Housing and Homelessness as a Public Health Issue

Abstract

The United Nations declared housing to be a fundamental human right in 1991, and the United States reduced overall homelessness by 20% between 2005 and 2013. However, homelessness continues to be a recalcitrant public health problem in the United States, as those experiencing homelessness have high rates of chronic mental and physical health conditions, co-occurring disorders, and barriers to health care and affordable housing. Homeless individuals also overuse emergency services, leading to higher treatment costs. Numerous evidence-based strategies are being employed to end homelessness by increasing access to housing options and supportive services for housing stability; examples include the Housing First model, housing subsidies for extremely low-income families, permanent supportive housing services for those with complex health needs, and pathways to financial stability through access to disability income and employment support. Interventions in housing, health, and income stabilization should be holistically integrated, allowing individuals experiencing homelessness to find their unique path to recovery. To achieve an end to homelessness, APHA sets forth recommendations for federal, state, and local policymakers and agencies to work collaboratively in funding evidence-based housing acquisition practices and supportive housing stability services, as well as supporting future innovations in integrated services for individuals experiencing homelessness. 

Relationship to Existing APHA Policy Statements 

• APHA Policy Statement 9718(PP): Supporting a National Priority to Eliminate Homelessness 
• APHA Policy Statement 9611: Linkage of Medical Services for Low-Income Populations with Mental Health, Substance Abuse, and Other Addictions 
• APHA Policy Statement 9210: Homelessness as a Public Health Problem 
• APHA Policy Statement 9003: Health Care for Homeless Pregnant Teenagers 
• APHA Policy Statement 8413: Basic Needs of the Homeless and Homeless Mentally Ill in the US 

Problem Statement 

The United Nations declared “the right to adequate housing” to be a fundamental human right in 1991.[1] Across the European Union, more than 400,000 individuals are homeless on any given night, with an estimated 4.1 million people experiencing a homeless episode each year (although varying definitions and methodologies make it challenging to determine precise numbers).[2] The United States has made significant progress in ending homelessness since its Opening Doors plan was implemented in 2010, but it remains a recalcitrant public health problem. 

The 2016 U.S. Department of Housing and Urban Development (HUD) Annual Homeless Assessment Report to Congress estimated that 549,928 people experienced homelessness on a single night in 2016, with 32% of individuals staying in unsheltered locations. Demographically, more than 39% of individuals experiencing homelessness self-identified as Black or African American, a significant overrepresentation relative to the percentage in the U.S. population as a whole (13.3% in 2016). One in five people experiencing homelessness were Hispanic or Latino, 3% were Native American, 2% were of Pacific Islander descent, and 1% were of Asian descent. Men represented 60% of those counted; 40% were women, and less than 1% were transgender. Geographically, New York, Florida, and California had the highest numbers of people experiencing homelessness, although significant increases in the number of homeless people were seen in rural states such as Idaho, Wyoming, and Oklahoma. The count included 39,471 veterans, with 8% of that total accounted for by female veterans. Of all homeless individuals, almost 121,000 were children (22% of the total), 35,686 (7%) were unaccompanied young people 18 to 24 years of age, and more than a third were experiencing homelessness as part of a family.[3] It is important to note that these figures capture a single point in time, and millions more adults and children experience episodes of homelessness during a given year or are at risk of experiencing homelessness as a result of financial and housing instability. 

It is difficult to obtain accurate data on the prevalence of youth homelessness in the United States; according to estimates, however. between 500,000 and 2.1 million young people 13 to 21 years old are homeless.[4,5] Homeless youths are typically defined as unaccompanied individuals 12 years or older (up to age 17, 21, or 25) who live in shelters, on the street, or in other unstable living conditions without family support.[4,6] Overall, homeless youths are more likely than their housed counterparts to experience negative health outcomes, including chronic health conditions or problems such as HIV, substance abuse, violence, and mental health issues.[4,5,7,8] Such risks are a consequence of street-entrenched lifestyles as well as early childhood traumas including family breakdowns, discrimination, and poverty.[5,9] In addition, historically marginalized groups are disproportionally represented in homeless youth populations. Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youths represent between 30% and 45% of the overall homeless youth population, as compared with an estimated 5% to 10% of the overall youth population. LGBTQ homeless youths are significantly more likely than their heterosexual homeless youth counterparts to have major depressive episodes, posttraumatic stress disorder, suicidal ideation, and at least one suicide attempt. In addition, they have increased rates of sexual and violent victimization.[10–12] Homeless youths are also three times more likely to be pregnant, to have impregnated someone, or to already be a parent.[5]

Many homeless youths seek health services only when peer advice and self-care are no longer effective, and minor, treatable injuries often escalate into more severe health problems.[5,13] This problem is compounded by limited access to health care among homeless youths, who frequently use drop-in centers that provide free, instant health care and emergency rooms that often fail to offer the necessary level of care and are much more expensive than the services of a primary care physician.[5,14] Access to preventative health care directly affects young people’s ability to safely and successfully exit the streets. 

Similarly, housing instability and homelessness among children and families is a significant issue, with an estimated 2.5 million children (one in every 30) experiencing homelessness in a given year. Child and family homelessness is likely undercounted in national surveys, as many families “double up” with friends or relatives and may withhold information about their housing instability to avoid stigma. Furthermore, an estimated 51% of homeless children are younger than 6 years and may not be accurately counted, as they do not attend school.[15] Risk factors for family homelessness include inadequate social support, domestic violence, a history of children being placed in foster care, parental drug or alcohol use, parental mental illness, and racial/ethnic minority family background.[16] As a corollary, children who experience family homelessness are at risk of higher stress levels, health problems, and need for pediatric health care during and after such adverse episodes.[17] Homeless children display mental health symptoms requiring clinical evaluations at a rate of two to four times that of their low-income housed peers, and they often exhibit developmental or cognitive delays. Research indicates that 90% of mothers experiencing homelessness have been exposed to at least one form of severe traumatic stress, and between 20% and 50% of women cite intimate partner violence as the cause of their homelessness.[15] 

Ending homelessness is a public health issue, as those experiencing homelessness have high rates of chronic mental and physical health conditions, co-occurring disorders, and barriers to care, such as inability to access care when needed or comply with prescribed medications. The correlation between disabilities and homelessness is high, with almost 20% of individuals experiencing homelessness in 2016 reporting a severe mental illness and 17% reporting a chronic substance use problem.[3] Research on personal and structural barriers in accessing treatment for co-occurring substance use and mental health disorders indicates that individuals experiencing homelessness or those with criminal justice involvement often have fewer treatment resources, lack transportation, and have more limited access to services, particularly those in rural areas.[18] These barriers to treatment may lead to increases in chronic conditions and may hinder housing and income stability. 

Research also indicates that individuals experiencing homelessness have a risk of mortality that is 1.5 to 11.5 times greater than the risk in the general population.[19] Research across the European Union and Canada supports findings of higher mortality rates and chronic disease loads among individuals experiencing homelessness than among those who are housed.[2] Living in an unsheltered or temporary location can exacerbate conditions such as diabetes and hepatitis C, which a study in Boston showed to be two times and 12 times, respectively, more prevalent in a cohort experiencing homelessness than in the general population. Managing diabetes requires access to clean needles and testing supplies and refrigeration of insulin, and treating hepatitis C depends on detailed medication management, which can be difficult or impossible for individuals experiencing homelessness. Along with treatment of chronic health conditions, stable housing is integral in preventing communicable diseases such as tuberculosis and HIV.[20] In addition, food insecurity (defined as being without access to food or not having the ability to acquire food), as faced by many who are homeless , can further worsen mental health outcomes.[21] 

Furthermore, individuals experiencing homelessness overuse emergency services, leading to higher costs for treatment. Studies report that a quarter to one third of homeless individuals are hospitalized during a given year and that these individuals have significantly higher rates of emergency department (ED) use than the general population.[20] A national study of ED use showed that homeless individuals were three times more likely than members of the non-homeless population to return to the same ED within 3 days of an evaluation in that department and twice as likely to use an ED within 1 week of a hospitalization. The study also revealed that homeless individuals were more likely to be transported to the hospital via an ambulance, further increasing treatment costs.[22]

Research on factors predicting ED use among individuals experiencing homelessness shows that unstable housing status and disease burden are more predictive of overuse than insured status. A study in Toronto reported that homeless insured adults visited an ED eight times more frequently than their low-income housed counterparts, while a study in Boston concluded that unstable housing, mental illness, and substance use disorders were significantly associated with frequent ED use among homeless insured patients.[23,24] These costs add up, and research estimates that maintaining a person living on the street or in a shelter can cost between $35,000 and $150,000 annually, accounting for added expenses due to ED use and contact with law enforcement.[25] As a result, increasing housing stability and ending homelessness are critical factors in reducing health system costs. 

However, the lack of affordable housing and high rent costs are barriers to achieving housing stability. HUD defines households with incomes 30% or more below their area median as “extremely low income,” and in 2016 the National Low Income Housing Coalition found that only 3.2 million affordable housing units were available for the 10.4 million extremely low-income households in the United States. Without access to affordable housing, 75% of extremely low-income households are severely cost burdened, paying 50% or more of their income toward housing costs.[26] These housing shortages have a particular impact on individuals with disabling conditions. A 2014 study showed that the national average rent for a modest one-bedroom unit exceeded 100% of monthly Social Security Supplemental Security Income (SSI) payments, and the national average rent for a studio/efficiency was equivalent to 90% of monthly SSI payments.[27] Housing subsidies, such as HUD’s housing choice vouchers (HCVs), are critical to assisting individuals in accessing safe, affordable housing without being too cost burdened to meet other basic needs such as food and transportation.

Individuals with complex health needs, particularly those with severe mental illness and co-occurring substance use disorders, often have difficulty in maintaining housing without appropriate supportive services, even with the provision of affordable housing.[28] Increased access to low-barrier, permanent housing with wraparound supportive services is essential to meeting the needs of this population. Key supportive housing services include medical and psychiatric treatment, case management, and resources designed to support independent living, which are often funded through Medicaid.[29]

Income stability is critical to retaining housing for individuals who have disabling conditions, and cash benefits and health insurance provided by Social Security disability programs, SSI, and Social Security Disability Insurance (SSDI) make it possible for these individuals to access important treatment and supportive services. However, despite high levels of disabling conditions, many individuals experiencing homelessness never apply for benefits, and those who do have a very low chance of approval without receiving active assistance in documenting their disabilities.[30] Nationwide, an average of 28% of all initial SSI/SSDI applications are approved, and this figure can be as low as 10% to 15% among individuals experiencing homelessness.[31,32] Denials typically result from the Social Security Administration’s inability to contact individuals, missed appointments, and, more generally, lack of adequate documentation.[33] People experiencing homelessness face many challenges when applying for disability benefits, including inconsistent treatment, difficulty in locating medical records, lack of a stable address or telephone number for contact with Social Security, and difficulty in understanding complex and fragmented application processes.[32]

Further impeding income stability is the high prevalence of unemployment (estimated to be as high as 80% to 90%) among individuals experiencing homelessness, particularly those with severe mental illness. Frequently cited barriers to employment include difficulties in obtaining psychiatric care, substance use, criminal histories, lack of child care, and limited education. Lacking a stable address, phone, work attire, and transportation further compounds barriers to stable employment.[34,35] While day labor positions may provide limited income for homeless individuals, particularly those with lower educational attainment and criminal and alcohol use histories, they are not a reliable form of income due to exploitation and inequality in the day labor market.[35] Increasing access to permanent, supportive employment options among individuals experiencing homelessness is critical for income stability. 

Finally, criminalization measures in effect across the United States that target activities associated with homelessness are not only ineffective in reducing homelessness and costly to enforce but serve as a barrier to income and housing stability. In 2016, the National Law Center on Homelessness and Poverty conducted a survey of the municipal codes in 187 cities and found that despite a shortage of housing and shelter options, many cities are choosing to criminally punish individuals for carrying out life-sustaining tasks such as sleeping in public, loitering, sitting or lying down in public, sleeping in vehicles, sharing food, and panhandling. The survey results showed that 53% of cities prohibit sitting or lying down in public places, 43% prohibit sleeping in vehicles, 76% prohibit begging in particular public places, and 9% prohibit sharing food with people experiencing homelessness. These criminalization measures do nothing to address the underlying causes of homelessness, as most police interventions are temporary and result in a fine that homeless individuals are often not able to pay, exacerbating their financial instability.[36] Criminalization of these measures is costly for taxpayers to enforce, and a study in Colorado showed that six of the state’s cities spent more than $5 million enforcing 14 anti-homelessness ordinances.[37] Criminal records negatively affect an individual’s access to housing, benefits, and employment, and these barriers are not limited to homeless adults. Homeless children and youths are also subject to liability under these ordinances, along with ordinances that apply uniquely to them such as status offenses and truancy.[36]

As documented above, individuals and families experiencing homelessness are more vulnerable to health inequities and have disproportionately poor health outcomes. The World Health Organization emphasizes that improving social determinants of health is critical in achieving health equity within a generation. Improving the conditions of daily life for vulnerable individuals, tackling the structural drivers of inequities (e.g., ineffective social programs or inequitable economic opportunities), and raising public awareness of social determinants of health are crucial to this process,[38] as are recognizing homelessness in the United States as a public health issue, addressing barriers hindering access to treatment and housing, and continuing to support research that measures the effectiveness of social policies designed to end homelessness. 

Recent successes in addressing homelessness demonstrate that there are available solutions to this public health issue. From 2005 to 2013, overall homelessness decreased by 20%, while chronic homelessness decreased by 42% and homelessness among veterans by 24%.[3] These reductions have been attributed, at least in part, to concurrent dissemination and implementation of data-driven, results-oriented approaches to housing and homelessness.[25] These interventions vary, as does the quality of evidence supporting them, according to differing types or characteristics of homelessness and the unique barriers faced. 

Evidence-Based Strategies to Address the Problem

Numerous evidence-based strategies are being employed to end homelessness by increasing access to housing options and supportive services for housing stability. Examples of these evidence-based strategies are described below. 

Housing First model: The Housing First model was developed as an alternative to the paradigm that individuals need to achieve “housing readiness” by attaining sobriety, complying with psychiatric treatment, and learning skills for independent living prior to qualifying for a permanent housing placement. In contrast, the Housing First model is based on the tenet that housing is a basic right and should be provided without prerequisites; this harm reduction approach values consumers’ choices in terms of their own needs and readiness for treatment or substance use reduction.[39] While the Housing First model encourages the provision of supportive wraparound services, its use is not limited to permanent supportive housing, and the principles should be applied whenever housing services are provided to individuals experiencing homelessness. 

A review of 31 studies focusing on outcomes associated with the Housing First model showed that the model resulted in faster housing placements than traditional treatment-dependent programs as well as increased levels of housing retention, including among individuals with co-occurring substance dependence and mental disorders. The increased levels of housing retention also led to decreases in costly shelter use and fewer jail stays. In addition, several of the studies documented that participants reported a higher perceived quality of life and sense of choice.[40] Conversely, in another study, individuals who had to enter interim housing and wait for an available permanent housing placement reported worsening mental health symptoms, reduced their engagement with service providers, and had inconsistent progress in non-housing-related recovery goals.[39] 

Interventions incorporating the Housing First model are not limited to urban settings. While rural settings may have additional challenges (e.g., limited housing stock), the Housing First principles can be equally effective. An evaluation of Housing First interventions implemented in rural areas in Vermont demonstrated an 85% housing retention rate over 3 years.[41] A critical aspect of the successful implementation of this model was landlord engagement, particularly among tenants with criminal histories or substance abuse disorders. In a study of landlord perceptions of participating in Housing First, many of the landlords reported seeing the social value of helping individuals integrate into the community. These landlords indicated that they were more willing to rent to tenants whom they would have not rented to before.[42] Innovative landlord engagement at the community level can result in significantly increased housing opportunities for people experiencing homelessness. Policies aimed at ending and preventing homelessness should prioritize use of the Housing First model given its positive housing, health, and economic outcomes . 

Housing subsidies, including housing choice vouchers: More than 5.1 million low-income households in the United States receive federal rental assistance so that they can afford housing, with funds directed to elderly citizens, people with disabilities, veterans, and working families. Federal rental assistance is delivered through a number of programs, including public housing, Section 8 project-based housing, U.S. Department of Agriculture initiatives, and the HCV program. The HCV program serves the largest number of households, 2.1 million, and allows very-low-income families, individuals with disabilities, and the elderly to choose safe, affordable housing in the private market. Public housing agencies (PHAs) receive HUD funding to administer the program and pay a subsidy directly to a landlord on behalf of the family; the family is responsible for the cost difference between the actual rent of the property and the subsidized amount, which is typically 30% of the family’s monthly adjusted income.[43]

Federal rental assistance allows individuals and families to exit homelessness and greatly reduces housing instability and overcrowding. In addition, research into the effects of vouchers on families with children indicates that voucher use cuts foster care placements in half (as children are not removed from homes due to housing instability) and greatly reduces the number of moves from one school to another, which in turn improves academic performance and reduces behavioral and attention problems. By spending less on rent, families are also better able to meet food and other basic needs such as transportation, educational support for children, and health care.[44] In HUD’s Family Options Study, which evaluated the effectiveness of various types of housing support for homeless families, researchers found substantial long-term benefits from the use of permanent supportive housing subsidies. Families who received priority access to these subsidies reduced their housing instability by more than half, as evidenced by reductions in subsequent stays in shelters and places not meant for human habitation. They also showed improvements in multiple measures of adult and child well-being and reduced their food insecurity.[45] 

Permanent supportive housing: Permanent supportive housing is a combination of safe, stable housing and supportive services for individuals who have serious mental illnesses or other disabling conditions and who need additional services to remain stably housed. It is recognized by the Substance Abuse and Mental Health Services Administration, HUD, and the U.S. Interagency Council on Homelessness as an evidence-based practice for chronically homeless individuals or those with complex health needs. Through this model, individuals receive flexible support based on their choices and needs, which can include case management, substance abuse or mental health counseling, assistance in increasing their income through employment or disability benefits, training in independent living skills, vocational services, and other tenancy support services.[46] These supportive services are a critical part of improving housing stability outcomes in permanent housing programs. An example of a federal permanent supportive housing initiative is the HUD-VASH (Veteran Affairs Supportive Housing) Program, which combines HCV rental assistance for homeless veterans with case management and clinical services provided by the Department of Veterans Affairs (VA). From 2008 to 2015, more than 85,000 HUD-VASH vouchers were awarded.[47] A review of research on permanent supportive housing showed that this model is effective in reducing homelessness, increasing housing stability, and reducing hospitalizations and ED use.[48] There are multiple types of permanent supportive housing programs that can facilitate better health outcomes and promote housing stability, including Housing First, harm reduction, and consumer-driven program designs.[49,50]

Numerous additional studies have documented that supportive housing for chronically homeless individuals reduces expensive ED usage. A study in Oregon revealed a 55% reduction in Medicaid claims for individuals 1 year after they obtained housing, while research in Chicago showed that housing and supportive services led to a 29% reduction in hospital days and a 24% reduction in ED visits.[51,52] In addition, the New York Frequent Users Service Enhancement initiative, which provided supportive housing to 200 individuals with frequent jail and shelter stays, documented that 91% of participants remained stably housed after 12 months, and annual total costs for crisis medical and behavioral health care services were reduced by $7,308 per person.[53]

The levels and types of support services offered are intentionally designed to be flexible and adaptive to the population being housed by a given program. The variety and extent of the service needs of tenants in permanent supportive housing must influence the types of services provided. Funding for effective permanent supportive housing program delivery should ensure appropriate staff-to-tenant ratios and services. Some tenant populations (particularly those with special needs) and services are more resource intensive than others, requiring programs to increase the proportion of costs relative to housing subsidization and operating costs. Insufficient resources allocated to supportive services result in underperformance with respect to program outcomes (e.g., housing instability, unsafe conditions for tenants and staff).[54]

National Housing Trust Fund: The U.S. Congress established the National Housing Trust Fund (NHTF) under the Housing and Economic Recovery Act of 2008. This block grant, administered by HUD, is intended to supplement other federal and state efforts to provide safe, affordable housing for extremely low-income households and families experiencing homelessness. States are allocated a minimum of $3 million per year and use these funds to acquire or construct new affordable housing units and rehabilitate existing units; 80% of the funding is dedicated to rental housing. The NHTF began receiving contributions from Freddie Mac and Fannie Mae in 2014, and HUD allocated the first $174 million in May 2016.[55] This federal support for increasing the number of affordable housing units is invaluable in terms of ensuring housing stability and ending homelessness; however, additional funding mechanisms to increase contributions to the NHTF are necessary to ensure that states and the District of Columbia receive enough funds to support these goals. 

Increasing income support to promote housing stability: The federal strategy to end homelessness, Opening Doors, emphasizes the need for individual economic security in order to achieve housing stability. Programs aimed at increasing income stability and financial independence should be integrated into housing and health interventions, as the provision of housing alone will not be sufficient to end and prevent homelessness.[56] 

In the case of individuals with disabling conditions, increasing access to Social Security disability benefit programs or VA disability benefits for veterans helps provide the cash benefits and health coverage that are key for housing retention. With respect to overcoming barriers in application processes, research indicates that comprehensive application assistance can increase the approval rate for homeless individuals from 28% to 73%.[33] Additional research documents that programs providing SSI/SSDI application assistance to homeless individuals exiting the justice system report increased housing stability and reductions in rearrests and incarcerations, thus decreasing system costs.[57]

Increasing income stability through employment is also critical to housing stability, and while unemployment rates are high among individuals experiencing homelessness, research shows that most members of this population, particularly those with severe mental illness, want to work and are capable of working.[58] Supportive employment services have documented success in increasing access to and retention of competitive employment. A 2014 study revealed that, among individuals with psychiatric disabilities, those who received employer-provided accommodations for their disabilities worked 7.68 more hours per month and retained their job for almost 7 months longer; also, each job accommodation individuals received reduced their risk of job termination by almost 13%.[59] In addition, the Individual Placement and Support (IPS) model, which focuses on competitive employment, consumer preferences, rapid job search, and individualized job support and does not require extensive preemployment readiness or training, has demonstrated success across 23 randomized controlled trials involving individuals with mental illnesses. Across these studies, an average of 60% of individuals using the IPS model obtained competitive employment; also, these individuals retained their initial job placement for 8 to 10 months and reported higher self-esteem and reduced mental health service use.[58] 

Homelessness prevention programs: While interventions for those experiencing literal homelessness are critical, public policy and resources should also focus on preventing homelessness, particularly among youths, families, and veterans. Youths exiting foster care are at high risk of homelessness due to lack of social support, poorer health outcomes, and underemployment, and many young homeless families are led by those who recently exited foster care.[16] Homeless prevention programs for youths transitioning from foster care should include increased access to mentoring, employment and education support, and connection with permanent housing.[16,25] In addition to educational and vocational resources, supportive services for families who are at risk of homelessness should focus on identifying and addressing developmental delays in children, increasing access to treatment for parental substance abuse or mental health conditions, and providing parental support.[15] Multidisciplinary teams working across schools, clinics, and social services are critical in identifying children and families in need and arranging for appropriate resources.[16]

In the case of veterans who are at risk of homelessness, the VA has dedicated more than $1 billion in funding for homelessness prevention and rapid rehousing initiatives through the Supportive Services for Veteran Families (SSVF) program. In the first four years of the program, which began in 2012, SSVF served more than 238,000 veterans, and 87% of those who received homelessness prevention assistance were able to access or maintain permanent housing at the end of the assistance, which lasted 96 days on average. More than half of veterans served through SSVF have one or more disabling conditions, and most (70%) earned less than 30% of the median income in their area upon program entrance. The SSVF program achieves successful homelessness prevention by providing time-limited cash assistance combined with targeted service-intensive interventions to support access to employment and benefits.[60] The VA has shown that limited-cost, short-term prevention efforts can be successful in regaining housing stability, and further research should explore the applicability of such findings to other subpopulations. 

Evaluations of programs aiming to prevent homelessness have yielded mixed results. In New York City, one such program was shown to reduce new shelter entries by 5% to 11% on average.[61] Shelter length of stay, while not typically a targeted outcome of prevention programs, nevertheless does not appear to be effected by prevention efforts.[62] HUD’s Homelessness Prevention and Rapid Re-Housing Program was discontinued in 2012 after demonstrating only mixed success. However, the lack of any increase in homelessness from 2009 to 2012 during an economic recession in the United States has been attributed to large-scale increases in prevention funding. In addition, many lessons were learned from the implementation of that program, and these lessons have led to a better understanding of how to generate and measure program impact.[63] Other countries, such as England and Germany, have documented greater success in homeless prevention programs; however, these countries have more widely available housing subsidies, greater access to public or social housing, and more flexible cash assistance.[64] 

Constructive alternatives to the criminalization of homelessness: Many states and municipalities continue to pass laws that criminalize behaviors associated with homelessness, such as sharing food and loitering. While some of these laws have been struck down, many more are taking up costly resources to enforce and are ineffective in reducing homelessness or the criminalized behavior they are intended to deter. Internationally, human rights courts and national constitutional courts are increasingly recognizing a fundamental right to housing and pursuing housing-related solutions to these behaviors, rather than a criminal remedy. As a result, it is critical for communities in the United States to adopt constructive alternatives to criminalizing basic life-sustaining activities that individuals must perform in public spaces if there is no shelter or housing available.[36,65]

The housing-focused solutions detailed above are critical to reducing the behaviors that these laws are designed to deter. Individuals and families who have a safe, permanent place to live will no longer need to sleep in public or be targeted as loitering. However, while pursuing housing is the ultimate goal, decriminalizing the life-sustaining behaviors of people experiencing homelessness and recognizing their fundamental human rights are essential. Money spent on enforcement of these laws could instead be spent on developing affordable housing options, reinvesting in community services for homeless citizens, or establishing street outreach teams to increase engagement in services. Homelessness outreach teams staffed by police officers in Houston, Minnesota, and Milwaukee have proved successful in diverting homeless individuals away from jails when they are in a mental health crisis, saving the criminal justice system additional funds. Finally, many cities and states across the country have enacted a homeless bill of rights, which is legislation that prohibits the criminalization of homelessness and discrimination against those experiencing homelessness. These rights include the right to move freely in public places, share food, rest, and ask for donations while being protected from harassment from police or others.[36]  

Summary: In conclusion, there is no single strategy sufficient to completely address or end homelessness. Interventions in housing, health, and income stabilization should be holistically integrated, allowing individuals experiencing homelessness to find their unique path to recovery. Further innovations and strategic interventions beyond the currently accepted evidence-based strategies will likely be required to achieve this goal. Such innovations will require interdisciplinary and cross-sector collaboration, including coordinated, focused efforts from policymakers, governmental agencies, social services agencies, the health care industry, and researchers. 

Opposing Arguments

Those opposing state funding for shelters, permanent housing, and social welfare programs for the homeless often cite systemic inefficiencies and fraud. They claim that these funds could be better used to create jobs or provide family and career counseling. Others argue that since an individual is responsible for his or her homelessness, providing such support is immoral because it creates a culture of dependency and encourages free-riders. The argument that “homelessness is a choice” includes the belief that individuals are choosing not to work, and thus to not have income for housing, and the belief that individuals are homeless through “deviant” life choices such as using drugs or alcohol.[66] However, these lines of argument disregard the health and economic factors leading to homelessness (as discussed above). Being homeless is a complex issue covering individual adults and children, as well as two-person and single-parent families. 

Responding to homeless families raises some complex ethical issues, such as whether it is better to keep children with parents in a homeless shelter or whether or not to return abuse victims to potentially dangerous situations.[67–69] While these concerns are valid and could be addressed if better evidence were made available, this does not preclude the need to provide support to families and their children in times of need. Children who experience family homelessness are at risk of higher stress levels, health problems, and need for pediatric health care, which also increases costs to the overall system when interventions to address episodes of homelessness are not addressed.[17]  

In addition, there is political and philosophical opposition to prioritizing social services for housing and homeless programs (so-called “political will”) within governmental entities and in communities at large that contribute their taxes to such programs and elect representatives to reflect such priorities. Underprioritization of such services tends to disregard the preventative and cost-saving characteristics of social services aimed at addressing homelessness and instead focuses on opportunity cost trade-offs and a cost-minimization approach to governance. This means that such political will fails to recognize the costs of services already being supported to address the adverse effects of homelessness such as health care and criminal justice system costs.[25] 

Another political solution often proffered comes in the form of exclusionary or punitive policies tasked to law enforcement services. These policies, such as bans on panhandling or sleeping in public, are counterproductive to the interventional objectives of housing and homelessness agencies. However, these services have been shown to stem from socialized reactions such as disgust or a desire for physical separation from symbols of poverty, and they were not derived from evidence-based or outcome-oriented solutions.[70] Instead, these policies are studied in similar terms to the micro-aggression phenomena associated with homelessness, such as dangerousness, assumptions of substance abuse, laziness, and intellectual inferiority.[71] Such negative public perceptions of individuals experiencing homelessness also implicitly support and bolster counterarguments to implementation of housing and homelessness services. 

While the HCV program provides much-needed assistance to individuals experiencing homelessness, critics argue that waiting lists for these vouchers are extensive, with many PHAs not accepting new applicants and many eligible voucher holders waiting 2 years for an available unit.[72] PHAs are constrained by the amount of funds they receive from HUD and cannot serve every household that qualifies for the program; as a result, PHAs must ration vouchers and have wide discretion over eligibility criteria.[73] Furthermore, a recent meta-analysis of the program documents that participants are not moving to areas of lower poverty, thus not fulfilling one of the program aims of deconcentrating areas of poverty, and that almost one third of qualifying families are returning vouchers unused. Limitations on voucher usage result from a variety of factors, including participants not being able to afford a security deposit, lengthy wait times for PHA inspections of properties before move-in, and unpredictable timing of voucher availability.[74] In addition, individual landlords have the choice of whether or not to accept vouchers from applicants, which decreases the geographic and socioeconomic range of sites available to those accessing the program. However, many of these limitations can be overcome through adequately funding the HCV program to reduce waiting lists and increasing the stability of voucher availability. In addition, programs that foster income stability and financial independence can enable families to return vouchers when they are no longer needed, allowing PHAs to target voucher use toward families with the highest needs. 

Such regulatory limits to the effectiveness of housing vouchers also play a role in the causal pathway to homelessness, along with limiting the effectiveness of interventions to resolve it. Economic conditions such as fluctuations in wage and employment levels, the rising costs of housing even at the lowest levels, and income or wage gaps all play a part in driving individuals into episodes of homelessness, increasing the complexity of the problem. Similarly, beyond such economic drivers, there are a wide range of reasons why individuals become homeless. Families may experience homelessness as a result of conditions in or outside of their control, such as unsafe home environments, traumatic or violent events, natural disasters, unexpected costs that overwhelm financial safety nets, and temporary lapses in availability for employment. These complexities can be pointed to as a reason for programs’ inability to “end” homelessness, but they do not eclipse support for expansion of programs that seek to solve current homelessness or prevent future homelessness from occurring. 

This issue of complex economic, systemic, and social drivers is also connected to the notion that housing support and other homelessness services will end up being a permanent crutch to individuals accessing them. In fact, such a model of homelessness simultaneously supports the case that homelessness is in some ways beyond the control of the individuals it affects, contrary to the aforementioned negative perceptions held by political entities and members of society. If the complex web of causes of homelessness stems even in part from factors external to individual behaviors or characteristics, then interventions intended to either temporarily or systematically remedy those factors cannot be dismissed outright. 

Finally, the popular media often cites widespread fraud in social programs as a reason to defund housing and income support services.[75] Despite media portrayals of widespread disability fraud, the Social Security Administration found in 2012 that only 1% of payments were inaccurate and that most cases of fraud are detected prior to an individual receiving payment.[76] Similarly, HUD found that just over 1% of families living in public housing exceeded income limits, and the agency has taken action to encourage PHAs to withdraw vouchers from these families and target vouchers to those with the highest needs.[77]

Action Steps

This policy statement represents APHA’s strong commitment to ending and preventing homelessness. As a means of reaching this goal, APHA: 

1. Calls upon federal agencies such as HUD and the U.S. Department of Health and Human Services, states, and local providers of housing and homelessness services to promote programs that demonstrate adherence to the Housing First model, prioritizing low-barrier access to housing for individuals experiencing homelessness across all housing program types, with an emphasis on harm reduction approaches to housing and consumer-driven program designs and structures. 
2. Urges Congress to adequately appropriate funds for rental assistance options, including the HCV program, to ensure that HUD and the U.S. Department of Agriculture can meet future commitments and community needs for affordable housing. 
3. Urges Congress to identify additional funding mechanisms for the National Housing Trust Fund to ensure that states receive adequate funding to increase the availability of affordable housing units.
4. Urges federal, state, and local agencies funding housing and homelessness services to expand their commitments to provide resources for permanent supportive housing programs, rapid rehousing programs, and prevention of homelessness appropriate to levels of unmet need, as demonstrated in federal reports.
5. Calls upon federal, state, and local agencies funding or providing regulatory oversight for housing and homelessness services to provide sufficient funding for supportive services in all housing and homelessness interventions and flexible program budgeting to permit appropriate funds for supportive services to meet the greater needs of high-acuity populations. 
6. Urges federal, state, and local agencies funding housing and homelessness services to adopt a “health in all policies” approach to policy decision making by incorporating health considerations into impact estimates, evaluations, and reporting across all sectors and policy-making or policy-guiding entities involved with housing and homeless services. 
7. Calls upon federal, state, and local agencies to identify and adopt alternative solutions to criminalizing homelessness, including adoption of a homeless bill of rights.
8. Urges federal, state, and local agencies funding housing and homelessness services to support tailoring of interventions for special populations demonstrated to be at excess risk of homelessness, particularly vulnerable while homeless, or disparately accessing or receiving housing or homelessness services.
9. Calls upon federal, state, and local agencies to promote allocation of expanded and new funds for services that target prevention of homelessness, including rental assistance, outreach to schools and low-income communities, and vocational and educational resources and supportive services for families found to be at risk of homelessness.
10. Calls upon federal, state, and local agencies to provide comprehensive assistance to homeless individuals with disabling conditions in applying for any disability benefits for which they qualify.
11. Calls upon federal, state, and local agencies to promote allocation of funds and services that provide individualized employment support and training to assist homeless individuals in obtaining competitive employment.
12. Calls upon federal, state, and local agencies to promote regulatory opportunities and provide technical assistance highlighting improved integration of occupational training, mental health care, primary health care, medicolegal and legal services, and other ancillary services into housing or homelessness program services. 
13. Urges federal, state, and local agencies to increase funding for academic and community-based research to develop the necessary evidence base for current interventions and evaluate the impact of new programs as they are developed, incorporating guidance from consumer priorities and the expertise of the scientific community. 

References

1. Office of the United Nations High Commissioner for Human Rights. The right to adequate housing. Available at: http://www.ohchr.org/Documents/Publications/FS21_rev_1_Housing_en.pdf. Accessed January 9, 2018. 

2. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384:1529–1540. 

3. U.S. Department of Housing and Urban Development. 2016 annual homeless assessment report to Congress, part 1: point-in-time estimates of homelessness. Available at: https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Accessed January 9, 2018. 

4. Perlman S, Willard J, Herbers JE, Cutuli JJ, Eyrich Garg KM. Youth homelessness: prevalence and mental health correlates. J Soc Social Work Res. 2014;5:361–377. 

5. Terry MJ, Bedi G, Patel N. Healthcare needs of homeless youth in the United States. J Pediatr Sci. 2010;2:1. 

6. Rice E, Winetrobe H, Rhoades H. Hollywood homeless youth point-in-time estimate project: an innovative method for enumerating unaccompanied homeless youth. Available at: http://hhyp.org/wp-content/uploads/2013/02/HHYP_Point-in-Time_Brief_5.pdf. Accessed January 9, 2018. 

7. Heerde JA, Hemphill SA, Scholes-Balog KE. ‘Fighting’ for survival: a systematic review of physically violent behavior perpetrated and experienced by homeless young people. Aggress Viol Behav. 2014;19:50–66. 

8. Petering R, Rice E, Rhoades H, Winetrobe H. The social networks of homeless youth experiencing intimate partner violence. J Interpers Viol. 2014;29:2172–2191. 

9. Milburn NG, Rice E, Rotheram-Borus MJ, et al. Adolescents exiting homelessness over two years: the risk amplification and abatement model. J Res Adolesc. 2009;19:762–785. 

10. Abramovich A, Shelton J. Where Am I Going to Go? Intersectional Approaches to Ending LGBTQ2S Youth Homelessness in Canada & the U.S. Toronto, Ontario, Canada: Canadian Observatory on Homelessness Press; 2017.

11. Crossley S. Come out come out wherever you are: a content analysis of homeless transgender youth in social service literature. McNair Scholars Online J. 2015;9:1. 

12. Keuroghlian AS, Shtasel D, Bassuk EL. Out on the street: a public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. Am J Orthopsychiatry. 2014;84:66–72. 

13. Vanderleest J. Medically uninsured and the homeless. In: Johnson N, Johnson L, eds. The Care of the Uninsured in America. New York, NY: Springer; 2009:153–160. 

14. Busen NH, Engebretson JC. Facilitating risk reduction among homeless and street-involved youth. J Am Acad Nurse Practitioners. 2008;20:567–575. 

15. National Center on Family Homelessness. America’s youngest outcasts: a report card on child homelessness. Available at: http://www.air.org/sites/default/files/downloads/report/Americas-Youngest-Outcasts-Child-Homelessness-Nov2014.pdf. Accessed January 9, 2018. 

16. Biel MG, Gilhuly DK, Wilcox NA, Jacobstein D. Family homelessness: a deepening crisis in urban communities. J Am Acad Child Adolesc Psychiatry. 2014;53:1247–1250. 

17. Cutuli JJ, Ahumada SM, Herbers JE, Lafavor TL, Masten AS, Oberg CN. Adversity and children experiencing family homelessness: implications for health. J Child Poverty. 2016;23:41–55. 

18. Priester MA, Browne T, Iachini A, Clone S, Dehart D, Seay KD. Treatment access barriers and disparities among individuals with co-occurring mental health and substance use disorders: an integrative literature review. J Subst Abuse Treat. 2016;61:47–59. 

19. Gambatese M, Marder D, Begier E, et al. Programmatic impact of 5 years of mortality surveillance of New York City homeless populations. Am J Public Health. 2013;103:S193–S198. 

20. Bharel M, Lin W-C, Zhang J, O’Connell E, Taube R, Clark RE. Health care utilization patterns of homeless individuals in Boston: preparing for Medicaid expansion under the Affordable Care Act. Am J Public Health. 2013;103:S311–S317.

21. Jones AD. Food insecurity and mental health status: a global analysis of 149 countries. Am J Prev Med. 2017;53:264–273. 

22. Ku BS, Scott KC, Kertesz SG, Pitts SR. Factors associated with use of urban emergency departments by the U.S. homeless population. Public Health Rep. 2010;125:398–405. 

23. Chambers C, Chiu S, Katic M, et al. High utilizers of emergency health services in a population-based cohort of homeless adults. Am J Public Health. 2013;103:S302–S310. 

24. Lin W-C, Bharel M, Zhang J, O’Connell E, Clark RE. Frequent emergency department visits and hospitalizations among homeless people with Medicaid: implications for Medicaid expansion. Am J Public Health. 2015;105:S716–S722. 

25. American Academy of Social Work and Social Welfare. The grand challenge of ending homelessness. Available at: http://aaswsw.org/wp-content/uploads/2015/12/WP9-with-cover.pdf. Accessed January 9, 2018. 

26. National Low Income Housing Coalition. Housing spotlight. Available at: http://nlihc.org/article/housing-spotlight-volume-6-issue-1. Accessed January 9, 2018.

27. Technical Assistance Collaborative. Priced out in 2014: the housing crisis for people with disabilities. Available at: http://www.tacinc.org/knowledge-resources/priced-out-findings/. Accessed January 9, 2018. 

28. Pearson CL, Locke G, Montgomery AE, Buron L. The applicability of Housing First models to homeless persons with serious mental illness. Available at: https://www.huduser.gov/portal/publications/hsgfirst.pdf. Accessed January 9, 2018.

29. Burt MR. Serving people with complex health needs: emerging models, with a focus on people experiencing homelessness or living in permanent supportive housing. Am J Psychiatr Rehabil. 2015;18:42–64. 

30. Key Strategies for Connecting People Experiencing Homelessness with SSI/SSDI. Washington, DC: United States Interagency Council on Homelessness; 2015. 

31. Annual Statistical Report on the Social Security Disability Insurance Program. Washington, DC: U.S. Social Security Administration; 2015.

32. Dennis D, Lassiter M, Connelly WH, Lupfer KS. Helping adults who are homeless gain disability benefits: the SSI/SSDI Outreach, Access, and Recovery (SOAR) Program. Psychiatr Serv. 2011;62:1373–1376. 

33. Kauff JF, Clary E, Lupfer KS, Fischer PJ. An evaluation of SOAR: implementation and outcomes of an effort to improve access to SSI and SSDI. Psychiatr Serv. 2016;67:1098–1102. 

34. Poremski D, Whitley R, Latimer E. Barriers to obtaining employment for people with severe mental illness experiencing homelessness. J Ment Health. 2014;23:181–185. 

35. Lei L. Employment, day labor, and shadow work among homeless assistance clients in the United States. J Poverty. 2013;17:253–272. 

36. Bauman T, Rosen J, Tars E, et al. No safe place: the criminalization of homelessness in US cities. Available at: https://www.nlchp.org/documents/No_Safe_Place. Accessed January 9, 2018. 

37. Adcock R, Butler-Dines R, Chambers D, et al. Too high a price: what criminalizing homelessness costs Colorado. Available at: http://www.law.du.edu/documents/homeless-advocacy-policy-project/2-16-16-Final-Report.pdf. Accessed January 9, 2018.

38. World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Available at: http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf. Accessed January 9, 2018. 

39. Zerger S, Pridham KF, Jeyaratnam J, et al. The role and meaning of interim housing in Housing First programs for people experiencing homelessness and mental illness. Am J Orthopsychiatry. 2014;84:431–437. 

40. Woodhall-Melnik JR, Dunn JR. A systematic review of outcomes associated with participation in Housing First programs. Housing Stud. 2015;31:287–304. 

41. Stefancic A, Henwood BF, Melton H, Shin S-M, Lawrence-Gomez R, Tsemberis S. Implementing Housing First in rural areas: Pathways Vermont. Am J Public Health. 2013;103:S206–S209. 

42. Aubry T, Cherner R, Ecker J, et al. Perceptions of private market landlords who rent to tenants of a Housing First program. Am J Community Psychol. 2015;55:292––303. 

43. U.S. Department of Housing and Urban Development. Housing choice vouchers fact sheet. Available at: https://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/programs/hcv/about/fact_sheet. Accessed January 9, 2018.

44. Center for Budget and Policy Priorities. Research shows housing vouchers reduce hardship and provide a platform for long-term gains among children. Available at: http://www.cbpp.org/sites/default/files/atoms/files/3-10-14hous.pdf. Accessed January 9, 2018.

45. U.S. Department of Housing and Urban Development. Family Options Study: 3-year impacts of housing and services interventions for homeless families. Available at: https://www.huduser.gov/portal/sites/default/files/pdf/Family-Options-Study-Full-Report.pdf. Accessed January 9, 2018.

46. Substance Abuse and Mental Health Services Administration. Permanent supportive housing evidence-based practice kit. Available at: http://store.samhsa.gov/product/Permanent-Supportive-Housing-Evidence-Based-Practices-EBP-KIT/SMA10-4510. Accessed January 9, 2018. 

47. U.S. Department of Housing and Urban Development. HUD-VASH vouchers. Available at: https://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/programs/hcv/vash. Accessed January 9, 2018. 

48. Rog DJ, Marshall T, Dougherty RH, et al. Permanent supportive housing: assessing the evidence. Psychiatr Serv. 2014;65:287–294. 

49. Buck DS, Rochon D, Davidson H, McCurdy S. Involving homeless persons in the leadership of a health care organization. Qual Health Res. 2004;14:513–525. 

50. Glasser N. Giving voice to homeless people in policy, practice, and research. Available at: http://homelesshub.ca/resource/giving-voice-homeless-people-policy-practice-and-research. Accessed January 9, 2018.

51. Center for Outcomes Research and Education. Integrating housing and health: a health-focused evaluation of the apartments at Bud Clark. Available at: https://shnny.org/images/uploads/Oregon-SH-Report.pdf. Accessed January 9, 2018.

52. Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009;301:1771–1778. 

53. Aidala AA, McAllister W, Yomogida M, Shubert V. Frequent Users Service Enhancement initiative: evaluation report. Available at: http://www.csh.org/wp-content/uploads/2014/01/FUSE-Eval-Report-Final_Linked.pdf. Accessed January 9, 2018.

54. Hannigan T, Wagner S. Developing the support in supportive housing: a guide to providing services in housing. Available at: http://www.csh.org/wp-content/uploads/2011/12/Tool_DevelopingSupport_Guide.pdf. Accessed January 9, 2018.

55. U.S. Department of Housing and Urban Development. HUD allocates $174 million through new Housing Trust Fund. Available at: https://portal.hud.gov/hudportal/HUD?src=/press/press_releases_media_advisories/2016/HUDNo_16-068. Accessed January 9, 2018.

56. United States Interagency Council on Homelessness. Opening Doors: federal strategic plan to end homelessness, as amended in 2015. Available at: https://www.usich.gov/resources/uploads/asset_library/USICH_OpeningDoors_Amendment2015_FINAL.pdf. Accessed January 9, 2018.

57. Dennis D, Ware D, Steadman HJ. Best practices for increasing access to SSI and SSDI on exit from criminal justice settings. Psychiatr Serv. 2014;65:1081–1083. 

58. Drake RE, Bond GR, Goldman HH, Hogan MF, Karakus M. Individual placement and support services boost employment for people with serious mental illnesses, but funding is lacking. Health Aff (Millwood). 2016;35:1098–1105. 

59. Chow CM, Cichocki B, Croft B. The impact of job accommodations on employment outcomes among individuals with psychiatric disabilities. Psychiatr Serv. 2014;65:1126–1132. 

60. Supportive Services for Veteran Families FY 2015 Annual Report. Washington, DC: U.S. Department of Veterans Affairs; 2015. 

61. Goodman S, Messeri P, O’Flaherty B. Homelessness prevention in New York City: on average, it works. J Housing Econ. 2016;31:14–34. 

62. Goodman S, Messeri P, O’Flaherty B. How effective homelessness prevention impacts the length of shelter spells. J Housing Econ. 2014;23:55–62. 

63. Homelessness Prevention and Rapid Re-Housing Program (HPRP): Year 3 and Final Program Summary. Washington, DC: U.S. Department of Housing and Urban Development; 2016. 

64. Culhane DP, Metraux S, Byrne T. A prevention-centered approach to homelessness assistance: a paradigm shift? Housing Policy Debate. 2011;21:295–315. 

65. Tars ES, Johnson HM, Bauman T, Foscarinis M. Can I get some remedy: criminalization of homelessness and the obligation to provide an effective remedy. Columbia Hum Rights Law Rev. 2013;45:738.

66. Parsell C, Parsell M. Homelessness as a choice. Housing Theory Soc. 2012;29:420–434. 

67. Gunn JA, Rikabi G, Huebner CG. Do you see me? Ethical considerations of the homeless. J Health Ethics. 2013;9:4. 

68. Abbarno GJM. The Ethics of Homelessness: Philosophical Perspectives. Amsterdam, the Netherlands: Rodopi; 1999.

69. LaBossiere M. Homelessness. Available at: http://blog.talkingphilosophy.com/?p=5088. Accessed January 9, 2018.

70. Clifford S, Piston S. Explaining public support for counterproductive homelessness policy: the role of disgust. Polit Behav. 2016;39:503–525. 

71. Torino GC, Sisselman-Borgia AG. Homeless microaggressions: implications for education, research, and practice. J Ethn Cult Diversity Soc Work. 2017;26:153–165.

72. Leopold J. The housing needs of rental assistance applicants. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.447.6467&rep=rep1&type=pdf. Accessed January 9, 2018.

73. Moore MK. Lists and lotteries: rationing in the housing choice voucher program. Housing Policy Debate. 2016;26:474–487. 

74. Graves E. Rooms for improvement: a qualitative metasynthesis of the housing choice voucher program. Housing Policy Debate. 2015;26:346–361. 

75. Matthews M. Government programs have become one big scammer fraud fest. Available at: http://www.forbes.com/sites/merrillmatthews/2014/01/13/government-programs-have-become-one-big-scammer-fraud-fest/#1fcae355747b. Accessed January 9, 2018.

76. U.S. Congress, House Committee on Ways and Means, Subcommittee on Social Security. Statement of Carolyn W. Colvin, deputy commissioner, Social Security Administration, January 24, 2012. Available at: https://www.ssa.gov/legislation/testimony_012412.html. Accessed January 9, 2018.

77. U.S. Congress, House Committee on Appropriations, Subcommittee on Transportation, Housing and Urban Development, and Related Agencies. Testimony of David A. Montoya, Office of Inspector General, U.S. Department of Housing and Urban Development, March 15, 2016. Available at: https://www.hudoig.gov/sites/default/files/HouseAppropsTestimony_3-15-16.pdf. Accessed January 9, 2018.