‘Housing-first’ is only the first step to solving homeless crisis in San Francisco

‘By the time we give people housing, they are near death’

Tracey Mixon never imagined she’d experience homelessness.

She lived for 30 years in a Hayes Valley apartment before she and her 8-year-old daughter were forced to leave in 2018. New management took over, a paperwork issue disqualified her from the subsidized rent and she couldn’t keep up with the market-rate payments.

Life became a revolving door of short-term housing fixes: couch surfing, a stint at First Friendship Baptist Church on Steiner Street, the Raphael House shelter on Sutter Street and back to couch surfing.

“We managed to survive it, but I wouldn’t wish it on my worst enemy,” Mixon said.

It took nearly a year, but Mixon, 50, was placed into a unit in the Eddy and Taylor Family Housing building in the Tenderloin, a permanent supportive housing facility where many apartment residents are eligible for subsidized rent and have ready access to voluntary services such as mental health care, job training and counseling. She said it changed her life because it gave her and her daughter “a new beginning,” and the chance to stabilize work, education and well-being.

This is the promise of the housing-first philosophy, which San Francisco was one of the first major cities to adopt: give someone a permanent place to live, provide convenient access to robust care and resources and a cascade of positive outcomes will follow.

“Homelessness is, literally, the lack of a home,” said Margot Kushel, who runs the Benioff Homelessness and Housing Initiative at the University of California San Francisco. “The solution is housing.”

Mixon wound up placed in housing, but the scale of human suffering seen citywide suggests San Francisco has yet to crack the code on turning this rosy philosophy into effective policy.

“Solving the homelessness crisis will take resources and a commitment to house everyone — and then the ability to match services to the need,” Kushel said.

Numerous cities have run pilots showing the efficacy of housing-first policies at a small scale. The easiest way to look at this is how stable people become once they enter the unit, which means they’re able to make reduced rent payments, remain in housing and engage in services as needed.

Denver placed 365 chronically homeless individuals into housing where they had access to extensive services. Of those, 86% remained in their homes after one year and 77% after three years, according to the Urban Institute. Their health improved, too. After two years living in supportive housing, participants saw a 40% decrease in emergency department visits and a 65% drop in city-run detox facilities.

Santa Clara County ran a similar pilot for people who were frequent users of acute medical, psychiatric and other emergency services prior to selection for housing. Between 2015 and 2019, those who were placed in permanent supportive housing remained there for 93% of the study period, and they had lower rates of emergency department visits. By contrast, those who weren’t placed in supportive housing units were less likely to find stable housing.

San Francisco’s shelter-in-place hotel program also demonstrated the potential benefits of moving people off the streets and into apartment-like units. The City moved swiftly to put over 3,700 people experiencing homelessness in rooms in 25 various hotels throughout the pandemic, buoyed by federal funding to reimburse those costs. Service providers say they’ve seen greater engagement with residents and improvements to quality of life, mental health and substance use.

Scaling up

San Francisco has one of the highest per capita rates of permanent supportive housing of any major city in the country and an extremely low rate of eviction from these facilities that hovers around 2%, according to Emily Cohen, deputy director of the Department of Homelessness and Supportive Housing (HSH). Yet 8,000 people still lived on the streets or in temporary shelters as of the last point-in-time count in 2019, and many people believe that number has surged during the pandemic.

Additionally, there were 984 permanent supportive vacancies out of an 8,000-plus unit portfolio as of June 30. Of those sitting vacant, 633 were ready for someone to move in after referral.

Cohen acknowledged that failure to grow the scale of a housing-first program to meet the local need “is one of the reasons that people don’t necessarily feel the success of housing first.”

Part of the trouble scaling up is lack of funding, an obstacle that should be significantly mitigated by the $1.1 billion The City has allocated to spend on homelessness in the next two years and the statewide effort to bolster supportive housing called Project Homekey.

Whereas Kushel said the Santa Clara pilot program succeeded because of its laser-sharp focus on investing in low-income housing, Cohen said San Francisco historically has struggled to pick one strategy to stick with at a time.

Mayor London Breed’s Homelessness Recovery Plan could be a start toward the kind of massive investment that’s likely needed to make housing first a focused, viable solution in San Francisco.

The City plans to place 4,500 people into permanent supportive housing units and grow its stock of such units by at least 1,500 by June. If successful, this would be the largest expansion in 20 years.

However, according to the latest numbers from DataSF, The City has purchased 714 permanent supportive housing units and has placed just 823 people into existing ones, more than one year since Breed announced her proposal.

Cohen acknowledged The City needs to move faster: “San Francisco isn’t living up to its potential on the speed at which people should be placed into housing. That process takes too long right now from assessment to referral and referral to placement.”


Some believe part of the answer lies in right-to-shelter laws, like the one in New York City that mandates that every person facing homelessness be provided shelter. The result is a sprawling municipal shelter system that more than 18,000 adults per day slept in last fiscal year, according to New York City’s homeless services department.

Lawmakers have tried — and failed — to create something similar in San Francisco. Most recently, Supervisor Rafael Mandelman proposed legislation in April that would have required The City to create a plan to shelter all people without a house in tent sites, tiny homes or other options within two years. It’s been tabled at committee for now.

While there will always be a need for emergency short-term shelter options, Kushel said “a focus on shelter in lieu of housing is the worst of all options” because it “costs society a lot and doesn’t solve homelessness.”

Yet, San Francisco has increased its shelter bed capacity to 5,080 from 3,493 between January 2019 and January 2021, according to Homelessness and Supportive Housing data. There were 4,000 people living in shelters or emergency hotel rooms at the start of this year.

“When people are in shelter, they are very much homeless,” Kushel said. “They may be more out of the public eye, so it ‘solves’ the problem for people who are housed, but that is not who is at risk in this crisis.”


While housing first helps to move people into a more stable situation, the harsh reality remains that by the time someone gets into a place they can call their own, it’s often too late.

The Santa Clara study showed “extremely high death rates” even among those who were successfully housed. Of the 423 participants — some who received housing placement, others who did not — the average age was 51, but 70 people died.

Another 2015 study published in BMC Public Health showed the death rates of chronically homeless individuals remained relatively unchanged, even as people entered supportive housing.

“Homelessness is absolutely devastating to health,” Kushel said. “By the time we give people housing, they are near death, and then they die. To blame that on housing-first is, well, a bit rich, but nonsensical.”

For every person experiencing homelessness in San Francisco, there are more who are on the brink of falling into it. All it took for Mixon was a string of tough months financially for her to lose her home of three decades. Making affordable housing more readily available for people on the precipice of homelessness could gradually reduce the tragic impacts of life on the street.

“That’s exactly why we have housing first, and why we need housing first,” Cohen said. “These are the people most likely to die in the street if we don’t intervene. Now, do we need to intervene sooner? I would argue yes.”

Breed’s plan to increase The City’s supply of permanent supportive housing units might stop the proverbial bleeding, but there’s no solution to chronic homelessness that doesn’t involve prevention.

The $1.1 billion also includes unprecedented investment in these prevention efforts, guided by a general rule of thumb. Cohen says: For every added shelter resource, there should be four prevention and two housing resources added as well.

“We can’t house our way of out of this,” she said. “We need to also prevent people from falling into homelessness and providing a safe space for people to be while homeless.”


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