The number of unhoused individuals in the U.S. reached a record high of 770,000 at the end of 2024 (Porter 2024). Homelessness policy remains a source of vehement partisan debate. Some argue that homelessness is, in fact, a housing problem, with permanent housing solutions required to help those most in need. Others argue that those who are chronically unhoused must have issues that go beyond lack of affordable housing; instead, untreated mental illness and substance use are often at the heart of the problem. Should homelessness policy target housing or mental health treatment? My research reveals surprising insights about which approach actually saves more lives—findings that have important implications as the Trump administration prepares to dramatically shift federal homelessness policy.
In the 1990s, homelessness advocates developed the concept of “Housing First” – the idea that for those most in need, highly subsidized permanent housing should be given unconditionally, before any other underlying issues are addressed. Advocates argue that requiring conditions for housing only creates barriers to care, and that it is hard to address underlying mental health issues without having a stable home first.
Housing First programs are pitted against "Treatment First" approaches – which require people to address mental health and addiction before finding permanent, unsubsidized housing on their own. In these models, individuals generally enter transitional housing, or temporary communal housing in which substance use and mental health treatment are required, sometimes along with sobriety. After a one to two-year stay in these transitional homes, individuals are deemed ready to enter regular, generally unsubsidized housing. Proponents of Treatment First argue that Housing First does not address the root cause of homelessness nor incentivize any behavioral changes.