informal supports engaged in addressing household instability. Conceptually, connections can be informal interpersonal communities or formalized through agreements and contracts. Homeless services at the hub denote efforts to weave a safety net of supports for households. Systems vary in the extent to which nonresidential supports are specific to the residential service or carry over with households as they transition into and out of homelessness ( 11 , 30 ). Regardless, homeless systems rely on extensive cross-systems collaboration to promote stability and remove barriers that prolong homelessness ( 10 , 19 , 90 ).

Use of interagency networks responds to the complexities of addressing homelessness. Foremost, referral networks allow for quicker access to a wide range of supports, which can handle the extensive heterogeneity of needs among homeless populations. Networks also provide flexibility to expand and contact with shifts in demand for services ( 10 , 19 , 73 , 87 ). A timely example concerns displacement due to conflict that triggers surges in refugee populations with various needs within a community or country; Germany, for example, saw a 150% increase in homelessness from 2014 to 2016 composed primarily of refugees ( 92 ). In times of greater need such as an influx of refugee families, interagency networks allow for sharing information and resources to respond more quickly. Likewise, collaborative organizations avoid hierarchal approval processes; instead, decision making on service delivery is distributed across providers within agencies that potentially speed up resource allocations ( 82 ). A network structure provides a dynamic and adaptive response to homelessness.

Collaborative networks introduce their own complexities for homeless service delivery. Actual efficiencies of the system depend on the mutually agreed upon rules that drive resource allocation ( 8 , 82 ). Partnerships must continuously devote time toward planning and monitoring mutually agreed upon goals, which shifts resources away from the core service missions of each agency ( 35 ). Given the constant pressure for social services, a dynamic emerges that threatens continued investment in collaboration ( 59 ). Instability can create oscillations in the quality of network performance toward ending homelessness ( 35 ). Virtuous cycles emerge within collaborations that have clear goals, strong leadership, and investments in backbone supports ( 62 ). Challenges exist for sustainable efforts.

Taken together, coordinated approaches to homelessness must consider the extensive heterogeneity in the population, as well as in the types and timing of services. Given the multiple pathways into homelessness and the diversity of the homeless population, a one-size-fits-all approach is inadequate. Collaborations represent a flexible strategy to address homelessness. However, system performance toward ending homelessness depends in large part on continuous investments in partnerships.

3. TRANSFORMING COORDINATED RESPONSES TO HOMELESSNESS

3.1. housing first as an organizing philosophy.

The complex systems delivering homeless assistance organize around key theories on ending homelessness. Formal and informal policies operationalize these theories, and structure emerges to coordinate resource allocation across intersecting networks ( 8 ). A paradigm shift has moved homeless systems toward a housing first philosophy ( 76 ). Although housing first also refers to a specific case management intervention, the philosophy more generally aligns services to stabilize accommodations quickly and without preconditions. This approach contrasts with the earlier treatment first, or staircase, approach that require homeless persons to demonstrate housing readiness or compliance with service plans as a condition of obtaining and maintaining housing supports. Fundamentally, the shift in philosophies moves toward a person-centered and recovery-oriented approach that assumes housing serves as a platform for reintegrating into communities.

Housing first interventions provide access to housing plus ongoing supports ranging in duration and intensity ( 11 , 107 ). Examples include assertive community treatment (ACT), critical time intervention (CTI), and Pathways to Housing. Early experimental studies in the 1980s and 1990s showed that homeless persons experiencing severe mental illness achieved stability more quickly and more consistently when randomly assigned to housing first instead of to treatment first services ( 87 , 102 ). Moreover, early studies suggested that the delivery of case management yielded savings from avoided costs for shelter, hospitalization, and criminalization ( 51 , 85 ). The initial evidence challenged assumptions of housing readiness to highlight cheaper and more effective options for homeless service delivery.

Well-designed studies subsequently tested the implementation and impact of housing first models with different homeless populations. Several large experiments in the United States and Canada randomly assigned homeless individuals and families to different housing interventions and carefully monitored the impacts of service delivery on a host of outcomes ( 2 , 45 , 87 ). Evidence from these and other studies generally support permanent housing approaches for improving stability ( 84 ). Benefits of permanent housing on well-being and quality-of-life improvements are more elusive; treatment effects are smaller and less consistent across outcomes and populations ( 32 , 45 ). Additionally, emerging evidence on rapid rehousing interventions providing time-limited rental assistance shows little impact on stability or well-being ( 14 , 45 , 58 ). As a whole, the body of evidence firmly dismisses housing readiness requirements for homeless assistance.

3.2. Dissemination and Implementation of Housing First

Numerous rigorous investigations into widespread dissemination and implementation of housing first provide important considerations for complex homeless systems. Studies show that fidelity to specific housing first models promotes household outcomes ( 2 , 40 , 87 ). Yet, model adherence requires substantial investment in training and technical assistance ( 2 , 40 , 69 ). Using the interactive systems framework ( 115 ), a national rollout of Pathways to Housing in Canada showed that fidelity diminished in communities with less initial buy-in and support ( 2 , 69 ).

Similar findings emerged from an initiative to provide housing first to 85,000 veterans across the United States ( 55 , 56 ). The organizational transformation model ( 63 ) directed substantial investment and technical assistance to deliver supportive housing as part of the health care system for veterans. Housing readiness requirements diminished through transformational efforts; however, model fidelity for client-centered supportive services remained inconsistent ( 54 ). Both studies emphasize the necessity of strong leadership and buy-in for achieving housing first model adherence ( 2 , 39 , 40 , 54 ). The studies show the difficulty in shifting cultures toward housing first principles even in well-resourced initiatives.

Systems integration of services for housing first also proves challenging. An innovative early experiment of supportive housing for homeless individuals experiencing severe mental illness also tested impacts on systems of care ( 43 ). The study randomly assigned individuals to receive supportive housing, as well as communities to receive technical assistance for systems transformation to integrate services. Community-level interagency networks were assessed over time to see if resources for supportive housing triggered new and stronger partnerships for nonresidential services. Findings suggested little change in systems of care, and technical assistance failed to integrate services ( 73 , 86 , 88 ).

3.3. Housing First Adoption and Adaptations

Despite implementation challenges, the housing first philosophy has been broadly adopted within homeless services around the world ( 11 , 76 ). This shift is most apparent in the integration of housing first principles into national strategies for addressing homelessness in Australia, Austria, Belgium, Canada, Denmark, France, Finland, Germany, Great Britain, Greece, Italy, the Netherlands, Portugal, Scotland, Spain, Sweden, and the United States ( 76 ). Policies focus on the provision of housing as a platform for connection to other services necessary for ending homelessness ( 79 , 112 ). However, considerable variation exists in adherence to evidence-based interventions as well as adaptations for system-wide implementation ( 11 , 76 ).

The United States provides an example of both broad adoption and adaptations of housing first philosophy. The Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009 (Pub. L. 112–141) introduced federal legislation that required every community across the country to develop and implement coordinated responses to homelessness. Guided by housing first principles, policies focus on procedures for community-wide screening and allocation of homeless assistance based on level of need; resources are prioritized for homeless persons deemed most vulnerable ( 62 , 113 ). The emphasis on vulnerability coincides with a shift in resources toward the literal homeless and away from the broader demand for supports to maintain housing ( 10 , 19 , 94 ). The housing first tenets were codified in a redefinition of homelessness and eligibility for services, as well as national agendas for ending homelessness ( 113 ; Pub. L. 112–141).

Figure 2 illustrates the implementation of housing first policies through shifts in new and reallocated resources. Plotting year-round beds available for homeless persons since 2007, the system has increasingly used housing first rapid rehousing and supportive housing, whereas use of shelters and temporary housing has declined. Trends in total federal funding for homeless assistance also demonstrate increases in capacities. Although annual budgets fail to disaggregate funds by service type, increases in funding correspond with shifts toward rapid rehousing and supportive housing. Decreases in the number of persons served through homeless assistance over the same period further suggest that the homeless systems provide more intensive services ( 46 ).

Capacity trends of homeless assistance in the United States. Bars indicate the number and type of year-round beds according to Continuum of Care Housing Inventory Counts; the red trend line represents overall federal funding of homeless services through the US Department of Housing and Urban Development (HUD), Veterans Affairs (VA), and Community Development Block Grants (CDBG). Other abbreviations: ES, emergency shelter; OPH, other permanent housing; PSH, permanent supportive housing; SH, safe haven.

3.4. Housing Insecurity and Coordinated Responses to Homelessness

Capacity shifts also signal the role of housing insecurity in the coordinated response to homelessness. Although US policy requires communities to include prevention in coordinated responses to homelessness, the availability and funding for such efforts are not tracked. Moreover, annual assessments of homeless system performance required by federal regulations do not consistently measure successful prevention efforts (Pub. L. 112–141). A similar pattern emerges in countries across the world; European countries that record funding show disproportionate spending on homeless interventions relative to prevention ( 66 , 78 ). Only Wales systematically monitors the total demand and response to prevention services ( 66 , 68 ). In the absence of metrics that track the implementation and outcomes of prevention, it is difficult to understand how well-coordinated responses address overall demand for homeless assistance.

Crises in affordable housing throughout the United States and globally suggest widespread unmet demand. Figure 3 , for instance, presents an indicator of housing insecurity in the United States. The figure plots the annual number of renting households paying more than 50% of income toward rent, referred to as severe rent burdened ( 111 ). A spike of 10 million households in 2012 has declined in recent years, and the trend line of severely burdened as a proportion of all renting households suggests some relief for the lowest-income households. Yet, reductions have yet to return to prehousing crises levels ( 52 ). Markets around the world face similar shortages in affordable housing that create a constant demand for homeless assistance ( 27 , 60 , 92 ).

Number ( blue bars ) and percent ( red line ) of households in the United States with severe rent burden 2007–2017. Data obtained from the American Community Survey 1-year estimates ( 111 ).

3.5. Prevention in Coordinated Responses to Homelessness

The lack of focus on housing insecurity reflects ambivalence in national policies regarding prevention ( 67 ). On one hand, most countries emphasize prevention as a key component of housing first strategies ( 11 , 37 , 66 , 113 ). Prevention frameworks are based on a public health conceptualization of homelessness and generally refer to policies and practices that promote connections to stable homes ( 37 , 67 , 94 ). As illustrated in Figure 4 , prevention efforts target populations at varying levels of risk for homelessness with evidence-based resources that increase in intensity ( 42 , 67 , 94 ). Universal prevention is broadly available to ensure access to housing, such as the right to housing legislation that guarantees access to housing supports, as well as duty to assist policies that require governments to respond to requests for housing supports ( 11 , 67 , 103 ). Selective prevention targets resources toward groups vulnerable for homelessness, for instance families under investigation for child maltreatment, youth aging out of foster care, and veterans returning from combat ( 14 , 32 , 33 ). Indicated prevention focuses on populations demonstrating vulnerability for homelessness, such as households facing evictions and foreclosures and low-income families screening high for housing instability ( 44 , 95 , 114 ). Coordinated prevention initiatives combine multiple intervention types to stem the inflow into homelessness. National policies aspire to avoid human and social costs through timely assistance that addresses housing insecurity.

Homelessness prevention targets based on population and intensity of housing supports.

On the other hand, policy agendas struggle to reconcile aspirations with the feasibility of meeting the broad demand posed by housing insecurity ( 11 , 19 , 67 ). Prevention proves challenging, given the difficulty in predicting whether timely assistance averts homelessness that would have occurred otherwise; inefficiencies in targeting create false alarms that diminish cost-effectiveness ( 12 , 94 , 95 ). Moreover, prevention efforts that fail to address societal determinants of homelessness—including structural poverty, violence, and marginalization—are perceived as misguided ( 12 , 94 ). In the context of scarcity, persuasive arguments suggest a responsibility to deliver services for households most likely to avoid homelessness and associated costs ( 12 , 19 , 94 ). Prevention efforts shift toward avoiding reentry into homelessness instead of promoting connections to housing ( 14 , 67 , 104 ).

Policy ambivalence results in inconsistent applications of prevention across countries ( 67 ). Debates over prevention-oriented approaches to homelessness have persisted over three decades ( 19 , 50 , 94 ). Few national strategies currently include structured processes for delivering and monitoring prevention activities, and instead, countries vary considerably in basic definitions on targeting of services ( 67 , 68 ). In the United States, coordinated responses allow allocation of homeless funds for prevention without guaranteeing access. Even most communities that recognize housing as a basic right ensure only connection with supports (regardless of appropriateness and legality) and not accommodations ( 12 , 67 ). Homeless assistance relies on diverting demand driven by housing insecurity toward community-based services and other social welfare resources outside of homeless systems ( 12 , 19 , 72 ). If the adage that what gets measured gets done is correct, the lack of accountability reveals the unsystematic role of prevention within coordinated responses to homelessness ( 67 , 68 ).

4. SOLVING HOMELESSNESS FROM A COMPLEX SYSTEMS PERSPECTIVE

4.1. homeless assistance from a complex systems perspective.

Complex systems provide a critical perspective on the delivery of coordinated responses to homelessness. Complex systems are composed of multiple interacting agents that produce nonlinear patterns of behaviors, and they continually adapt and evolve in response to conditions within the system ( 24 , 64 , 93 , 101 ). Dynamics emerge from feedback mechanisms, influencing future system behaviors. Reinforcing feedback generates patterns of growth (positive or negative), whereas balancing feedback limits unconstrained growth (homeostasis). Interactions between feedback processes often produce counterintuitive results when trying to change a system. Given the nature of homelessness, complex systems offer a unique tool for evaluating coordinated responses.

Complexity characterizes homelessness and systematic responses. At the household level, transitions between stable and unstable accommodations create oscillations over time that characterize homelessness ( 83 , 89 , 96 ). The patterns challenge accurate predictions and effective responses to homelessness ( 38 , 44 , 95 ). The elaborate ties across persons, agencies, and service systems enable extensive customization to unique and dynamic demands for services ( 1 , 57 , 81 ).

A complex systems perspective offers insights into sustainable solutions to homelessness. Framed as a dynamic problem ( 49 , 100 ), total homelessness is a function of the initial levels plus the ongoing movement of people in and out of homelessness. Mathematically, the dynamic is articulated in the differential equation:

where d represents change, homelessness represents total persons homeless, t represents time, entries represents persons entering homelessness at a given time, and exits represents persons exiting homelessness at a given time. Homelessness trends depend on the population size plus the rate of entries and exits over time. This stock-and-flow dynamic is analogous to water levels in a bathtub and produces counterintuitive results ( 100 , 101 ). For instance, to drain a tub, the volume of water from the tap must be less than the volume of outflow after pulling the stopper. Thus, water levels will continue to rise after opening the drain completely without also closing the tap. Likewise, closing the tap will raise water levels if the drain remains blocked. As anyone who has dealt with an overflowing toilet knows, the complexity can trigger poorly timed and counterproductive reactions.

Community-wide coordinated responses to homelessness attempt to manage stock-and-flow dynamics under conditions of far greater uncertainty. Efficient solutions likely address the net flow of homelessness, as opposed to one part of the system. However, the interacting processes that respond to the need for homeless assistance (see Figure 1 ) produce nonlinearities that obscure optimal choices for system-wide strategies ( 71 , 100 ). A number of common results from intervening in complex systems challenge decision making, such as delayed effects, tipping points, and worse-before-better scenarios ( 100 ). The dynamics make decisions about resource allocation toward housing first adaptations or prevention approaches difficult.

4.2. A System Dynamics Model of Coordinated Responses to Homelessness

A system dynamics model allows investigation into coordinated responses to homelessness. The systems science method uses informal and formal models to represent complex systems from a feedback perspective ( 49 , 64 , 100 ). Computer simulations test assumptions of the system, as well as help identify leverage points that represent places to intervene in the system for maximum benefit ( 70 ).

Figure 5 represents a dynamic hypothesis for solving homelessness. Historical trends present the annual number of persons receiving homeless services in the United States ( 97 ). Hoped and feared trajectories represent theorized responses to homelessness. The trajectories define the dynamic problem as a need for innovative policies that disrupt the status quo ( 49 , 67 , 100 ). Although the example uses annual national data on homeless persons served in the United States, similar hopes and fears likely emerge in many local and national contexts ( 35 ).

Dynamic hypothesis of coordinated responses to homeless in the United States. Historical trends ( black ) present the annual number of persons receiving homeless services. Hoped ( blue ) and feared ( red ) trajectories represent theorized responses to homelessness. Based on trends in the United States, the vertical axis reports the number of persons served by homeless assistance annually, whereas the horizontal axis represents time as 10 years in the past and future. The left half of the graph shows the observed linear decline in homeless, which is interpreted as progress ( 97 ). The right half of the graph articulates the hopes and fears of coordinated responses to homelessness.

Policy shifts toward housing first adaptations as well as prevention-oriented approaches hypothesize a sharp and sustainable downward trajectory of homelessness. However, the mechanisms underlying the dynamic differ on the basis of philosophy. Housing first adaptations assume moving more homeless persons into stable housing more quickly will drive down demand for homeless assistance, whereas prevention-oriented approaches hypothesize that supports provided before homelessness will reduce demand. A third hypothesis from a complex systems perspective suggests that a combination of approaches disrupt homeless trajectories. Articulating the theories of change allow researchers to model the dynamics.

Figure 6 presents an informal model of coordinated responses to homelessness. The structure elaborates on the previous formulation to capture stock-and-flow dynamics, and a formal computational model incorporates additional differential equations to capture dynamics ( 100 ). Using system dynamics conventions, stocks refer to accumulations of people, whereas flows represent transitions in and out of stocks. People exit stocks into stable housing defined as not needing housing assistance. In addition to homelessness, the model tracks individuals experiencing housing insecurity who are seeking assistance versus hidden homeless, which incorporates the different targets of prevention. Dynamics emerge as people transition in and out of stable housing. The model assumes that the average time in homeless assistance is 3.5 years, and housing insecurity represents a transitional state through which most exit within two years, loosely based on definitions of chronic homelessness ( 97 ).

System dynamics model of people receiving homeless assistance and those experiencing housing insecurity and hidden homelessness. Boxes represent accumulations of people, arrows represent transitions in and out of stocks, and clouds represent stable housing.

Computer simulations test a series of policy experiments for solving homelessness. The first experiment tests efforts to improve housing first by decreasing time spent in homeless assistance before exiting to stability. The second experiment expands universal, selective, and indicated prevention by reducing each inflow into homelessness assistance. The third experiment tests combined housing first and prevention strategies. Each experiment improves performance by 50%, and combined interventions do not exceed 50% effects. All analyses were conducted within Stella Architect Version 1.2.1. A web-interface provides access to the model and allows real-time experiments ( https://socialsystemdesignlab.wustl.edu/items/homelessness-and-complex-systems/ ).

4.3. Simulation Results

Initial analyses assessed confidence in the model. Simulations replicate observed trends in persons seeking homeless assistance ( Figure 3 ) and housing insecurity ( Figure 2 ) in the United States between 2007 and 2016. Moreover, exploratory analyses suggest that the model is insensitive to initial values; similar patterns emerge when increasing stocks and reducing transition times ( 100 ). Different indicators of homelessness and insecurity produce similar results, which further suggests that the model captures the population-level dynamics of homelessness.

Figure 7 displays results from policy experiments on trends of homeless assistance and total housing insecurity (seeking assistance plus not seeking assistance). Findings demonstrate support for the complex systems perspective. Optimizing housing first approaches results in incremental reductions in the number of persons in homeless assistance with no impact on the rates of housing insecurity; results suggest that the system is already optimized for reducing homelessness quickly, and it currently strains to keep up with the constant demand for homeless assistance. By reducing the demand for homeless assistance, prevention improvements qualitatively shift the trajectory of housing insecurity, while generating similar incremental improvements in homeless assistance trends as housing first optimization. The same shifts occur when experimenting with smaller improvements in efficiencies; prevention always outperforms housing first adaptations. For instance, a 5% improvement in prevention generates a similar decrease on total need for housing as a 5 0% improvement in housing first adaptations. Thus, prevention represents a leverage point to enhance coordinated responses to homelessness, and tests reveal that universal plus indicated preventions account for the greatest shifts. However, the optimal response to homelessness comes from a multipronged approach that incorporates prevention with housing first, which generates shifts in housing insecurity and homeless assistance. As hypothesized by the complex systems perspective, managing the net flow achieves desired outcomes of moving toward solving homelessness.

Policy experiments showing the impact of housing first and prevention efforts on the number of people in homeless assistance ( a ) and number of hidden homeless ( b ) with services as usual ( dark blue line ); housing first only ( light blue line ); universal, selective, and indicated prevention ( red line ); and housing first plus universal, selective, and indicated prevention ( yellow line ).

Results must be considered in context. Simulations use US national data to build confidence that the model replicates trends; however, the forecasts are not meant as point estimates for planning purposes. Likewise, national data aggregate across communities that may experience different outcomes from coordinated responses. Using local data and different indicators of system performance would improve confidence in the simulation, as well as in the dynamics of homeless assistance. Finally, the simulations fail to provide an oracle; malleability exists in how policy responds and adapts to trends in homelessness that may alter the system dynamics. The models also make no assumptions about the implementation of prevention. Reducing demand by 50% may exceed realistic expectations, and the simulations fail to consider policy resistance generated from current paradigms. Regardless, simulations suggest small improvements in prevention generates qualitative shifts in demand for assistance.

4.4. Implications for Coordinated Responses to Homelessness

Homeless systems across the world are optimizing policies toward solving chronic homelessness. Resource allocation increasingly prioritizes on the basis of vulnerability and moral preference (e.g., households with children, veterans, seniors). However, simulations warn of unintended consequences that arise from constant pressure for stable housing. Systems that focus on the most vulnerable risk ignoring the unseen needs of the many households unable to access timely supports. Effective responses need to manage both the inflows and outflows to produce intended declines in homelessness rates.

A complex systems perspective presents a number of implications for homeless policies and practices. First, prevention represents a necessary component for sustainable reductions in homelessness. Although declines are achievable and have been demonstrated through coordinated efforts ( 67 ), the dynamics of the system challenge population-level reductions in the absence of considerable ongoing investment of resources. Second, the efficiency of prevention questions the fairness of current policies that prioritize on the basis of vulnerability. Not only does accumulating evidence question the reliability of prioritization tools ( 6 , 108 ), but also simulations suggest that withholding prevention potentially harms a large population of individuals who are unable to access useful services. Policies must consider an equitable distribution of both benefits and harms in resource allocation strategies. Third, history warns of resistance to reorienting systems toward prevention ( 17 , 19 , 94 ). A shift requires longer-term investment and introduces delays in observing results, which proves challenging in the presence of human suffering associated with current homelessness, as demonstrated by the well-meaning appeal of prioritization on the basis of vulnerability. Policies, and especially system performance goals, need to create incentives for balancing crisis response with upstream interventions. Fourth, an immediate step toward a prevention framework requires communities to track and actively monitor broader demand for housing assistance beyond entry into homeless services. As communities increasingly move toward a coordinated entry into homeless services, existing policies typically emphasize or require a homelessness determination for access and, thus, fail to connect with the delivery of prevention services. The oversight results in limited information being provided to assess and improve prevention responses; for instance, communities may be unable to track demand for prevention beyond those who receive the limited services available. The lack of success of disorganized resources further undermines investments in prevention. System performance metrics contingent on homelessness reductions must also reward prevention successes. Finally, rights-based housing policies provide the most conducive framework for broad-scale prevention ( 29 , 66 ). Duty to assist legislation enacted in Wales ensures households seeking housing supports receive best effort responses, which include counseling plus short-term housing only if necessary ( 67 , 68 ). Households that still need assistance and those already homeless enter more intensive interventions. Policies structure services to capture demand for and effectiveness of prevention responses in ways that allow for ongoing system improvements.

Homelessness represents a global public health challenge. Coordinated responses leverage flexible networks to deliver a range of services tailored to complex needs. However, current policies that prioritize services on the basis of vulnerability miss opportunities for prevention, thus contributing to overwhelming pressure on the service system. To achieve broad and sustainable reductions in housing insecurity, homelessness prevention must be fully integrated into existing service networks. Prevention-oriented policies that ensure timely responses to housing insecurity extend the housing first philosophy and leverage the considerable capacity of homeless services.

ACKNOWLEDGMENTS

This project was supported by award number 90CA1815 (principal investigator: Fowler) from the Administration for Children and Families–Children’s Bureau. We acknowledge Kenneth Wright and Katie Chew for their research assistance and help with visuals. We are also very grateful for the many consumers and providers of homeless services who greatly informed our thinking.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Children’s Bureau.

LITERATURE CITED

4 Charts That Explain How People Slide Into Homelessness

P eople don’t usually become homeless suddenly. It’s often a chutes and ladders process, except with lots of chutes and hardly any ladders. And there’s a period right before they slide into having nowhere to live, during which, many experts believe, a couple of well-placed nets might be able divert them from being forced to sleep on the streets, in their cars, or other places that are not meant as homes.

A large new statewide study done by the University of California, San Francisco Benioff Homelessness and Housing Initiative takes a closer look at that period just before homelessness, by asking a representative sample of almost 3,200 homeless people from all over the state about the chutes they fell into, and what would have helped. (Marc and Lynne Benioff, funders of the UCSF initiative, are also co-chairs and owners of TIME.) The study, published on June 20, was conducted between October 2021 and November 2022, and is the largest of its kind since the 1990s.

Some of the findings of the California Statewide Study of People Experiencing Homelessness , or CASPEH, were unsurprising: in the state with the nation’s largest homeless population , people are unhoused because they don’t have enough money, and their lives and health and safety get much worse after homelessness strikes—a quarter of all participants had experienced sexual violence at some point. But some of the report’s data runs counter to popular perception: most homeless people were not from out-of-state, contrary to the myth that people lacking housing move there because of the weather and policies, for example, and 40% of them were contending with homelessness for the first time.

The study also interviewed more than 300 of the participants in depth to get a more finely grained image of their situation and particularly the events that immediately preceded their misfortune. We asked the study’s lead author, Dr. Margot Kushel, a doctor and professor of Medicine at UCSF, to answer four questions about what the study found.

What Is the Link Between Homelessness and Mental Health?

The prevalence of mental illness and substance use among those experiencing homelessness is clear, but Kushel cautions that the vast majority of mental illness among the study participants is anxiety and depression. It’s likely the lack of resources exacerbates those conditions, rather than the illness causing the homelessness, she says.

“I think that the driving issue is clearly the deep poverty, that the median [monthly] household income for everyone in the household in the six months before homelessness was $960, in a state with the highest housing costs in the country,” she says. Other studies have noted that the end of pandemic stimulus payments and rising inflation has led to rents outpacing wages . The study notes that in 2023, California had only 24 units of affordable housing available for every 100 extremely low-income households.

Column: I Lived in My Car and Now I’m in Congress. We Need to Solve America’s Housing Crisis.

Nevertheless, Kushel also noted that treatment for substance addiction needed to be more available. Citing figures from the study, she notes that “one in five people who had a substance use problem while they were homeless wanted treatment, and couldn’t access it. That number should be zero.” Similarly the study found that two thirds of participants had mental health issues currently and only 18% were receiving any treatment. “That should be 100%,” says Kushel.

Where Were Homeless People Living Before?

There are three main places from which people tumble into homelessness: an institution like a prison, jail or drug treatment facility; a residence to which they had some legal connection, such as a mortgage or a lease; and a residence owned by somebody else, such as a family member or a friend.

The report suggests solutions include more—and more effective—halfway houses for formerly incarcerated people, and more— and more effective—eviction-prevention programs so people don’t lose the housing they have. But neither of those is going to help the large number of people whose penultimate stop is a relative’s or friend’s home. “You can’t build a homelessness prevention program only around eviction prevention,” says Kushel. “Those programs are important, but you’re going to miss a big chunk of people.”

Kushel points out that people who live with relatives and friends—and don’t have their name on the lease or mortgage—can’t, for example, provide a a notice of eviction. Their hosts are under no obligation to provide the 30-days notice that landlords have to provide. “That’s just not how it works,” says Kushel. “If you have no legal rights, your brother can kick you out at 3am if he wants to.” In response, the study suggests mediation services or other programs that can move more swiftly to catch people before they have to move out suddenly, as well as pilot programs for shared housing or for stipends to friends or relatives who open their homes.

Read more: Constance Woodson Worked Hard All Her Life. How Did She End Up Homeless During a Pandemic?

Why Did They Have to Leave Their Last Place?

Many people fall into what Kushel calls a “doom loop” of homelessness, where they have jobs, but those jobs don’t quite pay enough for them to be able to cover their expenses, so they lose their homes. Then they move into a family or friend’s home, which puts that living situation under pressure. “We’re talking about 10 people living in a one-bedroom apartment,” says Kushel. The chaotic sleeping, hygiene, and transport arrangements make it tough to keep working. And if they lose their jobs and can’t contribute any money, the tension ratchets even higher. Of the people living with relatives the researchers interviewed, 43% of them were paying no rent at all.

Kushel says there are off ramps on this loop that should be more widely used, pointing to “really exciting models of homelessness prevention, where in low income communities, they’ll have subway and bus posters saying, Are you at risk of becoming homeless? Call us. ” These programs might offer anything from infusions of cash and mediation services to a bunk bed and negotiations over cleaning. “What was really striking to us, was how little money people thought it would have taken,” says Kushel. Most participants suggested less than $500 a month or a one time payment of $10,000, would have kept them housed.

Where Did They Turn For Help Before Being Evicted?

The report found that two thirds of all the people interviewed did not seek help from anyone before they became homeless. And almost a quarter of those who turned to someone else for support, turned to families. In a perverse way, this might be good news, because it could mean that existing homelessness prevention services are working and people who seek help are able to stay housed. But it also suggests that the message that some help is available is not percolating to where it needs to go.

“What we know is that for prevention programs to work, there needs to be enough money and the right services,” Kushel says. “And also, they need to be targeted at the right people.” The CASPEH report recommends raising awareness about programs in places like local medical clinics, unemployment offices, public schools, churches, and bus stops in low income neighborhoods. It also advocates for educating those leaving institutional settings on their options for support. There aren’t currently enough services to meet the needs in California, says the report, and it calls for more. “But we also need to do a better job of getting the word out,” says Kushel. “We kind of know where people are at risk, and we need to meet them there.”

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Despite a national spike in homelessness, some US regions are finding solutions

Subscribe to transformative placemaking, hanna love and hanna love fellow - brookings metro , anne t. and robert m. bass center for transformative placemaking tracy hadden loh tracy hadden loh fellow - brookings metro , anne t. and robert m. bass center for transformative placemaking.

February 5, 2024

Last month, volunteers across the United States braved frigid temperatures to conduct the Department of Housing and Urban Development’s annual point-in-time (PIT) count , which tallies the number of people experiencing homelessness in a community. As the numbers are added up, it’s important to ask: What is the nation learning from this data? And more importantly, how are local leaders using it to craft more effective and humane homelessness policies?

Related Content

Hanna Love, Tracy Hadden Loh

December 7, 2023

Late last year, we published an in-depth analysis of pandemic-era homelessness trends in major U.S. cities and found a complicated picture: While homelessness was up significantly over the last decade in some cities, such as Seattle, others major cities, including Chicago, New York, and Philadelphia, saw meaningful and sustained declines. Our research made it clear that there is no “one-size-fits-all” barometer for understanding America’s challenge with homelessness, and instead, paying attention to regional variations in homelessness trends can help policymakers understand what’s working to reduce it.

This piece provides an updated analysis of homelessness in U.S. cities using the most recently published PIT count data , from 2023 (data collected in January 2024 will not be released until the end of the year). We once again find a nuanced patchwork of trends across cities and regions that reveals stark new challenges in some cities (e.g., New York), but also bright spots of success in reducing homelessness in others (e.g., Austin, Texas and Indianapolis). These findings make it clear that cities have the evidence and tools at their disposal to reduce homelessness—there just needs to be the political will to invest in and scale them.

As Jeff Olivet , executive director of the U.S. Interagency Council on Homelessness, told us while participating in Washington, D.C.’s PIT count last month, “What we do tonight matters, but what we do tomorrow matters more.”

Place matters for understanding homelessness in the US

The national picture of recent homelessness trends is grim. The U.S. overall saw a 12% increase in homelessness between 2022 and 2023 , with a 15% increase in major cities. But looking more closely at the trends, there are some bright spots.

In nine out of the 44 major cities that completed full PIT counts in 2023, homelessness rates either remained stable or declined between 2022 and 2023, with rates in Austin, Texas, Raleigh, N.C., Indianapolis, and Colorado Springs, Colo. declining over 10 percentage points. On the other hand, New York, Albuquerque, N.M., Portland, Ore., Atlanta, and Boston saw sharp increases in total homelessness.

Of the four cities we examined more closely in our original report (Chicago, New York, Seattle, and Philadelphia), stories of both progress and setbacks emerge (Figure 1). Last year, our findings revealed that despite perceptions of rising homelessness in these cities, total homelessness rates had declined over the last decade in three of the four: Chicago (42% decline), Philadelphia (25%), and New York (16%). Seattle was the outlier, with total homelessness increasing by 23% and unsheltered homelessness by 88%.

Between 2022 and 2023, however, we found that while longer-term trends remained relatively consistent in three cities, New York saw a 42% increase in total homelessness over that year (Table 1, Column 3)—the biggest spike in the country in absolute terms (an additional 314 homeless people per 100,000 population). This partially reflects the large influx of international migrants to the city since spring 2022, but also the primary root cause of homelessness: high housing costs and low inventory , particularly of affordable units. Chicago also saw its total homelessness population increase between 2022 and 2023, but the city has still exemplified a story of progress over the long term, with homelessness falling by 7% since 2015 and unsheltered homelessness falling by 51%, including progress in the most recent year.

Looking at the larger picture of short- and long-term total and unsheltered homelessness trends, it’s clear that there are pockets of both progress and setbacks in U.S. cities—reinforcing the need for upstream solutions that can meet cities and regions where they are.

The policies that work to reduce homelessness

The chief driver of homelessness in U.S. cities is inadequate housing supply. Thus, any plan to reduce homelessness requires increasing the supply of all types of housing, particularly affordable housing.

In addition, there are a number of short- and long-term policies that local leaders can embrace to target structural conditions associated with homelessness—spanning from reentry and workforce development programming to alternative crisis response models—while also building stronger regional economies. Below are five evidence-based recommendations for local leaders to more effectively reduce homelessness; for a fuller explanation of each recommendation, see our December 2023 report .

• Ensure that housing policy is homelessness policy. As a longer-term solution, local governments should align their housing, land use, and homelessness plans to increase the supply of all types of housing; remove barriers to affordability and shelter construction (such as single-family-only zoning, parking minimums, and parcel shape regulations); and adopt evidence-based “housing first” models. In the shorter term, cities should adopt and scale the pandemic-era  preventative measures  that helped avoid a spike in homelessness, including investments in emergency rental assistance, eviction defense, tenants’ rights, and economic stimulus, as well as mitigation measures such as converting hotels into temporary housing.
• Scale alternative crisis response models to better respond to people with behavioral health and substance-use emergencies while improving public safety. To better address safety concerns surrounding homelessness, mental health, and quality-of-life offenses, local leaders should adopt and scale non-police alternative crisis response models—following the evidence and successes from  Denver ,  Eugene, Ore. , and  other cities . In doing so, they should take care to not only prioritize crisis response models that provide an alternative for low-level offenses (such as substance use or homelessness), but also include models that address intimate partner violence—an area where victims are disproportionately likely to experience homelessness as a result of the circumstances surrounding victimization.
• Strengthen housing and employment supports for those reentering communities after incarceration . To better address the cycle between incarceration and homelessness,  study after study  shows that bolstering reentry supports—particularly access to housing and employment—is critical to reducing recidivism and homelessness, while also improving public safety. Effective policies include reducing  barriers for returning citizens to enter public housing ; providing tailored services for those most at risk of homelessness prior to release (including workforce and housing supports); and explicitly addressing the unique needs of returning citizens in regional housing and homelessness plans,  among other reforms .
• Leverage the capacity of place governance organizations to humanely address homelessness, particularly in central business districts. Place governance organizations such as business improvement districts (BIDs) have at times been  complicit in the act of displacing homeless people  and  embracing hostile architecture . However, BIDs have also been innovative and effective partners in reducing homelessness by implementing  inclusive management practices  aligned with a public health approach, such as employing community ambassadors; providing access to drinking water and public restrooms; supporting placemaking activities and other built environment improvements that enhance safety, vibrancy, and belonging in the public realm; and connecting residents to social services, employers, and workforce development providers. BID leaders should follow these inclusive management practices and continue to partner with local governments and Continuum of Care providers to humanely address homelessness in downtown districts.
• Take a regional, data-driven approach to homelessness.  To respond to the structural challenges that prevent people across a region—not just within city boundaries—from accessing affordable housing,  there is a movement to establish regional homelessness authorities  that correspond to merged, regional Continuums of Care and align resources and service delivery programs across a region. Regions should adopt this “regional approach” to homelessness and  coordinate on cross-jurisdictional challenges to addressing homelessness  by aligning regional funding, communications, coordination, social delivery infrastructure, data collection, performance management, training, and capacity-building.

“Behind every data point is a human life,” Jeff Olivet told us during last month’s PIT count. While the data we use to understand homelessness isn’t perfect, it is clear about one thing: Far too many human lives are being harmed by unequal access to stable housing, food, and services. A large, unsheltered homeless population does not have to be an inevitable part of cities. There are solutions at our disposal to not only respond effectively to the needs of people experiencing homelessness today, but to create the conditions that prevent homelessness tomorrow.

Housing Placemaking

Brookings Metro

Anne T. and Robert M. Bass Center for Transformative Placemaking

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August 21, 2024

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August 20, 2024

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August 19, 2024

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Demographics

Homelessness in the U.S. - Statistics & Facts

Who are the homeless, homelessness: the cause and the cure, key insights.

Detailed statistics

Number of homeless people in the U.S., by state 2022

Share of homeless individuals in the U.S. by age 2022

Share of homeless individuals in the U.S. by gender 2022

Editor’s Picks Current statistics on this topic

Rate of homelessness in the U.S. by state 2022

Estimated number of homeless people in the U.S. 2007-2022

Number of homeless people in the U.S., by race 2022

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• Basic Statistic U.S. poverty rate of the top 25 most populated cities 2021
• Premium Statistic Estimated number of homeless people in the U.S. 2007-2022
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• Premium Statistic Rate of homelessness in the U.S. by state 2022
• Premium Statistic Share of homeless individuals in the U.S. by age 2022
• Premium Statistic Share of homeless individuals in the U.S. by gender 2022
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U.S. poverty rate of the top 25 most populated cities 2021

Percentage of people who live below the poverty level in the most populated cities in the United States in 2021

Estimated number of homeless people in the United States from 2007 to 2022

Estimated number of homeless people in the United States in 2022, by state

Estimated rate of homelessness in the United States in 2022, by state (per 10,000 population)

Estimated share of homeless individuals in the United States in 2022, by age

Estimated share of homeless individuals in the United States in 2022, by gender

Estimated number of homeless people in the United States in 2022, by race

• Premium Statistic Number of homeless people in the U.S., by state and shelter status 2022
• Premium Statistic Share of unsheltered homeless population, by county of residence U.S. 2020
• Premium Statistic Number of homeless people in families in the U.S. by sheltered status 2007-2022
• Premium Statistic U.S. people experiencing homelessness 2022, by type and sheltered status
• Premium Statistic Share of homeless people in the U.S. by place of residence before shelter 2021
• Premium Statistic Number of beds for homeless people in the U.S. by housing type 2022
• Premium Statistic Share of U.S. households in homeless shelters 2021, by length of stay

Number of homeless people in the U.S., by state and shelter status 2022

Estimated number of homeless people in the United States in 2022, by state and shelter status

Share of unsheltered homeless population, by county of residence U.S. 2020

Share of homeless population who were unsheltered in the United States in 2020, by county of residence

Number of homeless people in families in the U.S. by sheltered status 2007-2022

Estimated number of homeless people in families in the United States from 2007 to 2022, by sheltered status

U.S. people experiencing homelessness 2022, by type and sheltered status

Share of people experiencing homelessness in the United States in 2022, by type and sheltered status

Share of homeless people in the U.S. by place of residence before shelter 2021

Share of homeless people in the United States in 2021, by place of residence before entering homeless shelter

Number of beds for homeless people in the U.S. by housing type 2022

Number of beds available to homeless people in the United States in 2022, by housing type

Share of U.S. households in homeless shelters 2021, by length of stay

Share of households accessing homeless shelters in the United States in 2021, by length of stay

Homeless veterans

• Premium Statistic Number of homeless veterans in the U.S., by state 2022
• Premium Statistic Estimated number of homeless veterans in the U.S. by shelter status 2007-2022
• Premium Statistic Share of homeless veterans in the U.S. by gender 2022
• Premium Statistic Share of homeless veterans in the U.S. by race 2022
• Basic Statistic Poverty status of U.S. veterans 2022, by age

Number of homeless veterans in the U.S., by state 2022

Estimated number of homeless veterans in the United States in 2022, by state

Estimated number of homeless veterans in the U.S. by shelter status 2007-2022

Estimated number of homeless veterans in the United States from 2007 to 2022, by sheltered status

Share of homeless veterans in the U.S. by gender 2022

Estimated share of homeless veterans in the United States in 2022, by gender

Share of homeless veterans in the U.S. by race 2022

Estimated share of homeless veterans in the United States in 2022, by race

Poverty status of U.S. veterans 2022, by age

Poverty status of veterans in the United States in 2022, by age

Homeless youth

• Premium Statistic Number of homeless youth in the U.S., by state 2022
• Premium Statistic Estimated number of homeless youth in the U.S. by sheltered status 2016-2022
• Premium Statistic Share of unsheltered homeless youth population by county of residence U.S. 2020
• Premium Statistic Share of unaccompanied homeless youth in the U.S. by gender 2022
• Premium Statistic Share of unaccompanied homeless youth in the U.S. by race 2022
• Premium Statistic Number of homeless parenting youth in the U.S., by state 2022
• Premium Statistic Share of homeless public school students U.S. 2020/21, by primary nighttime residence

Number of homeless youth in the U.S., by state 2022

Estimated number of homeless people under 25 in the United States in 2022, by state

Estimated number of homeless youth in the U.S. by sheltered status 2016-2022

Estimated number of unaccompanied homeless people under the age of 25 in the United States from 2016 to 2022, by sheltered status

Share of unsheltered homeless youth population by county of residence U.S. 2020

Share of unaccompanied homeless youth population who were unsheltered in the United States in 2020, by metropolitan area of residence

Share of unaccompanied homeless youth in the U.S. by gender 2022

Estimated share of unaccompanied homeless youth in the United States in 2022, by gender

Share of unaccompanied homeless youth in the U.S. by race 2022

Estimated share of unaccompanied homeless youth in the United States in 2022, by race

Number of homeless parenting youth in the U.S., by state 2022

Estimated number of homeless parents under 25 in the United States in 2022, by state

Share of homeless public school students U.S. 2020/21, by primary nighttime residence

Share of public school students experiencing homelessness in the United States in the 2020/21 school year, by primary nighttime residence

Health & wellbeing

• Premium Statistic Special populations served by health centers in U.S. 2022
• Premium Statistic Mentally ill homeless people in the U.S. by sheltered status 2022
• Premium Statistic Homeless people with substance abuse in the U.S. by sheltered status 2022
• Premium Statistic Homeless domestic violence victims in the U.S. by sheltered status 2022
• Premium Statistic Homeless people with HIV/AIDS in the U.S. by sheltered status 2022
• Premium Statistic Number of attacks on homeless people in the U.S. by type 1999-2019
• Premium Statistic Non-lethal attacks on homeless people in the U.S. by type 2019

Special populations served by health centers in U.S. 2022

Number of special populations served by health centers in the U.S. in 2022

Mentally ill homeless people in the U.S. by sheltered status 2022

Estimated number of severely mentally ill homeless people in the United States in 2022, by sheltered status

Homeless people with substance abuse in the U.S. by sheltered status 2022

Estimated number of homeless people with chronic substance abuse in the United States in 2022, by sheltered status

Homeless domestic violence victims in the U.S. by sheltered status 2022

Estimated number of homeless people who are victims of domestic violence in the United States in 2022, by sheltered status

Homeless people with HIV/AIDS in the U.S. by sheltered status 2022

Estimated number of homeless people with HIV/AIDS in the United States in 2022, by sheltered status

Number of attacks on homeless people in the U.S. by type 1999-2019

Number of attacks on homeless people in the United States from 1999 to 2019 by type

Non-lethal attacks on homeless people in the U.S. by type 2019

Number of non-lethal attacks on homeless people in the United States in 2019, by type of attack

U.S. opinion and personal experience

• Premium Statistic Economic reasons why homeless people in California left their last housing U.S. 2022
• Premium Statistic Social reasons why homeless people in California left their last housing U.S. 2022
• Premium Statistic California: experiences of physical or sexual violence while homeless U.S. 2021
• Premium Statistic Places where homeless people in California slept in the last six months U.S. 2022
• Premium Statistic U.S. beliefs on what is a major cause of homelessness 2023, by political party
• Premium Statistic U.S. opinion on who is to blame for homelessness 2022
• Premium Statistic U.S. beliefs on who is most responsible for addressing homelessness 2023, by party
• Premium Statistic U.S. support for their government taking various steps to combat homelessness 2023

Economic reasons why homeless people in California left their last housing U.S. 2022

Share of people experiencing homelessness in California with various economic reasons for why they left their last housing in the United States from October 2021 to November 2022

Social reasons why homeless people in California left their last housing U.S. 2022

Share of people experiencing homelessness in California with various social reasons for why they left their last housing in the United States from October 2021 to November 2022

California: experiences of physical or sexual violence while homeless U.S. 2021

Share of homeless people in California who experienced physical or sexual violence while homeless in the United States from October 2021 to November 2022

Places where homeless people in California slept in the last six months U.S. 2022

Share of all places where people experiencing homelessness in California slept for at least one night in the last six months in the United States from October 2021 to November 2022

U.S. beliefs on what is a major cause of homelessness 2023, by political party

Share of Americans who believe that select issues are a major cause of homelessness in the United States in 2023, by political party

U.S. opinion on who is to blame for homelessness 2022

How much, if at all. do you blame each of the following for homelessness in the United States?

U.S. beliefs on who is most responsible for addressing homelessness 2023, by party

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Homelessness in the U.S. hit a record high last year as pandemic aid ran out

Jennifer Ludden

The latest national count taken in January found more than 650,000 people living in tents, cars and shelters. Business Wire Via AP hide caption

The latest national count taken in January found more than 650,000 people living in tents, cars and shelters.

Homelessness in America spiked last year, reaching a record high, according to an annual count that provides a snapshot of one night in January. The report, released today by the department of Housing and Urban development, found more than 650,000 people were living in shelters or outside in tents or cars. That's up a whopping 12% from the year before.

To advocates, it hardly comes as a surprise.

"We simply don't have enough homes that people can afford," says Jeff Olivet, executive director of the U.S. Interagency Council on Homelessness. "When you combine rapidly rising rent, that it just costs more per month for people to get into a place and keep a place, you get this vicious game of musical chairs."

Homelessness has been rising since 2017 in large part because of the country's massive shortage of affordable housing. There was a pause during the pandemic, and Biden administration officials say that's because of sweeping federal aid that kept people from getting evicted. But last year, in a triple whammy, that aid started running out . Inflation spiked to its highest level in a generation, and median rent hit a record high . Research has found that where rents rise, so does homelessness.

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This year's big jump was driven by people who lost housing for the first time, which Biden administration officials say reflects the sharp rise in rent. The largest increase was among families, and the count also finds a significant rise among Hispanics. Nearly 40% of the unhoused are Black or African-American, and a quarter are seniors. The annual count does not include the many people who couch surf with friends or family, and who may be at high risk of ending up on the street.

One family sleeps in a Walmart parking lot

In July, Takia Cheeks and her four children joined the surge in families losing housing for the first time.

They'd moved to Virginia so she could take a higher paying job at a corrections facility, and Cheeks was excited to no longer have to live "paycheck to paycheck." But it did not go well. Two of her children have disabilities, and she kept having to miss work to get them enrolled in school and set up with accommodations. After six days' absence, her employer let her go.

Meanwhile, the family's new apartment turned out to have no hot water or AC, not even screens to be able to open the windows. Cheeks had complained, and after losing her job she was evicted in a court hearing where she had no lawyer. She put the family's belongings in a storage unit and they all slept crammed into her Ford Fiesta in a Walmart parking lot.

"I'm not getting sleep because I'm watching over my children, because it's a lot of people walking around," she says. She would get everyone up at 6:00 in the morning to go to a Wawa across the street. "Therefore I know it's not that many people in the bathrooms, for my children just to wash up," she says.

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It was so hot in the car that Cheeks's daughter got first and second degree burns. "I had to take her to the hospital," she says. Their rescue dog Max was also suffering so she gave him up, even though he'd been an emotional support animal for her son with autism.

After a few weeks, Cheeks got another job making deliveries for Amazon, and that let the family stay in a motel for a couple months. In October, they finally moved into a house with rental assistance, but that aid is temporary.

Migrants likely added to the higher numbers in some places

The surge in migrants showing up at shelters around the country likely also helped push up the numbers, says Ann Oliva, CEO of the National Alliance to End Homelessness. It's not clear how many may have been included, because back in January the volunteers conducting the count did not ask whether someone was seeking asylum. But Oliva says homeless service providers who'd already been overwhelmed are now struggling with this added population.

"We saw it in the state of Maine, in Minneapolis, in Chicago," she says. "Our big concern is that there is a huge inflow of folks that are coming into these systems without any resources for these systems to serve them."

Oliva's group wants the Biden administration to make it easier for migrants to legally work, and to have their asylum cases heard more quickly. She also says the federal government needs to provide far more rental assistance. Unlike food and healthcare, housing aid is not an entitlement, and only a quarter of people eligible for it actually receive a subsidy.

A few places did see a decrease in homelessness

The annual count found homelessness numbers down from the previous year in Houston, Newark and Chattanooga. "Homelessness is solvable and should not exist in the United States," HUD Secretary Marcia Fudge said in a statement .

The Biden administration says it's stepped up funding and streamlined the process for housing vouchers, among other things, and that helped move more people into permanent housing this year. They also point out that a record number of new apartments — about a million — were under construction.

'Frustration all across the board.' A day with homelessness outreach workers in L.A.

To tackle homelessness faster, LA has a kind of real estate agency for the unhoused

Inflation has also eased, but housing and food remain much more expensive than just a few years ago. Food pantries say they continue to see large numbers of people. And while rents on luxury condos in some places may be coming down, the massive housing shortfall is worst for the lowest-income renters, many of whom pay more than half their income on rent .

To really bring down these numbers, advocates say there should be far more federally subsidized housing. Right now only one in four people who are eligible actually gets it, but expanding that would need more funding from Congress.

• homelessness
• affordable housing
• rental assistance

Homelessness in America: Statistics, Analysis, and Trends

The Population of People Experiencing Homelessness Reached an All-Time High of Over 653,000 in 2023

Despite rising inflation rates, the U.S. economy is holding up impressively. As of the first quarter of 2024, unemployment is low and inflation – although still elevated – is slowing down. That doesn’t mean, however, that every American is doing well. One harsh indicator of that was the significant jump in homelessness over the past year.

According to the Department of Housing and Urban Development (HUD), a record number of people are currently unhoused in the U.S. Several factors are driving this increase, such as rising housing costs, surging immigration, and the end of many COVID-19 relief programs.

HUD’s 2023 Annual Homelessness Assessment Report (AHAR) found that more than 650,000 people in America lack permanent shelters. That represents the most documented homeless individuals since the inaugural report produced in 2007 and reflects a 12 percent increase over 2022.

Continuing Security.org’s commitment to highlighting housing insecurity, this report delves into the numbers to discern which communities suffered the most. This article is our 5th annual report on the issue (see previous reports from 2023 , 2022 , 2021 , and 2019 ).

Key Findings:

• 653,104 people experienced homelessness in the U.S. in 2023. That number represents a record-high tally and a 12 percent increase over 2022.
• 111,620 children were without homes in America last year.
• Homelessness increased in 41 states between 2022 and 2023, with New Hampshire, New Mexico, and New York having the highest percentage increases.
• New York, Vermont, and Oregon had the highest per-capita rates of homelessness in 2023.
• More than one-half of America’s homeless individuals reside in the nation’s 50 largest cities. New York City and Los Angeles alone contain one-quarter of the country’s unhoused people.
• Every ethnic group endured an increase in homelessness last year. The Asian community experienced the most significant percentage increase (64 percent), while Hispanics/Latinos saw the most significant surge in raw numbers (an additional 39,106 people).

Table of Contents

American homelessness in 2023: an overview.

• Geographical Trends in Homelessness

Special Populations Experiencing Homelessness

• Factors Influencing Homelessness Today

Methodology

Data appendix.

HUD’s report, which came out in 2023, was based on a detailed report on homelessness that the department conducted earlier in the year. The 2023 AHAR reveals a grim truth – across the nation, 653,104 Americans were homeless. The agency describes homelessness as lacking a fixed, regular, and adequate nighttime residence.

Compared to the previous year, the number of homeless people in 2023 reflects a 70,642 increase. That’s equivalent to a 12-percent jump. The homelessness rate in 2023 is also the largest number the agency has seen throughout its 18-year history of taking surveys on homelessness. On top of that, homeless people in 2023 represented 0.19 percent of the national population that year – the highest rate since 2012.

Unfortunately, 2023 also marks the sixth consecutive year in which homelessness has grown, following a yearly decline between 2012 and 2015.

The share of homeless persons living in shelters remained roughly the same as in 2022. Six in ten individuals without housing (396,494 people) received temporary shelter via emergency facilities, transitional housing programs, or local safe-havens. The remaining 40 percent (256,610 people) slept in conditions deemed unfit for habitation, such as sidewalks, bus stations, empty buildings, or abandoned vehicles. Unsheltered homelessness rose for the seventh straight year.

Individuals experiencing homelessness on their own accounted for 72 percent of the total homeless population. Among them, only 49 percent live in shelters. The remaining 51 percent remain unsheltered.

Alarmingly, families experiencing homelessness increased in 2023 by 16 percent compared to 2022. These family units accounted for 186,084 individuals belonging to 57,563 family households. They account for nearly one-third of the total homeless population.

The silver lining – if we can call it that – is that most homeless families are sheltered. Of all the 57,563 families, 91 percent received temporary shelters.

Overall, unsheltered individuals comprised the most significant subset of people without housing, followed by sheltered individuals, sheltered family members, and unsheltered families.

No single cause has driven the troubling trend of increased American homelessness, though experts cite several prominent factors. An unequal financial recovery, a shortage of affordable housing, limited access to critical healthcare, the cessation of COVID-era aid programs, and an immigration influx all bear a share of the blame.

Notably, the national rise in homelessness has affected nearly every cross-section of society. The numbers have risen for all types of population centers and across genders, ethnicities, and age groups. As we detail below, some communities are more vulnerable than others.

Geographic Trends in Homelessness

Homelessness in America extends beyond harsh city streets or isolated regions; it impacts population centers of all shapes and sizes and extends from coast to coast.

State Rankings

Demonstrating the breadth of this endemic issue, the five states with the highest homeless rates range from the eastern seaboard (New York and Vermont) to the Pacific coastline (Oregon and California), out to the westernmost island (Hawaii).

Using this interactive map, you can explore the rates of homelessness per 100,000 residents for all 50 states and Washington, D.C.

California, New York, Florida, Washington, and Texas had the biggest overall homeless populations, and California and New York alone accounted for 44 percent of all Americans experiencing homelessness. Aside from being among the country’s most populous, these states share several traits that historically contribute to homelessness or attract people without homes. A high cost of living (as in New York, California, Washington, and Oregon) makes affordable housing scarce, while warm weather (Texas and Florida) can make states more appealing to those without secure housing.

On a per capita basis, the District of Columbia has the nation’s most pronounced homeless problem (725 people without homes per 100,000 citizens). Among states, New York posts the highest rate (527 per 100,000). Vermont had the second worst rate –- but its diminutive population (less than 650,000 inhabitants) can distort per capita ratings.

The homeless population increased in 41 states between 2022 and 2023, with New Hampshire recording the most dramatic escalation. The population of people experiencing homelessness there increased 52 percent year over year. In terms of raw numbers, New York’s unhoused population increased most, rising by nearly 30,000. This represents a 39 percent increase from 2022. State officials cited the end of the COVID eviction moratorium, high housing costs, improved counting methods, and an uptick in asylum seekers ( many transported from Texas ) to explain the startling upsurge.

Of the nine states with a decrease in homelessness in 2023, Louisiana (-57 percent) and Delaware (-47 percent) posted the most impressive declines. Louisiana attributed most of its improvement to re-housing residents displaced by 2021’s Hurricane Ida. Delaware’s one-year improvement was welcome, yet still left its unhoused population seven percent higher than pre-pandemic levels.

For a complete state-by-state list of homelessness numbers, see the data appendix following the article.

Population Centers for Homelessness

California and New York are particularly susceptible to housing issues due to their concentration of large urban centers. Nationwide, more than one-half of all people experiencing homelessness live in major cities.

Amazingly, nearly one-quarter of all of America’s unhoused individuals (24 percent) reside in New York City or Los Angeles alone. Seattle, San Diego, and Denver round out the five cities with the highest homeless populations, each with more than 10,000 unhoused residents.

Though major cities saw the most remarkable spike in 2023 homelessness, the number of people without homes climbed in every type of setting – including a 10 percent jump in rural areas.

Population density is only one factor affecting housing status. Homelessness rates also vary widely by gender, age, and ethnicity – with a heightened impact felt by several specific communities.

No two tales of homelessness are identical, though many stories share certain elements. Some individuals leave the workforce or struggle with civilian life after military service. Many battle prejudices, substance abuse, or mental health issues. Some have never known life off the street, while others arrive penniless on promising new shores.

As we dissect national statistics, we must recognize that every number represents human suffering. We may uncover effective, targeted solutions by assessing the plights of narrower populations.

Children Without Homes in America

The 57,000 unhoused families have at least one child under the age of 18. In total, there are 111,620 homeless children in the U.S. Even more alarmingly, 10,548 of them are living outside shelters, and more than 3,000 are living on their own without guardians. While they represent a small percentage of the homeless population, it’s concerning to know that there are children without permanent shelter – one of their basic rights.

Beyond the children under 18, another 34,147 young adults aged 18-24 live alone and unhoused. Worse yet, most advocates warn that this number may be low – homeless children and youths are notoriously undercounted .

This resurgent crisis of underage homelessness threatens to undo a decade of steady progress. The number of people in families with minor children experiencing homelessness had dropped by one-third in the ten years leading to 2022. Last year, however, that total jumped 16 percent, growing by more than 25,000.

Massachusetts has the highest proportion of childhood homelessness: 39 percent of its unhoused population is under age 18. Other states with serious problems include Maine (29 percent), Minnesota and New York (28 percent each), and Delaware (27 percent). Setting better examples are Wyoming and Nevada, where children comprise less than 10 percent of their unhoused populations.

Ethnic Disparities: Race and Homelessness in America

As a nation of immigrants, America is a great melting pot but still struggles with economic equality. Despite recent gains by communities of color, there remains a wide wealth gap across racial divides – particularly for Black communities and Hispanic/Latin groups.

These disparities show through in the latest homeless numbers, which reveal that nearly two-thirds of the nation’s unhoused individuals are Black or Hispanic/Latino, despite these groups comprising only one-third of the country’s population.

The Black community experiences homelessness most disproportionately, at a rate nearly triple its population share.

From 2020-2022, the number of unhoused Black individuals dropped by 5 percent. Unfortunately, it jumped again in the past year, along with most other self-identified ethnic groups.

The Asian community endured 2023’s most considerable homelessness escalation by percentage, primarily because their previous numbers were consistently low – the total increase over 2022 was 60 percent but comprised only 3,313 additional people.

Hispanics registered the most considerable raw uptick of homelessness last year: the 2023 AHAR noted 39,106 more unhoused Hispanic/Latino individuals than in 2022. With 86 percent of this influx sheltered in temporary facilities, officials believe this increase is influenced by immigrants and asylum seekers who arrived from Central and South America.

Fallen Soldiers: Homeless American Veterans

2023’s homelessness surge even affected veterans – a segment that had seen steady improvement over the previous decade.

At the outset of the Obama administration, homelessness among veterans was a shameful and chronic blight. HUD first tracked veteran homelessness in 2009, finding that ex-servicepeople experienced homelessness at twice the national rate, with more than 75,000 living without homes.

A concentrated effort that included billions in spending and an array of outreach programs became a blueprint for success , reducing the number of unhoused veterans by more than half between 2011 and 2022. That progress was interrupted last year. 2023 brought the most significant increase in veteran homelessness since HUD began tracking the situation; 2,445 additional individuals joined the ranks of the unhoused.

Even so, efforts of the Department of Veterans Affairs seem to have softened the blow; homelessness was up 12 percent nationally but only increased by seven percent among veterans. However, the number of unhoused veterans more than doubled in New Mexico and Arkansas in 2023.

Wyoming and Nevada – the two states with the lowest levels of child homelessness – registered the highest percentage of veterans among their unhoused population. They might look to New York for answers , as that state has cut its homeless veteran numbers by more than 80 percent since 2009, and now only one percent of its unhoused population are veterans.

Chronic Homelessness: Expanding Desperation

The most insidious aspect of the nation’s housing crisis is chronic homelessness – defined as individuals with disabilities who have been homeless for more than 12 months or have experienced several periods of extended homelessness over the past three years.

In 2023, nearly one-third of all unhoused individuals (31 percent) exhibited chronic patterns of homelessness – the highest proportion since record-keeping began. The number of chronically unhoused individuals has increased annually since 2016, nearly doubling during that span.

The worsening problem is particularly pervasive in western states: California, Washington, Oregon, Nevada, and Hawaii experienced the most significant increases in chronic homelessness since 2007. California alone contains nearly one-half of the nation’s chronically unhoused (47 percent, or 67,510 individuals). Los Angeles is home to more than 30,000 individuals experiencing chronic homelessness – more than six times more than the next most afflicted city (New York, with just over 4,500).

Factors Influencing Homelessness in 2024

The homelessness crisis in America has numerous causes, ranging from systemic economic inequalities to the recent end of COVID-era assistance. While progress has been made, 2023 was filled with setbacks. Analyzing the recent surge, experts identified several key contributors:

• Economic disparities: The unequal distribution of wealth worsened during the post-COVID recovery , impacting income and exacerbating homelessness risk. Despite a thriving economy, rising inflation eroded buying power for the working classes and further burdened those on the margins most at risk of becoming unhoused..
• Housing affordability: Skyrocketing housing costs , rents , and mortgage rates make homeownership unattainable for many. The resulting housing competition leaves numerous Americans without shelter.
• End of COVID-era assistance: Stimulus packages and protective programs that aided struggling Americans during the pandemic expired in 2023 , contributing to worsening living conditions and increased homelessness .
• Immigration surge: As Congress remains unable to pass immigration reform, record numbers of hopeful migrants and asylum seekers continue to cross America’s southern border . This influx strains resources in major cities.
• Limited healthcare access: Many of those experiencing chronic homelessness are trapped in cycles of poverty connected to substance abuse or other mental health issues . A broken healthcare system burdened with high prices, restrictive insurance coverage, and limited available resources makes accessing mental health care difficult in America. California and New York are experimenting with programs that include compulsory treatment for mental health issues among those seeking government assistance.

Targeted approaches like increasing funding for people with housing insecurities or launching local pilot programs in cities like Houston and Dallas can help dent the problem. However, until these more prominent systemic factors are addressed, true housing security will remain elusive.

The issue of homelessness has long plagued America as an embarrassing shortcoming in our land of plenty. Government initiatives and charitable efforts have progressed in the ongoing battle – particularly among specific societal cross-sections. Still, hundreds of thousands have remained without permanent shelter.

The end of pandemic economic assistance, alongside rising inflation, unaffordable housing costs, and a massive immigration inflow, all contributed to hardships that left more than 650,000 individuals across all demographics unhoused in our nation, nearly one-third of them chronically. This is the largest number of unhoused Americans in history.

Whether this upturn is a brief aberration or a sign of darker times ahead will depend on the economy, the upcoming election, and the efficacy of experimental approaches. Next year’s AHAR will help paint the picture, and Security.org will stand ready to break down the numbers.

All figures on homelessness in this report come from the U.S. Department of Housing and Urban Development’s Annual Homelessness Assessment Reports to Congress, with the latest statistics derived from its 2023 Point in Time homelessness count. The table below does not include U.S. territories, which are included in the HUD report and national totals. You can access the tables and HUD’s latest report to Congress here . Demographic information regarding the general population came from publicly available figures from the U.S. Census Bureau 2023 population estimates .

The State of Homelessness: 2024 Edition

This report provides a comprehensive analysis of homelessness in the U.S. and reveals rising trends, disparities based on race, ethnicity, and gender, and the challenges faced in providing shelter and assistance to those in need.

What Communities Need to Know About the Criminalization of Homelessness

A ruthless effort to criminalize homelessness is gaining traction in state legislatures across the country.

Take Action to End Homelessness

Tell Congress to support legislation that would fund critical homeless assistance programs.

Make Racial Equity a Priority

Evaluate your system to ensure equity and prevent racial disparities in outcomes using the Alliance's tools and resources.

Our Mission

The National Alliance to End Homelessness is a nonpartisan organization committed to preventing and ending homelessness in the United States.

Homelessness Reaches the Supreme Court: As It Weighs One Approach, A Better One Waits in the Wings

This report poses some significant questions that communities should consider when deciding how to address unsheltered homelessness.

Racial Equity Resources

Rapid re-housing toolkit.

Working in Homeless Services: A Survey of the Field

The fy24/25 nofo: creating a roadmap to an effective, efficient & equitable homeless response system, winter 2025 conference, hiding a city’s homelessness crisis through displacement: what the olympics remind us about harmful practices, privacy overview.

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Homelessness is a complex issue caused by a variety of factors including economic factors, family relationships, mental illness, lack of affordable housing, drug abuse, and alcoholism. You could concentrate on one issue and do in-depth research on that or use several of the questions below to focus more generally on the topic of homelessness.

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• Gimme Shelter podcast From CalMatters, this podcast dives into the many aspects of homelessness in California.
• Housing Not Handcuffs: Ending the Criminalization of Homelessness in U.S. Cities This report – the only national report of its kind - provides an overview of criminalization measures in effect across the country and looks at trends in the criminalization of homelessness, based on an analysis of the laws in 187 cities (including Modesto) that the Law Center has tracked since 2006.
• National Alliance to End Homelessness Begun in the 1980s, the Alliance works collaboratively with the public, private, and nonprofit sectors to build stronger programs and policies that help communities fight homelessness. They provide data and research to policymakers and elected officials in order to inform policy debates and educate the public and opinion leaders nationwide
• United States Interagency Council on Homelessness The mission of the United States Interagency Council on Homelessness (USICH) is to coordinate the federal response to homelessness and to create a national partnership at every level of government and with the private sector to reduce and end homelessness in the nation while maximizing the effectiveness of the Federal Government in contributing to the end of homelessness

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The 12 Biggest Myths about Homelessness in America

On a single night in January 2018, the US Department of Housing and Urban Development collected nationwide data to determine that there are now about 553,000 homeless people across the country—or nearly the same number as the entire the population of Albuquerque, New Mexico. While that is an improvement on the estimated 647,000 Americans who were homeless in 2007, it also reflects a lingering inability to solve a four-decade-old national crisis.

What exactly caused the American homeless rate to reach and sustain such heights? Some have cited the shutting of mental hospitals in the 1970s. Others have pointed to the lack of safety nets for military veterans with Post Traumatic Stress Disorder. Still others have called out urban housing prices and cuts in government subsidies for affordable housing. Blaming the homeless, too, is not uncommon—bad choices, substance abuse, or a preference for life on the street are all popular explanations.

But the statistical realities of homelessness upend many common assumptions about its causes, and how best to address it. Two-thirds of all homeless are single adults, while the remaining third are made up of families and unaccompanied youths. Most “self-resolve,” or exit homelessness within a few days or weeks—in fact, only about 16 percent are chronically homeless. And while there are 190,000 visible homeless each night on the street in the United States, many more live in shelters or are otherwise hidden from public view—sleeping in  cars, for example. Most often, popular perceptions of exactly why a person might be homeless are driven by those who are most visible, and by their portrayals in the media.

Silver School of Social Work professor Deborah K. Padgett , a leading scholar on homelessness, is the co-principal author of a recent study that found that New York City policies to stem street homelessness, while well-intended, can increase rather than reduce alienation because they rarely take into account a homeless person’s individual needs—such as pet ownership, health issues, or difficulties obtaining identification documents, among other factors. Much of Padgett’s work has explored the long-term cost benefit and effectiveness of providing housing and support to homeless individuals up front, without first requiring treatment compliance and drug and alcohol abstinence. This increasingly used approach, which originated in New York, is known as “Housing First.”

NYU News asked Padgett to debunk some of the most common homelessness myths:

1. Most are mentally ill.

Decades of epidemiological research reveals that one-third, at most, have a serious mental illness. De-institutionalization or closure of mental hospitals was initially believed to be a prime cause of homelessness, but this occurred well before the sharp increase in the 1980s.

2. The majority abuse drugs and alcohol.

It is believed that only about 20 to 40 percent of homeless have a substance abuse issue. In fact, abuse is rarely the sole cause of homelessness and more often is a response to it because living on the street puts the person in frequent contact with users and dealers. 

3. They’re dangerous and violent.

Homeless persons are far more likely to be the victims of violence than the perpetrators. Of course, some homeless individuals may commit acts of violence beyond self-defense but such acts rarely affect the non-homeless individuals they encounter. To put it another way, any violence by homeless persons is either self-defense or due to the rare violent perpetrator who preys on other homeless people. Non-homeless need to understand this.

4. They’re criminals.

Homeless persons are more likely to have criminal justice intervention. However, this is primarily because many of their daily survival activities are criminalized—meaning they might be given a summons or arrested for minor offenses such as trespassing, littering, or loitering.

5. “Bad choices” led to their homelessness .

Everyone makes mistakes, but the descent into homelessness is not necessarily the direct result of “choices.” Far more often a sudden illness or an accident, losing one’s job, or falling into debt leads to eviction—or doubling up with family or friends becomes untenable.

6. They prefer the freedom of life on the street.

There is no evidence to support this notion that homeless persons are “service resistant.” Since “Housing First” began in New York City in 1992 at the nonprofit Pathways to Housing, Inc., it became clear that the offer of immediate access to independent housing with support services is welcomed and accepted by most homeless. People on the street often reject the option of crowded, unsafe shelters— not housing in general.

7. They spend all their money on drugs and alcohol.

Interviews with street homeless persons show that most of their money goes to buying food and amenities such as socks, hygiene products, and bottled water. Although some do spend money on alcohol or drugs, the same can be said of anyone.

8. They just need to get a job.

A significant portion of homeless people do have jobs—they just cannot afford to pay rent. Some receive disability income due to physical or mental problems but still cannot afford rent. For those wanting to work—a common refrain among those interviewed by my research team—the complications of applying for a job with no address, no clean clothes, no place to shower, and the stigma of being homeless (or having a criminal record), make such individuals far less competitive in the low-wage job market.

9. The homeless are not part of “our community.”

Surveys have shown 70 to 80 percent of homeless persons are from the local area or lived there for a year or longer before becoming unhoused.

10. They live in unsanitary conditions because they don’t care.

Living outdoors means having no regular place for bodily functions, to dispose of trash, to store food safely, or to bathe. A homeless person who “cares” has few alternatives. Our research shows that lacking access to a shower is one of the more humiliating aspects of being homeless.

11. The legal “right to shelter” is the best way to end homelessness.

Currently, shelter construction and maintenance absorb the vast majority of the $3 billion spent yearly by the City of New York to address homelessness. Meanwhile, building affordable housing—the purview of state and local authorities that is left up to private developers—has not kept pace. Thus the “right to shelter” can, in practice, displace “the right to housing.”

12.  In coastal cities with low rental-housing vacancy rates, it is impossible to find enough housing for homeless individuals and families.

New York City has a vacancy rate of 3.6 percent. Of an estimated 2.2 million rental units in the city, this means 79,000 are vacant. This number is greater than the approximately 61,000 persons labeled “homeless” in the city. It means that the argument that “we simply do not have enough existing housing” should be examined more closely.    

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Overdose and Homelessness—Why We Need to Talk About Housing

• 1 Department of Emergency Medicine, New York University (NYU) School of Medicine, New York
• 2 Department of Population Health, NYU School of Medicine, New York
• 3 Department of Emergency Medicine, University of Washington School of Medicine, Seattle
• 4 Corporation for Supportive Housing, Philadelphia, Pennsylvania
• Original Investigation Drug Overdose Mortality Among People Experiencing Homelessness in Boston Danielle R. Fine, MD, MSc; Kirsten A. Dickins, PhD, FNP-C; Logan D. Adams, MD; Denise De Las Nueces, MD, MPH; Karen Weinstock, BS; Joseph Wright, MD; Jessie M. Gaeta, MD; Travis P. Baggett, MD, MPH JAMA Network Open

In their cohort study, Fine et al 1 found that drug overdose mortality among adults experiencing homelessness in Boston increased substantially from 2004 to 2018, with a particularly rapid growth in deaths that involved multiple drugs or synthetic opioids. The cohort’s standardized mortality rate from overdose was 12 times higher than that for the adult population of Massachusetts. 1 Other studies that were conducted elsewhere in the US have reported similar findings. 2 - 4 In Philadelphia, for example, drug overdose has been the leading cause of death among people experiencing homelessness since at least 2011, with the number of such deaths doubling in a 4-year period. 4

Fine et al 1 highlighted the frequently overlooked association between drug overdose death and homelessness. People experiencing homelessness are marginalized, often literally as witnessed in encampment clearings or sweeps. Federal funding favors research on pharmacologic treatments for addiction over research on interventions targeting the social and structural determinants of health, including housing. Consequently, many researchers and addiction practitioners may feel they are ill-equipped to address the seemingly insurmountable problem of homelessness.

The number of people experiencing homelessness, and particularly unsheltered homelessness, has been growing in the US since 2016, after several years of declines. At the national point-in-time count of homelessness in January 2020 (before the COVID-19 pandemic), there were more than 580 000 people living in shelters or unsheltered (eg, on the streets or in encampments). 5 Although representing the best available data, such counts underestimate the true extent of homelessness, in part because homelessness is often a transient or episodic state that may not be captured at a single point in time. For example, people may move between homelessness, institutions (eg, jails and hospitals), and staying with family or friends. Moreover, millions of people experience housing instability that is short of literal homelessness. People who use drugs are at heightened risk, with 1 study reporting that approximately one-third of US addiction program clients had recently experienced homelessness. 6 Studies in other subpopulations of people who use drugs have reported similarly high homelessness rates. 7

A common assumption is that there is a unidirectional causal pathway between drug use and homelessness; that is, people become homeless because of their drug use. This misconception places the blame on the individuals and away from the root structural contributors to homelessness as well as perpetuates stigma and points to the wrong solutions. In reality, the association between homelessness and drug use is bidirectional, and homelessness itself plays a role in drug use and overdose risk. People experiencing homelessness may use drugs for adaptive reasons, such as to stay awake or to sleep as needed or simply to adjust and cope with the trauma of homelessness. The criminalization of both homelessness and drug use compels potentially dangerous behaviors, such as using drugs hastily in public locations or alone in hidden spots. Depending on the locality, people experiencing homelessness may be arrested for something as basic as sitting down in the wrong location. As individuals cycle in and out of jail, they face disruptions in treatment and forced periods of nonuse, which may be followed by drug use upon release and thus increased risk for overdose. Constant movement, as induced by frequent street or encampment sweeps, makes connecting to resources and supports even more difficult.

Fine et al 1 emphasized the need to expand evidence-based treatment and overdose prevention strategies for people experiencing homelessness who use drugs, including supervised injection sites, naloxone distribution, safer drug supply, and substance use treatment offered in both nontraditional and office-based settings. Such interventions are important, particularly when tailored to meet the needs of people experiencing homelessness, to fill key gaps in the substance use treatment ecosystem. However, none of these interventions address the root cause of homelessness, which is lack of affordable housing. Because structural factors drive homelessness, interventions must include not only addiction treatment but also affordable housing, living wages, and a stronger social safety net. Furthermore, Fine et al 1 found that the relative difference in overdose mortality between people experiencing homelessness and the general population was substantially larger for White individuals compared with Black and Latinx individuals. This finding highlights that structural racism may disproportionately contribute to homelessness among Black and Latinx communities, even in the absence of individual factors such as substance use disorder or mental illness. Nationally, overdose rates among Black individuals have accelerated in recent years. 8 Addressing the racial and ethnic disparities in both homelessness and drug overdose requires countering structural racism, including thoroughly enforcing fair housing policies and redressing long-standing inequities in housing and health opportunities.

In our efforts to stem the tide of overdose deaths, we should not treat homelessness as a foregone conclusion. Homelessness is not inevitable or unactionable. The solutions to homelessness are known, evidence-based, and widely accepted, although they are not yet brought to scale. Rental subsidies (ie, Housing Choice Voucher Program, also known as Section 8, vouchers) are effective in durably resolving and preventing homelessness. 9 Historically, the number of available housing vouchers has been far lower than the need, but this situation may be improving somewhat with new federal investments on the horizon. Evidence also supports other types of interventions, such as eviction prevention programs that help people avoid losing their housing in the first place. 9 Given that transition periods pose risks for a drug overdose, such interventions to prevent homelessness might also serve to prevent overdose. For individuals who are already homeless and need additional support services, permanent supportive housing that operates under a Housing First model offers apartments with voluntary services, such as case management, without imposing the precondition of sobriety. Multiple randomized clinical trials have found that supportive housing resolves homelessness, including for residents who continue to use drugs. 9 Housing First model programs already exist in many communities but, again, have not yet been brought to scale across the US.

Additional research and programming are needed to prevent overdose in supportive housing and other types of housing, such as co-location of safe consumption sites, on-site provision of harm-reduction supplies, and expansion of peer workers. 10 Other needed steps are outside the footprint of housing itself, such as ensuring a safe drug supply and decriminalization of drug use. Future work in overdose prevention should focus on forging partnerships and aligning systems, such as the homelessness, harm reduction, and treatment sectors, as well as full-scale adoption of evidence-based interventions to provide affordable housing and prevent homelessness. New housing funds are available to communities from the federal Coronavirus Aid, Relief, and Economic Security Act and the American Rescue Plan Act. These new opportunities should align with harm reduction and other services to reach unhoused individuals who are at risk for overdose.

The study by Fine et al 1 adds to a body of literature that convincingly demonstrates an association between homelessness and drug overdose death. Although further research will be helpful in elucidating points of intervention, it is already clear that housing is a fundamental human right and should be guaranteed for all. This work by Fine et al 1 should prompt not only an acknowledgment of the risk of overdose among people experiencing homelessness but also action that drastically reduces the number of people without stable, affordable housing.

Published: January 7, 2022. doi:10.1001/jamanetworkopen.2021.42685

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Doran KM et al. JAMA Network Open .

Corresponding Author: Kelly M. Doran, MD, MHS, Research Division, Department of Emergency Medicine, NYU School of Medicine, 227 E 30th St, New York, NY 10016 ( [email protected] ).

Conflict of Interest Disclosures: Dr Maguire reported serving as a board member of Prevention Point Philadelphia. No other disclosures were reported.

Disclaimer: The views expressed herein are those of the authors and do not reflect the official policy or position of their employers or other organizations with which the authors are affiliated.

See More About

Doran KM , Fockele CE , Maguire M. Overdose and Homelessness—Why We Need to Talk About Housing. JAMA Netw Open. 2022;5(1):e2142685. doi:10.1001/jamanetworkopen.2021.42685

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A Controversial Crackdown on Homeless Encampments

Gov. gavin newsom has taken sweeping action in the wake of a landmark supreme court ruling..

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

From “The New York Times,” I’m Sabrina Tavernise. And this is “The Daily.”

In the weeks since a landmark Supreme Court ruling opened the door for cities and states to crack down on homeless encampments, California, the state with the largest homeless population, has taken some of the nation’s most sweeping actions against it. Today, my colleague, Shawn Hubler, on the race to clean up what has become one of the Democratic party’s biggest vulnerabilities before election day.

It’s Thursday, August 15.

So, Shawn, you’ve been reporting on this really remarkable moment in the long story of California and homelessness. Tell me about your reporting.

Sure. So California is, in many ways, the nation’s biggest and most wrenching example of homelessness. Something like 180,000 people are homeless in California. And most of them are living without shelter. Some live in cars, of course. Some are couch surfing. Some are in shelters.

But a lot of people sleep outside in California. And the most visible aspect of homelessness in recent years has become these encampments, people who have pitched tents in all sorts of places, in parks and on sidewalks and along riverbeds. And it’s a situation that’s increasingly visible here.

So there are a lot of reasons behind it, poverty — there’s mental illness, abuse, addiction. And everybody’s story is different. But the bottom line is that it has become a really defining characteristic of cities in California. So that’s where things stood. And then came this political season —

We’ve got a major homelessness problem. And the very left-leaning city council and mayor have the exact wrong prescriptions for that homelessness problem.

— which kind of intensified the challenge, because these camps are not only a humanitarian issue, but they’re also sort of a handy political tool for people who want to criticize the governance of California.

Our failed liberal policies, as well as our bad laws that we’ve passed recently, are just simply encouraging the situation.

And you’ll often hear commentators talk about how San Francisco is poorly run. And here’s an example of Democratic governance.

The homelessness is completely out of control.

They’re not going to enforce the law. They’re not going to keep the streets clean. They’re not going to make it livable for me to allow my children to play outside of our front gate without adult supervision.

Now the cities are kind of hellscapes in a way, and that Democrats are the ones who are responsible for it.

City after city facing these issues, they’re all run by Democrats.

OK, so in many ways, this place is really the face of Democrats in control. And the homelessness problem is right at the center of that. So let’s dig into that problem. Why has homelessness become such a big issue in California?

First of all, homelessness has been a big problem in California for a long time. I mean, it’s an extraordinarily complicated issue. It defies simple explanations. But basically, it really all begins in California with extreme income inequality and a severe lack of affordable housing. California’s one of the most expensive housing markets, really, in the country.

On top of that, there are no right-to-shelter laws in California like there are in the East Coast. It’s very difficult to force people into treatment if they’re mentally ill on the street because of commitment laws in the state. And the weather is temperate, so you can sleep outside. Local governments have a shortage of shelter beds, so a lot of reasons.

But for a long time, government officials in California just generally have seen homelessness less as a problem that can be solved exactly than as a problem to be managed, because solving it was going to be very, very expensive. But in 2018 —

I’ve laid out a detailed homeless strategy. There’s been no intentionality on homelessness in this state for decades. It’s not been a focus of the state of California. It is a disgrace. It’s the ultimate manifestation of our failure as a society. And that has to change with the next administration.

Gavin Newsom was elected governor. And he made homelessness one of his central and signature priorities.

As Californians, we pride ourselves on our unwavering sense of compassion and justice for humankind. But there’s nothing compassionate about allowing fellow Californians to live on the streets, huddled in cars, or makeshift encampments.

He called it an urgent moral issue. He said it was a public health crisis.

No place is immune. No person is untouched.

And he said he was going to really spend the amount of money that it was going to take to finally fix it.

I don’t think homelessness can be solved. I know that homelessness can be solved.

Then the pandemic hit.

And the issue that he had brought all this attention to and that he had really promised to make better exploded. Downtowns emptied out. Public health officials weren’t sure whether it was safe to really bring homeless people inside. They didn’t know how the virus spread. Cities more or less stopped sweeping, just adopted a hands-off policy.

And when they did that, these tent camps suddenly became a part not just of skid rows but of everybody’s landscape in California. So this kind of split screen emerged. The state was dumping the most money it ever has, really, billions and billions of dollars at this point, to get people into housing, to get them support for all of the various problems that had put them on the street in the first place. And yet the problem to people who lived here appeared the worst it has ever been.

The upshot was just this growing pressure on Newsom and on local politicians to clear these encampments. But until recently, there had been a handful of lower court decisions that limited just how far cities could go.

And just remind us what those were.

Right, so this was a ruling by the Ninth Circuit Court of Appeals, which covers the Western United States. It had found that if there was no shelter available, it was unconstitutional to punish people for sleeping outside if they didn’t have any place else to go legally.

And Governor Newsom gradually began to see these rulings as a real impediment to making progress on homelessness in California, and particularly on progress in encampments, because the ruling, in his opinion, was so broad that it was hamstringing cities, that they were so afraid of being sued that health and safety rules were going unenforced. And that was creating disease and predation and all sorts of problems for everybody, including people in the encampments. And so the governor threw his political might, really, into to helping to get the Supreme Court to weigh in.

And of course, the court did weigh in and, as we now know, reversed the status quo. What was the effect of that ruling?

The outcome of this ruling is essentially that cities can enforce anti-camping restrictions with less fear of being sued. No longer is their ability to cite people or issue tickets tied to the availability of shelter. They can issue fines. They can arrest people even who refuse to comply. That decision had major implications for the whole country. But in California in particular, it was seen as a game changer.

So on July 25, Governor Newsom issued a sweeping order. It directed state agencies to start clearing encampments on the state property, which is vast. It includes all the land under the freeways, for example, and parks and so on. And the governor also urged cities and counties to do the same. He offered them guidelines that he said would be legal and efficient and, he said, humane.

The playbook would be to give two days notice to people who were camped outside, offer them services, connect them with outreach workers and shelters and housing providers before you move them, gather their belongings, offer to store them for 90 days or 60 days so they could come back and retrieve them later on. But what was unsaid is that in a lot of jurisdictions, if campers didn’t comply, they might now be subject to a citation and maybe even arrest.

OK, so some pretty tough new tools, especially in a place like California that had traditionally been pretty lenient on this issue. Newsom orders this action. What happens?

Well, for all the talk of compassion, right, patience was thin and gloves were off. Some cities announced they were warming up the bulldozers. And San Francisco, Mayor London Breed, who is facing a very tough re-election, in part because of homeless encampments, went directly to an encampment that was outside of a DMV office in San Francisco and stood there while city workers started to clear it. And she told local authorities there that she not only wanted these encampments cleared, she wanted them to start offering bus tickets to people if they had a connection elsewhere.

Like bus tickets actually literally to ship them out of the state?

If they have connections there, yes, because as it stands, California still doesn’t have enough beds for all of its homeless people. The shelters are stressed. Permanent housing is often full. And so cities are looking for any measure they can take to try to ease the situation.

But not every place in the state reacted as quickly or as enthusiastically as Newsom’s hometown of San Francisco, most notably Los Angeles County, which has a huge homeless population and tremendous sway in the state. And that put the largest metropolis in California and California’s governor on a collision course.

We’ll be right back.

So, Shawn, you said that the biggest city in the state, Los Angeles, was skeptical of Newsom’s order. Tell me about that.

So Los Angeles County is an enormous place. The county has 10 million people, roughly. And the city of Los Angeles within it has something like four million. And they are, in many ways, as an electorate more liberal than the state overall. And the supervisors in Los Angeles County react to Newsom’s directive by saying, we’re not going to change anything.

And by the way, we’re not going to criminalize homelessness. We’re not going to put anybody in jail. We’re going to continue to do it our way. We have a lot of homeless people here. And if we dismantle these encampments, that’s fine. But it doesn’t do anybody any good to just move them down the street. We are not going to move anybody until we have a bed to put them in or a place to send them or a program to put them in.

So their view is that they are slowly but steadily going to bring people in inside. And they have been coaxing people in, more with carrots than with sticks, to shelter. And they have made some progress. The city of Los Angeles has made something like a 10 percent dent in the number of unsheltered homeless people over the past year. And the county overall has made a dent of about 5 percent in the number of unsheltered homeless people. And that’s a significant number of people. And it’s a significant dent. But it hasn’t happened very quickly. And that is in direct contrast to what Newsom is trying to accomplish here.

So what does Newsom do? How does he respond to this kind of intransigence from LA?

So last week, roughly two weeks after the order is issued, Newsom goes down to San Diego to welcome some pandas to the zoo. And while he’s in Southern California, a couple of hours later, he emerges 130 miles up the freeway in Los Angeles in a homeless encampment, saying in so many words, you don’t want to clean your house? I’ll come to your house. I’ll clean up this situation for you.

The camp where Governor Newsom is coming today is under a freeway overpass, Interstate 10.

So I went to the encampment, knowing that he was going to be there. And —

We’re walking in. We’re looking around. There’s trash everywhere, strewn everywhere.

It was just heartbreaking, actually. There was trash everywhere, rats, junk.

And I’m seeing in the corner here a man who’s asleep on what appears to be a trampoline.

There was a man passed out in a corner, lying on what appeared to be a broken trampoline that a kid might use, remains of campfires.

Hello, excuse me? Hi, I’m — wow, that is a cool-looking car.

And I spoke to the neighbors around, people who lived in the working-class neighborhood kind of around there.

I know homeless been around — yeah, they’ve been around since forever. You know what I mean? Yeah, but —

And they were really unhappy.

I came to work in the morning. And then I just seen a whole bunch of fire. And I’m like, whoa, a whole bunch of smoke. So I had to call them. And then once I was on the phone with them, they’re like, oh, we already have three or four calls already about that. We’re on their way.

They said that the fire department was there all the time, that they felt very sorry for the people who were living in this encampment, but it was just untenable.

Just kind of dangerous to walk, in the night time, especially.

Because I work —

It was hard for them to feel safe walking down the street or let alone going out with their children.

Governor, hello.

Oh, Shawn will have an audio, so be careful what you say.

Yes, I do have audio.

So a few hours after I got there, the governor arrived with his crew of state workers in their orange vests and their hard hats. And he began picking up trash.

Hey, tell me what you’re doing here.

Just part and parcel of the work we continue to do to try to clean up the state.

He said that it was not just Los Angeles County but counties all over California who needed to get serious now. Now that he had done his part, they needed to be good partners, too.

What I want now, I want to see results. It’s not about inputs. It’s about seeing — physically seeing the results. And that’s what we’re —

And he said that he was looking for accountability and that he wanted to see action. He wanted to see movement.

Butte County has been more determinative of whether or not we’re successful than LA County.

What do you want from LA County? What is it that they are not doing?

I think right now, it’s not an indictment of anyone. I think perhaps that’s the issue. There is no one. That’s the issue with counties, generally, is diffuse accountability. But for me, it’s about urgency. It’s just a different level of urgency. It’s not just —

And the governor also reminded county leaders throughout the state that they rely on the state for many, many billions of dollars of funding and that the state can giveth, and the state can taketh away.

The budget will reflect support for those communities that really stepped up. And with respect to the others, more support for those that stepped up. And I think that’s the spirit —

And that he was planning to reward financially counties who followed his playbook and that he was willing to take money away from counties that weren’t using the funding he was giving them that weren’t enacting his programs to show progress.

It’s a proxy for our performance on every other issue. We don’t have the luxury of other issues right now.

And he also pointed out that this had national implications for his party.

You heard the president just mocking Kamala Harris in California. It’s about this.

That the Democratic nominee for the presidency, Kamala Harris, was already being attacked about California homelessness.

And that’s what we’ll recommend.

We’ll have time for more — we’ll have a couple more questions.

So this is pretty remarkable. You have a Democratic governor going into LA territory, to Democratic officials’ backyard, and really pointing the finger at them and saying, hey, some of you aren’t getting the job done. And we’re going to do this my way.

Yeah, that was pretty radical. But it’s worth noting that only a handful of people were living in these encampments. The governor went to two encampments that day. There was something like — I don’t know — 200 people, something like that. And about half a dozen of them accepted some form of housing or shelter from local homeless outreach groups.

And the leaders in Los Angeles County reacted kind of tellingly, too. On background, people told me, look, this appears to be a little more than a stunt because it’s only proven that this is a long and hard process. Look at how hard he worked. He spent the entire day cleaning up homeless encampments. And he got six people into shelter. And he cleaned up two spots.

And someone else made the point that, look, even after you clean out an encampment, the studies show that they’ll just come back unless you have everything lined up, services and housing for them and guarantees that they can transition into a different way of living. And so it’s a long and arduous and tedious process. And there’s no fast way of doing it right.

It’s interesting hearing — and you talk about this conflict. It strikes me that everyone involved here — the governor, local officials — for the most part, they’re all Democrats who all want the same thing. They see this as a problem that needs to be solved. But the question is how exactly to do that and how fast to do that.

That’s right. And, Sabrina, it’s also worth noting that the Supreme Court decision came only about a month and a half ago. So this is really early stages, right, of this new era in California when it comes to dealing with its homelessness crisis.

And while we’ve seen a huge amount of activity, really, in the time since the Supreme Court’s ruling, everybody, including the governor, even if he doesn’t say so publicly, knows that this is really only the beginning. It’s going to take a very long time to solve this.

Which might not be fast enough for Democratic officials or for the party’s presidential nominee.

Yeah, exactly. Problems like this don’t necessarily fit into political or campaign timelines.

Shawn, thank you.

My pleasure.

Here’s what else you should know today. On Wednesday, the government released inflation data that provided fresh evidence that the central measure of American prices is moderating. The consumer price index was 2.9 percent in July on a yearly basis, down from 3 percent in June. The rate was still faster than the 2 percent pace that was normal before the coronavirus pandemic. But it was the first time since 2021 that inflation had slipped below 3 percent. The measure leaves the Federal Reserve firmly on track to cut interest rates at its next meeting in September.

And Columbia University’s president, Minouche Shafik, resigned on Wednesday over her handling of pro-Palestinian demonstrations and questions over her management of a bitterly divided campus. She was the third leader of an Ivy League university to resign in about eight months. Shafik, an economist who spent much of her career in London, said in a letter that after reflecting over the summer, she had come to the conclusion that resigning, quote, “would best enable Columbia to traverse the challenges ahead.”

Today’s episode was produced by Asthaa Chaturvedi, Olivia Natt, and Eric Krupke. It was edited by Liz O. Baylen and Michael Benoist, fact-checked by Susan Lee, contains original music by Dan Powell and Marion Lozano, and was engineered by Alyssa Moxley. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

That’s it for “The Daily.” I’m Sabrina Tavernise. See you tomorrow.

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In the weeks since a landmark Supreme Court ruling opened the door for cities and states to crack down on homeless encampments, California — the state with the largest homeless population — has taken some of the nation’s most sweeping actions against them.

Shawn Hubler, who covers California for The Times, discusses the race to clean up what has become one of the Democratic Party’s biggest vulnerabilities before Election Day.

On today’s episode

Shawn Hubler , a reporter covering California for The New York Times.

Background reading

Gov. Gavin Newsom cleared homeless camps in L.A. county , where he wants more “urgency.”

Mr. Newsom ordered California officials to remove homeless encampments.

There are a lot of ways to listen to The Daily. Here’s how.

We aim to make transcripts available the next workday after an episode’s publication. You can find them at the top of the page.

Fact-checking by Susan Lee .

The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Michael Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly. Special thanks to Sam Dolnick, Paula Szuchman, Lisa Tobin, Larissa Anderson, Julia Simon, Sofia Milan, Mahima Chablani, Elizabeth Davis-Moorer, Jeffrey Miranda, Maddy Masiello, Isabella Anderson, Nina Lassam and Nick Pitman.

Shawn Hubler is based in Sacramento and covers California news, policy trends and personalities. She has been a journalist for more than four decades. More about Shawn Hubler

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22 U.S. Cities with the Highest Homeless Populations

In January 2022, the U.S. Department of Housing and Urban Development (HUD) reported that approximately 582,462 people were experiencing homelessness on a single night. This number marked a slight increase from previous years, reflecting ongoing challenges in addressing homelessness across the country. Below are 22 U.S. cities with some of the highest homeless populations, highlighting the severity of the issue nationwide.

Eugene, Oregon

Eugene is known for its high homelessness rate, with about 432 homeless people per 100,000 residents. According to the Lane County 2022 Point-in-Time (PIT) Count, around 2,690 adults aged 25-64 were experiencing homelessness, and nearly 44% were chronically homeless. Additionally, about 73% of Eugene’s homeless population lives unsheltered, one of the highest rates in the country.

Sacramento, California

Sacramento County’s homeless population increased by 67% between 2019 and 2022, reaching 9,278 people. A significant 72% of these individuals were unsheltered, giving Sacramento one of the highest unsheltered rates in the nation. Chronic homelessness in the area also more than doubled during this period.

(Based on report by Sacramento Steps Forward)

San Diego, California

San Diego County reported a homeless population of 10,264 in 2022, marking a new record. The number of unsheltered individuals rose by 26%, with 5,171 people living without shelter. A particularly concerning trend is the 46% increase in homelessness among seniors, with 29% of the homeless population being 55 or older.

New York City, New York

As of 2022, New York City had the largest homeless population in the U.S., with around 63,000 people living in shelters. In 2019, about 3,600 individuals were unsheltered, using streets or public transit as their primary shelter. New York City consistently ranks as one of the top cities grappling with homelessness due to its dense population and housing challenges.

(Based on a report by Coalition For The Homeless)

Las Vegas, Nevada

Southern Nevada, which includes Las Vegas, estimated that 13,972 people experienced homelessness at some point in 2022. The region’s Black community is disproportionately affected, with 37% of the homeless population identifying as Black, despite making up only 12% of the overall population.

(Based on a report by Nevada Current)

Topeka, Kansas

The 2023 Point-in-Time Homeless Count for Topeka and Shawnee County recorded 537 homeless individuals, a 30% increase from the previous year. The data revealed that 62% of the homeless population in Topeka are men, underscoring the need for increased support and resources.

Los Angeles, California

Los Angeles County reported about 397 homeless people per 100,000 residents. In 2022, the county increased its shelter bed capacity by 68%, with 26,245 beds available. Programs have helped over 21,000 people each year find permanent housing since 2020, but the city still faces a massive homelessness crisis.

St. Joseph, Missouri

St. Joseph has a high per capita homelessness rate, with Black residents being disproportionately represented—40% of the homeless population is Black, compared to 14% of the county’s total population. White residents, who make up 79% of the overall population, account for 52% of the homeless population.

(Based on a report by National Heath Care for the Homeless Council)

Denver, Colorado

Denver’s homeless population increased from 5,728 in 2016 to 9,065 in 2023. The number of unsheltered homeless individuals rose by 247% between 2017 and 2023. Additionally, new cases of homelessness and chronic homelessness grew significantly, highlighting the city’s ongoing struggles.

(Based on a report by Common Sense Institute)

Fresno, California

Fresno has one of the highest rates of homelessness in the U.S., with 216 homeless individuals per 100,000 residents. The 2022 PIT count showed that 63% of the homeless population in Fresno and Madera counties were men, and the majority were between 18 and 63 years old.

Colorado Springs, Colorado

The 2022 PIT count in Colorado Springs recorded 1,406 homeless individuals, a decrease from previous years despite the city’s growing population. The proportion of unsheltered homeless dropped from 33.1% in 2018 to 19% in 2022, reflecting the impact of new policies and shelters.

Spokane, Washington

Spokane’s rising homelessness is largely due to the shortage of affordable housing. In 2022, a survey found that 20% of homeless individuals cited the lack of affordable housing as the main reason for their situation. Mental illness and substance abuse also contribute significantly, with 32% of adults reporting serious mental health issues.

Battle Creek, Michigan

Battle Creek saw nearly 1,400 homeless individuals receiving assistance from local shelters in 2022. The city has implemented various initiatives, including fundraising events like the “Roof Sit” to support emergency shelters like Inasmuch House.

(Based on a report by Haven of Rest Ministries)

Stockton, California

Stockton struggles with a high per capita homelessness rate. In 2022, the city had only 1,089 shelter beds available, which was insufficient to meet demand. A new $17 million shelter project, the Pathways Modular Unit, is expected to house a significant portion of the homeless population upon completion .

(Based on a report by Stocktonia)

Tallahassee, Florida

In Tallahassee, the unsheltered homeless population increased by 60% in 2023, reaching 269 individuals. This rise reflects the growing challenges in providing stable housing and shelter for the city’s most vulnerable residents.

(Based on a report by WFSU)

Amarillo, Texas

Amarillo has a chronic homelessness rate of 10.5%, with individuals who have been homeless for over a year or have experienced multiple episodes of homelessness. The city’s efforts to reduce chronic homelessness are ongoing, with significant progress made since 2018, when the rate was over 35%.

(Based on a report by City of Amarillo, TX)

Napa, California

Napa has long struggled with homelessness, partly due to high housing costs. The city has added over 100 new shelter beds and invested in permanent supportive housing, helping over 134 chronically homeless individuals secure stable housing with social support services.

(Based Tina. report by NAPA County California)

Vallejo, California

Vallejo faces significant homelessness challenges, exacerbated by high housing costs. In March 2018, the average rent for a two-bedroom apartment was $2,195 per month. The city has been working to address this issue, but affordable housing remains a critical need​.

(Based on a report by Apartments.com)

Reno-Sparks, Nevada

Reno-Sparks has approximately 254 homeless individuals per 100,000 residents. Substance abuse and mental health issues are prevalent, with about 50% of the homeless population dealing with substance abuse and 80% facing mental health challenges​.

(Based on a report by City Mayors Society)

Savannah, Georgia

Savannah reported 259 homeless individuals per 100,000 residents in 2022. The Chatham-Savannah Authority for the Homeless has provided emergency shelter to 1,577 people and other essential services, helping individuals transition to stable housing​.

Anchorage, Alaska

Anchorage’s homelessness rate stands at 274 individuals per 100,000 residents. The city recorded 24 homeless deaths during the winter of 2022-2023. Despite spending $161 million on homelessness since 2020, Anchorage still needs more shelter beds and housing units to meet the demand.

San Jose, California

San Jose has one of the highest per capita homeless populations in the U.S. In 2022, about a third of the homeless population could not work, while 41% were actively seeking employment. Santa Clara County’s housing programs have helped nearly 10,000 people find stable homes, but challenges remain.

(Based on a report by San Jose Spotlight)

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• Comparative treatment of homeless persons with an infectious disease in the US emergency department setting: a retrospective approach
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• Jessica Barnes 1 ,
• Larry Segars 2 ,
• Jason Adam Wasserman 3 ,
• Patrick Karabon 4 ,
• http://orcid.org/0000-0002-4739-7127 Tracey A H Taylor 3
• 1 Family Medicine , University of Michigan Health System , Ann Arbor , Michigan , USA
• 2 Basic Sciences , Kansas City University , Kansas City , Missouri , USA
• 3 Foundational Medical Studies , Oakland University William Beaumont School of Medicine , Rochester , Michigan , USA
• 4 Oakland University William Beaumont School of Medicine , Rochester , Michigan , USA
• Correspondence to Dr Tracey A H Taylor, Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI 48309, USA; tataylor2{at}oakland.edu

Background Research has long documented the increased emergency department usage by persons who are homeless compared with their housed counterparts, as well as an increased prevalence of infectious diseases. However, there is a gap in knowledge regarding the comparative treatment that persons who are homeless receive. This study seeks to describe this potential difference in treatment, including diagnostic services tested, procedures performed and medications prescribed.

Methods This study used a retrospective, cohort study design to analyse data from the 2007–2010 United States National Hospital Ambulatory Medical Care Survey database, specifically looking at the emergency department subset. Complex sample logistic regression analysis was used to compare variables, including diagnostic services, procedures and medication classes prescribed between homeless and private residence individuals seeking emergency department treatment for infectious diseases. Findings were then adjusted for potential confounding variables.

Results Compared with private residence individuals, persons who are homeless and presenting with an infectious disease were more likely (adjusted OR: 10.99, CI 1.08 to 111.40, p<0.05) to receive sutures or staples and less likely (adjusted OR: 0.29, CI 0.10 to 0.87, p<0.05) to be provided medications when presenting with an infectious disease in US emergency departments. Significant differences were also detected in prescribing habits of multiple anti-infective medication classes.

Conclusion This study detected a significant difference in suturing/stapling and medication prescribing patterns for persons who are homeless with an infectious disease in US emergency departments. While some findings can likely be explained by the prevalence of specific infectious organisms in homeless populations, other findings would benefit from further research.

• HOMELESS PERSONS
• Health inequalities
• PUBLIC HEALTH

Data availability statement

Data are available in a public, open access repository. The dataset used in this study was from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007 to 2010, emergency department subset, administered by the Centers for Disease Control and Prevention (CDC). reference: [dataset] 15. Centers for Disease Control and Prevention. NAMCS/NHAMCS—Ambulatory Health Care Data Homepage. https://www.cdc.gov/nchs/ahcd/index.htm . Published 2017. Accessed 20 December 2017.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/jech-2023-220572

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Homelessness and infectious diseases are both important public health issues. There is a gap in knowledge regarding the comparative treatment that persons who are homeless and have an infectious disease receive.

WHAT THIS STUDY ADDS

Homeless persons with an infectious disease in the USA had higher odds of receiving sutures or staples, ‘other procedures’, amebicide agents, antimalarials agents, tetracycline agents and glycopeptide agents, and lower odds of being provided medications for infectious diseases compared with privately housed persons during an emergency department visit.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

These findings provide a platform for continual public health research, potentially providing quality improvement measures for the emergency medical care for homeless persons with infectious diseases.

Introduction

Homelessness is a critical public health concern as 1.5 million individuals spend at least one night in transitional housing or an emergency shelter each year in the USA. 1 As of 2019, over 567 000 individuals were homeless on a single evening in the USA. 2 Homelessness is a complex term with many accepted definitions. The United States Housing and Urban Development definition for homelessness includes any, ‘individual or family who lacks a fixed, regular, and adequate night-time residence’, among many other qualifiers. 3

Homelessness is not homogenous in its distribution as California has 53% of all homeless individuals in the USA. 4 Certain racial groups face disproportionately high rates of homelessness; nearly all minority groups face higher rates of homelessness than their respective percentage of the population. 5 In particular, Black Americans represent approximately 13% of the national population, but comprise 40% of individuals experiencing homelessness. 5 This phenomenon is underpinned by systemic inequities facing minority groups, leading to disproportionate poverty, incarceration, healthcare inequity and housing discrimination—all of which can contribute to homelessness. 5

At its core, homelessness is a public health issue. Homeless individuals have significantly higher morbidity levels compared with their housed peers. In fact, persons facing homelessness die on average 12 years prior to the general US population. 6 Homeless individuals face higher rates of chronic conditions than the general population, ranging from cardiovascular disease to mental illness and are also at higher risk for violence and injury. 1 7 Despite the need and benefit, homeless persons often face access barriers to healthcare, including lack of health insurance and access to routine primary care. 8 Nearly, 75% of homeless persons experienced an unmet healthcare need in the previous year, ranging from medical or surgical care, need for prescription medications, mental healthcare, eyeglasses or dental care. 9 Factors associated with unmet healthcare needs included lack of insurance, past-year employment and food insufficiency—dilemmas disproportionately facing homeless populations and leading individuals to prioritise basic needs over healthcare. 9 Perhaps as a consequence, homeless persons visit emergency departments approximately four times more often than the general population, have high relapsing rates in the emergency room setting and eventually have more admissions to hospital, longer hospital stays and more costly healthcare stays. 8

Part of the increased morbidity facing homeless persons is due to increased rates of infectious diseases. Homeless persons face higher rates of infection by tuberculosis, hepatitis B and C, HIV, scabies, body lice and Bartonella quintana (a louse-borne disease). 7 10 The reasons behind these findings are complex and largely dependent on the specific living conditions of the individual, as well as their unique experiences. Homeless persons living in crowded, shared living spaces are at particular risk for airborne pathogens, such as tuberculosis. 10 There are data to suggest that homeless youth in particular are at higher risk for sexually transmitted infections such as Chlamydia trichamonas . 11–13 A lack of clothing changes combined with crowded, shared living conditions can be conducive to scabies or lice infestations, with subsequent louse-borne illnesses. 10 Previous studies have also demonstrated increased methicillin-resistant Staphylococcus aureus (MRSA) nasal colonisation in homeless individuals using homeless shelters, likely secondary to person-to-person transmission or via fomite transmission. 14 These unique experiences translate to higher rates of particular infectious diseases for individuals facing homelessness.

Interestingly, while there is ample research to demonstrate the high use of emergency department services and infectious diseases among homeless persons, there are little data demonstrating the comparative care that homeless persons receive for these infectious diseases. Our aim was to fill this gap in knowledge by searching for and describing a potential difference in the US emergency department infectious disease treatment between homeless and privately housed persons, by specifically looking for a potential difference in the diagnostic services provided, procedures performed and medication classes prescribed.

Study design

In this retrospective cohort study, we analysed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007 to 2010, emergency department data subset. The NHAMCS is administered by the Centers for Disease Control and Prevention, ultimately creating a deidentified, publicly available dataset that spans multiple decades. 15 This study was reviewed by the University Institutional Review Board and deemed to not be human subjects research.

Inclusion criteria

The study population included homeless persons (as denoted via NHAMCS) in the USA who sought emergency department services for an infectious or parasitic disease between the years 2007–2010. This population was compared with non-homeless persons (classified as private residence via NHAMCS). Infectious and parasitic diseases were defined according to the International Classification of Disease 9 codes volumes 1–3; specifically, this included codes 1–139, 176, 320–324, 326, 370, 373, 381–383, 391–392, 420–422, 460–466, 475, 480–488, 510, 513, 522–523, 551, 566, 566–567, 572, 590, 595, 670, 675, 681–682, 684, 686, 730, 771, V01–V06, V08–V09 and V73–V75. 16 There were no specific exclusion criteria but any data not meeting the inclusion criteria were not included in the dataset to be analysed.

Homelessness status (per NHAMCS) was the dependent variable. Non-homeless was defined as those in a private residence, and all other residency statuses (nursing home, other, missing, etc) were coded as missing, thus not included in analysis. Independent variables included diagnostic service variables: complete blood count, liver function tests, blood culture, other blood tests, HIV test, rapid influenza/influenza test, urinalysis, wound culture, other test/service and any imaging—all of which were converted into dichotomous variables. Procedural variables included intravenous fluids, suture/staples, incision and drainage, foreign body removal, pelvic exam, central line, endotracheal intubation and other procedure (each converted into a dichotomous variable). The total numbers of diagnostic services, procedures and medications provided were also investigated. In regards to medications, specific anti-infective medication classes were investigated, including both those provided and those prescribed, by creating dichotomous variables for each anti-infective medication class listed in the 2010 NHAMCS codebook.

Statistical analysis

Homeless and privately housed persons were compared using a complex sample logistic regression analysis for dichotomous variables and via complex sample linear analysis for continuous variables using SPSS software. Nearly, every variable was converted to a nominal variable, signifying if an individual did or did not receive a diagnostic test, procedure or medication class. Following the initial round of testing, analyses were repeated while controlling for potential confounding variables, including patient age, sex, race, ethnicity, HIV status, length of visit, month of visit and if seen in the emergency department in the last 72 hours. For example, homeless patients tend to be older, disproportionately men, have higher ED relapse and so on. Thus, the adjusted odds ratios (ORs) aim to correct for these factors.

The full unweighted sample size of the NHAMCS data set from the years 2007–2010 was 139 502 samples and when selecting for only infectious disease cases, it included 26 220 infectious disease patient visits. Of these, 128 patient visits were classified as homeless with an infectious disease (see online supplemental figure 1 ). According to the data stratification plan, this accounted for the population of the region where each NHAMCS data set was collected from, giving proportionate representation to the diverse regions where these data are collected. Within the infectious disease population, 54% were female and 46% were male. The majority of subjects were adults, with 43.5% of subjects under the age of 18 years old. The majority were non-Hispanic or Latino (66.9%) and identified as white (56%). And 23.4% of subjects identified as Black/African American, followed by Asian (1.7%), American Indian/Alaska Native (0.8%), more than one race (0.7%), and Native Hawaiian or other Pacific Islander (0.4%). Other study findings, after controlling for potential confounding variables, are described below. Additional demographic data for the total homeless patient visits and the total sample dataset are shown in online supplemental table 1 .

Supplemental material

There was not a statistically significant difference detected in diagnostic services provided to homeless persons compared with private residence individuals (including complete blood count, liver function tests, blood culture, other blood test, HIV test, rapid influenza/influenza test, urinalysis, wound culture, other test/service and imaging; figure 1 ), nor in the provision of diagnostic services, nor in the total number of diagnostic services provided.

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Diagnostic services provided to homeless versus privately housed persons with an infectious disease in US emergency departments. Diagnostic services from the National Hospital Ambulatory Medical Care Survey database with OR shown with 95% CI and p values.

Homeless persons had increased odds (adjusted OR 10.99, CI 1.08 to 111.40, p value: 0.043) of receiving sutures or staples when presenting to a US emergency department with an infectious disease compared with their housed counterparts (see figure 2 ). Homeless persons also had increased odds of receiving ‘other procedures’ (adjusted OR 3.35, CI 1.32 to 8.47, p value: 0.011). Other variables, including intravenous fluids, incision and drainage, and pelvic exam did not demonstrate a statistically significant difference between homeless and privately housed persons. Certain variables, including foreign body removal, central line placement and endotracheal intubation did not contain enough subjects within test parameters to yield usable test results. Complex linear testing on the total number of procedural interventions did not yield a statistically significant result between homeless and privately housed persons.

Procedures performed in homeless versus privately housed persons with an infectious disease in US emergency departments. Performed procedures from the National Hospital Ambulatory Medical Care Survey database with OR shown with 95% CI and p values.

When investigating the medication class provided during an emergency department visit, whether in the emergency department or at discharge, there were several significant differences in the treatment of homeless persons and privately housed persons. As shown in figure 3 , homeless individuals had higher odds of receiving amebicide agents (adjusted OR 5.78, CI 1.03 to 32.32, p value: 0.046), tetracycline agents (adjusted OR: 4.14, CI 1.087 to 15.76, p value: 0.037), antimalarial agents (adjusted OR 4.14, CI 1.09 to 15.81, p value: 0.037) and glycopeptide agents (adjusted OR 5.14, CI 1.56 to 16.89, p value 0.007). Furthermore, homeless persons had lower odds (adjusted OR: 0.29, CI 0.095 to 0.87, p value: 0.027) of being provided a medication in general (not specifically anti-infective agents) compared with private residence persons with an infectious disease. Other variables investigated, as shown in figure 3 , did not demonstrate a statistically significant difference in provision of medications. Certain anti-infective medication classes, including anthelmintics, leprostatics, quinolones, urinary anti-infectives, aminoglycosides, glycylcyclines and carbapenems did not have enough subjects fall within test parameters to yield usable test output.

Medications provided to homeless versus privately housed persons with an infectious disease in US emergency departments. Medications provided from the National Hospital Ambulatory Medical Care Survey database with OR shown with 95% CI and p values.

Following the investigation of medications provided to homeless and private residence individuals, anti-infective medication prescribing was investigated. Homeless persons had higher odds of being prescribed antimalarial agents (adjusted OR: 4.70, CI 1.23 to 17.94, p value: 0.024) and tetracycline agents (adjusted OR: 4.69, CI 1.23 to 17.88, p value: 0.024; figure 4 ). Other variables tested did not demonstrate a statistically significant difference in prescribing habits between homeless individuals and privately housed individuals ( figure 4 ). Certain anti-infective agents, including anthelmintics, antifungals, antituberculosis agents, carbapenems, leprostatics, quinolones, urinary anti-infectives, aminoglycosides, lincomycin derivatives and glycyclines, did not have adequate number of subjects fall within test parameters, thus did not yield usable test output.

Medications prescribed to homeless versus privately housed persons with an infectious disease in US emergency departments. Medications prescribed from the National Hospital Ambulatory Medical Care Survey database with OR shown with 95% CI and p values.

This project sought to detect and describe a potential difference in the management of homeless individuals seeking infection treatment in US emergency departments compared with their housed counterparts. A difference in management (defined as diagnostic services provided, procedures performed and medication prescribed) between these two populations was detected in regards to particular procedures performed, as well as specific medications provided or prescribed.

Diagnostic services

This study hypothesised that there would be a difference in the utilisation of diagnostic services for homeless persons seeking infection treatment in US emergency departments, compared with their housed counterparts. However, a statistically significant difference was not detected ( figure 1 ). These findings do not agree with previous research, which has demonstrated a slight increase in the number of diagnostic services provided to homeless individuals 17 ; however, the research did not specifically look at homeless persons with infectious diseases. Repeated studies with more recent data would be beneficial to elucidate an accurate trend.

This study hypothesised that there would be a significant difference in the procedures performed between homeless and non-homeless populations seeking US emergency department services with an infectious disease. Previous research has demonstrated that homeless young adults (although not those specifically seeking infectious disease treatment) had lower odds of having procedures performed in US emergency departments. 18 In our study, homeless persons presenting with an infectious disease had higher odds of receiving sutures or staples. This finding is perhaps due to clinicians having concerns over access to wound care, wound exposure on leaving the emergency setting and access to primary care treatment on leaving the emergency department. These concerns might lead clinicians to be more aggressive or comprehensive with wound closure via sutures or staples.

Medication provided and prescribed

This study hypothesised that there would be a significant difference in the medications provided to homeless populations seeking infection treatment in US emergency departments compared with their housed counterparts. Homeless persons had higher odds of being provided amebicide, antimalarial, tetracycline and glycopeptide agents. In general, homeless persons had lower odds of being provided a medication when presenting to an emergency department with an infectious disease. To the best of our knowledge, these findings have not been demonstrated in previous studies; however, we have hypotheses as to why these relationships exist.

In regards to amebicide agents, providers might be more apt to cover for amoeba infections in homeless populations due to a concern over increased exposure in outdoor environments or water sources. Thus, a homeless person presenting with a diarrhoeal illness might be more likely to receive a broader range of coverage compared with a privately housed person without potential increased exposure. It is also possible that there is increased prevalence of amoeba infections in homeless populations, thus leading to more treatment in this population; however, to our knowledge this has not been demonstrated In the literature. In regards to antimalarial agents, the reason behind their increased provision to homeless persons with an infectious disease is not immediately clear. Antimalarial medications are indicated for the treatment of a variety of autoimmune conditions, such as systemic lupus erythematous (SLE). Previous research has demonstrated SLE to be more prevalent in African American or Hispanic individuals—populations that also face higher rates of homelessness. 5 19 The variables of race and ethnicity were controlled for in the data analysis, and so should not be the causal factor of our findings in the absence of bias; however, because of the use of this large database, the contribution of bias is not known. We also explored the possibility that immigrants or refugees who are travelling into the USA—and might be exposed to malaria in countries where this pathogen is endemic, thus requiring malarial treatment—might be more prone to homelessness. However, previous research suggests that immigrants and refugees do not face higher rates of homelessness. 20 Thus, this finding remains incompletely explained and warrants further exploration.

Tetracycline agents were more likely to be provided to homeless persons presenting to US emergency departments with an infectious disease. Tetracycline antibiotics are first-line agents for Chlamydial sexually transmitted infections and while previous studies have yielded varied findings on the prevalence of sexually transmitted illnesses in homeless populations, there are data to suggest increased prevalence particularly among homeless youths, who are at increased risk for such illnesses. 12 21 This increased risk for sexually transmitted infections is multifaceted and can be associated with increased likelihood of unprotected sexual intercourse, drug and alcohol use and multiple sexual partners. 12 An increased prevalence of Chlamydial illnesses could explain the increased prescribing of tetracycline agents in this population. Furthermore, several studies have demonstrated serological exposure of homeless persons to a broad range of zoonotic pathogens, including Rickettsia spp and Borrelia spp. 22 23 Tetracycline antibiotics are indicated for many zoonotic infections, infections that homeless persons are perhaps exposed to more frequently due to the sheer nature of being outdoors more than housed populations, as well as living in crowded shelter conditions. 22 23 Beyond this, tetracycline antibiotics are generic (thus relatively inexpensive), effective and avoid the potential for cross-reactivity with penicillin allergies, making them an alluring drug choice in general. 24 Thus, the reasoning behind increased prescribing of tetracycline agents in homeless populations is likely multifaceted.

Glycopeptide antibiotics were provided more frequently to homeless individuals presenting to US emergency departments with infectious diseases. This may be related to the high efficacy in treating MRSA infections. 25 Previous studies have demonstrated that homeless persons face higher rates of MRSA colonisation compared with their housed peers. 14 26–28 This is likely related to the transmissibility of MRSA in crowded living environments; there is also an increased risk of MRSA infections with intravenous drug use, a phenomenon with a significant presence within the homeless community. 26 We hypothesise that the increased prevalence of MRSA exposure and colonisation in the homeless population is what accounts for increased prescribing of glycopeptide agents.

When specifically looking at the differences in the medications prescribed , rather than provided, to homeless persons presenting with an infectious disease, some medication classes ( figure 4 ) did not demonstrate statistically significant differences, including glycopeptide and amebicide agents. Vancomycin (a glycopeptide agent) is given intravenously, thus is more commonly provided within the hospital setting versus as an outpatient. 29 This likely contributes to this change in significance when looking only at prescribed medications. In regards to amebicide agents, it is possible that homeless persons are more likely to be initiated on amebicide therapy while in the emergency setting secondary to concerns over prescription access in the outpatient setting. Previous studies have demonstrated the significant barriers that homeless individuals face in regards to prescription access and medication adherence, which could perhaps lead providers to provide these more in the emergency setting for those facing homelessness. 9 30 31

There are several limitations in this study. By using a database collected by other individuals, there is potential for error and bias in the data collection process outside of our knowledge. This includes the inherent bias of differential likelihood of different populations presenting to the emergency department for care. Furthermore, residency status data may contain errors as it is self-reported by patients and could underestimate the true homelessness rate. 17 Because residency status records recorded as ‘other’ or ‘missing’ were not included in the analyses, this could have introduced some selection bias. Several tests conducted on this project did not have subjects fall within the test parameters and so in these instances, analysis could not be completed. However, given that so many tests were conducted and the majority of them produced valid results, this was deemed acceptable. Many of the findings in this study have not been demonstrated in the literature, and some findings contradict previously reported findings. Given this, repeated studies would be beneficial to support the findings demonstrated.

In conclusion, this study sought to fill a gap in the medical literature regarding the specific care that homeless individuals receive for infectious diseases in US emergency departments compared with privately housed counterparts. Through the use of a retrospective cohort study design using the NHAMCS-ED 2007–2010 database, this study sheds light on the differences in care for homeless persons with infectious diseases in US emergency departments. Homeless persons had higher odds of receiving sutures or staples, ‘other procedures’, amebicide agents, antimalarials agents, tetracycline agents and glycopeptide agents compared with privately housed persons. Homeless persons had lower odds of being provided medications during their emergency department visit. Other variables tested did not demonstrate significant differences. These findings provide a platform for continual public health research with more recent data, potentially providing quality improvement measures for the emergency medical care for homeless persons with infectious diseases.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Acknowledgments.

This study would not have been possible without the expertise of Amy Smark, MD, Misa Mi, PhD, and the Oakland University William Beaumont School of Medicine Embark Program.

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Presented at Poster for the Infectious Diseases Society of America online conference 2020; Oral presentation for the Oakland University Graduate Student Research Conference, Oakland University, Rochester, MI, 2020. Not published in a peer-reviewed manuscript.

Correction notice This article has been corrected since it first published. The middle name has been added for the third author.

Contributors Conception and design of the study: JB, JW, PK and TAHT. Acquisition of data: JW and TAHT. Analysis and/or interpretation of data, drafting the article, revising the article critically for important intellectual content and approval of the version of the manuscript to be submitted: all authors. Guarantor: TAHT.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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