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National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Policy and Global Affairs; Science and Technology for Sustainability Program; Committee on an Evaluation of Permanent Supportive Housing Programs for Homeless Individuals. Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness. Washington (DC): National Academies Press (US); 2018 Jul 11.

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Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness.

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Appendix BThe History of Homelessness in the United States


When first used in the United States in the 1870s, the term “homelessness” was meant to describe itinerant “tramps” traversing the country in search of work. The primary emphasis at this time was on the loss of character and a perceived emerging moral crisis that threatened long-held ideas of home life, rather than on the lack of a permanent home. One religious group described the problem as “a crisis of men let loose from all the habits of domestic life, wandering without aim or home” (DePastino, 2003, p. 25). The solution to homelessness today is often perceived to be the creation or availability of affordable housing, but during the early 20th century, jobs (rather than housing) were viewed as the solution to the plight of transients wandering the country.

Fewer than 7 percent of Americans lived in cities prior to the 1820s (Kim and Margo, 2003). Growing industrialization in the 19th century brought a steady migration to urban centers such as Boston, New York, and Philadelphia, and vagrancy records suggest a rise in the numbers of those in search of work in these cities. The Industrial Revolution ushered in a shift from the individual living and surviving on farms or working in skilled trades to the wage-earning worker dependent upon wealthy employers. By the 1850s, lodging rooms for vagrants located in police stations served as the major shelter system, and most major cities reported increasing numbers of vagabonds (Kusmer, 2002).

After declining briefly after the Civil War, homelessness first became a national issue in the 1870s. Facilitated by the construction of the national railroad system, urbanization, industrialization, and mobility led to the emergence of tramps “riding the rails” in search of jobs. Jacob Riis, the Danish-born social reformer and muckraker whose later photojournalism depicted the deplorable lives of those in slums and tenements, arrived in America in 1870 at the age of 21 and described his subsequent 3 years as a member of “the great army of tramps” seeking work across the country. This “army” of overwhelmingly young, able-bodied, white men created a culture that blended the search for work with a love of the open road and a disdain for the constraints of workers in industrialized America (DePastino, 2003). Willing to embrace hard work, they constituted a counterculture with rules and habits that often engendered the wrath of mainstream society. Francis Wayland, the dean of Yale Law School, wrote in 1877, “As we utter the word tramp there arises straightway before us the spectacle of a lazy, shiftless, sauntering or swaggering, ill-conditioned, irreclaimable, incorrigible, cowardly, utterly depraved savage” (Wayland, 1877, p. 10).

The word “hobo” first appeared in the 1880s in western America and softened the public's perceptions of tramps. This culture of migrant laborers was often romanticized in American literature, including by writers such as Walt Whitman, Bret Harte, and Sinclair Lewis. Jack London wrote vivid depictions of the “call of the road” as an escape from the oppression and monotony of factory work (Etulain, 1979). The storied hobo culture, popularized in the 1920s as “hobohemia” by Chicago sociologist and former tramp Nels Anderson (Anderson, 1923), faded as companies began to value loyalty and longevity and as seasonal jobs began to be taken by immigrant farm workers.

World War II emerged as an economic engine that put the nation to work. Over the ensuing three decades, the typical individual experiencing homelessness continued to be disproportionately white and male but became increasingly older (usually over 50 years old), disabled, dependent on welfare or social security, and resided in cheap hotels, flophouses, and in single room occupancy hotels (SROs) located in the poorest neighborhoods and Skid Row areas of urban America (Rossi, 1989). Ironically, these people living in SROs and rooming houses during this period would be considered “housed” under HUD's current definition of homelessness. This observation underscores the difficulty in defining and studying homelessness throughout U.S. history.


The early 1980s marked the emergence of what now may be considered the modern era of homelessness. Major forces that changed the complexion of homelessness in the modern era include gentrification of the inner city, deinstitutionalization of the mentally ill, high unemployment rate, the emergence of HIV/AIDS, an inadequate supply of affordable housing options, and deep budget cuts to the U.S. Department of Housing and Urban Development (HUD) and social service agencies in response to what was then the country's worst recession since the Great Depression (Jones, 2015). In some cities, property values increased dramatically in the areas near downtown, and Skid Row areas disappeared as the SROs and rooming houses that were home to thousands of transients were razed or converted into apartments and condominiums. Since the 1980s, rents in metro areas across the country have been increasing while wages have stagnated (Katz, 2006). Recent research indicates that families experiencing homelessness are more likely to continue to face poverty and homelessness in the future (Desmond, 2016).

Deinstitutionalization of the mentally ill has roots in the civil rights and civil liberties movements of the 1960s, which envisioned more fulfilling lives for those who had been languishing in understaffed psychiatric hospitals through new medications and robust community-based services. The number of patients living in state hospitals dropped from 535,000 in 1960 to 137,000 in 1980. California saw a dramatic reduction in state hospital beds from 37,000 in 1955 to 2,500 in 1983 (Flynn, 1985). Funding for the needed housing and community-based services proved inadequate, and, as cheap housing disappeared, vast numbers of previously institutionalized individuals with severe and persistent mental illness or those who might have gone to institutions in earlier eras drifted onto the streets and into temporary shelters.

The recession of the 1980s resulted in deep cuts to the HUD budget, which decreased from approximately $29 billion in 1976 to approximately $17 billion in 1990, and led directly to reductions in the budget authority for housing assistance (from almost $19 billion in 1976 to about $11 billion in 1990) and in subsidized housing for poor Americans (OMB, 2001). Two changes in policy particularly contributed to the rise in homelessness during that period. First, cuts in Supplemental Security Income (SSI) in the late 1980s, accompanied by a tightening of the disability eligibility process (Social Security Act of 1980), adversely affected mentally ill persons living in rooming houses. The subsequent loss of personal income contributed to homelessness for many of these individuals (Collin and Barry, 1987). The Social Security Disability Benefits Reform Act of 1984 was later enacted to pull back on some of the aspects of the 1980 Social Security Act, which impeded the efforts of some individuals experiencing illness and homelessness to pursue benefits. Second, public inebriation was decriminalized in many cities, and those once jailed for public drunkenness now avoided arrest and often entered shelters or remained on the streets (McCarty et al., 1991).

Homelessness and the HIV/AIDS Epidemic

Another major factor that increased the numbers of individuals experiencing homelessness during the 1980s was the HIV/AIDS epidemic. Culhane and colleagues (2001) presented data from the city of Philadelphia indicating that the two conditions, AIDS and homelessness, “frequently co-occur” (Culhane et al., 2001, p. 515). Those shelter users who were male, substance abusers, and diagnosed with a serious mental illness often had a co-occurring AIDS diagnosis due to risky behaviors such as sharing needles for intravenous (IV) drug use (Culhane et al., 2001). The authors also noted that Philadelphia shelter utilizers had nine times the risk of having AIDS compared to the general population.

Lebow et al. (1995) noted from their retrospective cohort study comparing housed individuals with AIDS and individuals experiencing homelessness with AIDS in Boston that the unhoused men with AIDS were more likely to be African American or Latino and be IV drug users when compared to the housed men. The authors noted that IV drug use was a common risk behavior for the homeless men when compared to the housed men. Further, “given the increasing number of AIDS cases among IV drug users and people of color in general,” it was observed that intravenous drug use may be at least partly responsible for the higher number of AIDS cases in the population of individuals experiencing homelessness (Lebow et al., 1995, p. 295).

In response to the co-occurrence of AIDS and homelessness, the Office of HIV/AIDS Housing in HUD was created in 1990 to manage the Housing Opportunities for Persons With AIDS (HOPWA) program under the Cranston-Gonzalez National Affordable Housing Act (P.L. 101-625). The program was created due to inadequate housing resources for low-income people living with AIDS, who also faced difficulty obtaining supportive services and experienced discrimination (GAO, 1997). HOPWA funds are provided to eligible states and cities based on a formula; there is also a small competitive grant program.

The confluence of these and other events changed the face of homelessness yet again. The typical homeless person of the 1980s was younger (less than 40 years old), more impoverished, and had a higher burden of co-occurring medical, mental health, and substance use disorders than previous generations of persons experiencing homelessness. For the first time, women and families appeared in significant numbers (Rossi, 1990). Shelters that had long served poor and older alcoholic men withstood a new and eclectic wave of impoverished men and women displaced from their homes, many of them struggling with undue burdens of co-occurring medical, psychiatric, and substance use disorders. Many others were simply living in poverty. Sociologists referred to this generation as experiencing “literal homelessness” with no access to conventional dwellings, such as houses, apartments, mobile homes, rooming houses, or SROs (Jones, 2015).

Different Types of Homelessness

The amount of time that individuals who experience homelessness are without stable housing varies considerably, from short to more extended periods. Kuhn and Culhane (1998) categorized homelessness with a temporal topography when examining the utilization patterns of single adults in public shelters in New York City (NYC) and Philadelphia during the 1990s. They identified three groups of individuals experiencing periods of homelessness: (1) transient, 80 percent of those using the shelter who had a single brief stay; (2) episodic, 10 percent of shelter users who had repeated but brief shelter stays; and (3) chronic, 10 percent of users who essentially spent each night in the shelter. Related studies in NYC (Culhane and Kuhn, 1998) found that the small group of chronically homeless adults comprised 18 percent of shelter use, staying for more than 180 days in their first year in the shelter system and accounting for 53 percent of the total shelter days used by single adults. Philadelphia data indicated that 10 percent of single adults staying in shelters accounted for almost 35 percent of the total shelter days. The identification of specific subgroups of individuals experiencing chronic homelessness shaped later federal policy.

Using administrative data regarding shelter utilization from NYC, Philadelphia, Columbus, Ohio, and the state of Massachusetts, Culhane et al., (2007) developed a typology of families experiencing homelessness. Families who are episodic shelter users were more likely than others to exhibit a behavioral health or social service history. The authors note that the number of families who are episodic shelter users is relatively small. Long-term shelter users among families experiencing homelessness, in contrast to single adult shelter users, were not more likely to have high service needs or barriers to housing stability. The authors argued that a simple policy solution to help families experiencing homeless would be to provide emergency or transitional rental subsidies.


Early Responses

Until the late 19th century, the problem of homelessness was in the hands of local and state authorities (Bostic et al., 2012). Urban slums in many cities, plagued with overcrowding, poor hygiene, and rudimentary sanitation, became a frequent source of outbreaks of major infectious diseases (Neiderud, 2015; Eisenstein, 2016). To address the growing problem of urban slums, in 1892 Congress allocated $20,000 to the Department of Labor (DOL) to investigate urban slums in cities with at least 200,000 residents (Congressional Research Service, 2004). In 1908, President Theodore Roosevelt formed a formal housing commission to continue these investigations, but these efforts were halted with the stock market crash of 1929.

Consequent to the Great Depression of the 1930s, there was a significant increase in the number of persons experiencing homelessness in America and a greater need to address poverty and to improve the quality and affordability of housing. In response, a number of federal policies and pieces of legislation were enacted to improve the overall quantity and affordability of housing. For example, the Emergency Relief and Construction Act of 1932 authorized the Reconstruction Finance Corporation to lend public funds to corporations to build housing for low-income families (Congressional Research Service, 2004).

Another relevant federal legislative act from this era included the National Industrial Recovery Act of 1933, which allowed the Public Works Administration (a government-sponsored work program) to use federal funds for slum clearance, the construction of low-cost housing, and subsistence homesteads; close to 40,000 housing units were produced that year.

Post-World War II Legislation

Decades of economic distress, followed by 5 years of World War II mobilization, resulted in severe housing shortages and led the federal government to lay the cornerstones for today's affordable housing system. For example, in response to the severe housing shortage after the war, Congress passed the Housing Act of 1949. Its goal was to offer “a decent home and a suitable living environment for every American family” (HUD, nd, p. 3). Unfortunately, the urban renewal programs it authorized often destroyed more housing than was created (Lipsitz, 2008). Its use of public housing to serve the displaced households, who were generally minorities, and creation of a Federal Housing Administration (FHA) mortgage program to finance suburban housing available only to whites helped to entrench poverty and segregation in America's cities, particularly for people of color. The Housing Act of 1954 continued and broadened slum clearance and urban redevelopment in inner cities. It was not until the Housing Act of 1956 (P.L. 84-1020) that relocation payments were authorized to those individuals and families who were displaced by the process of urban renewal (HUD, 2014).

The Housing and Urban Renewal Act of 1965 (P.L. 89-117) was enacted as a rent supplement for low-income, disabled, and elderly individuals. Legislation in 1965 also formally created the Department of Housing and Urban Development. Finally, Title VIII of the Civil Rights Act of 1968, the Fair Housing Act, established fair housing provisions to prohibit discrimination in access to housing. This act covers discrimination based on disability status or family status. Discrimination based on age was added in 1995 through the Housing for Older Persons Act. Enforcement of Title VIII is vested with HUD's Office of the Assistant Secretary for Fair Housing and Equal Opportunity (HUD, 2007b). The HUD Rule on Affirmatively Furthering Fair Housing, authorized in 1968, was not published until 2016. Perhaps not surprising insofar as it took 50 years to issue the rule, enforcement of its provisions has been lackluster and inconsistent.

The Housing and Community Development Act of 1974 (P.L. 97-35) merged several urban development programs into the broader Community Development Block Grant (CDBG) program. This legislation also created the Housing Choice Voucher program, also known as the Section 8 program, to provide low-income housing through rental subsidies paid to the private sector. The “tenant-based” form of these rent subsidies, whereby families with a voucher choose and lease safe, decent, and affordable privately owned rental housing, is the mainstay of today's federal housing assistance programs for homeless and low-income individuals and families. The program serves more than 2.1 million households (Congressional Budget Office, 2015).

The first federal legislation enacted to explicitly address homelessness was the 1977 Stewart B. McKinney Homeless Assistance Act (PL 100-77). In addition to defining homelessness (see Box B-1), which is important for allocating federal resources, it also made provisions for using federal money to support shelters for persons experiencing homelessness. The McKinney Act also created a targeted Health Care for the Homeless (HCH) primary care funding stream, with a distinct broad definition of homelessness, which now exists within the Federally Qualified Health Center (FQHC) program.

Box Icon


Definition of Homeless Person, according to Public Law 111-22, the Stewart B. McKinney Homeless Assistance Act, as amended by The Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009.

The 1997 Stewart B. McKinney Act also authorized the creation of the U.S. Interagency Council on Homelessness (USICH). USICH is an independent executive branch body established to better coordinate homelessness programs across government agencies. The USICH includes representative membership from all major federal agencies whose mission touches upon homelessness, including, among others, HHS, HUD, the Department of Veterans Affairs (VA), and the Federal Emergency Management Agency (FEMA).1 The council is charged with assessing the effectiveness of federal activities and programs for people experiencing homelessness, and to apprise state and local governments, public agencies, and private organizations about the availability of relevant federal programs and funding opportunities (USICH, 2016).

In 2002, the USICH spearheaded the Chronic Homelessness Initiative, asking states and local jurisdictions to create 10-year plans to end chronic homelessness. Another change in federal policy occurred in 2003, bringing a focus on “ending chronic homelessness” through low-threshold and permanent supportive housing programs (HUD, 2007a). At that time, through a collaborative process overseen by the USICH, the federal government formally defined chronic homelessness as “an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more or has had at least four episodes of homelessness in the past three years” (HUD, 2007a, p. 3).

The next reauthorization of the McKinney-Vento Act, called the HEARTH Act, was signed into law in 2009. The reauthorization consolidated several existing programs for individuals experiencing homelessness, created a federal goal that individuals and families experiencing homelessness be permanently housed within 30 days, and codified the planning processes used by communities to organize into Continuums of Care in order to apply for homeless assistance funding through HUD.2 New definitions of “homeless,” “homeless person,” and “homeless individual” were expanded. These changes were based on Congress identifying (1) a lack of affordable housing and limited housing assistance programs, and (2) an assertion that homelessness is an issue that affects every community.

In 2010, under President Obama's administration, a federal strategic plan to end homelessness was released (USICH, 2017). The federal strategic plan established four key goals: (1) Prevent and end homelessness among Veterans in 5 years; (2) Finish the job of ending chronic homelessness in 7 years; (3) Prevent and end homelessness for families, youth, and children in 10 years; and (4) Set a path to ending all types of homelessness.


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The USICH was not reauthorized from 1994-2000, was reinstated in 2001, and received a 1-year extension of its current authorization, until October 1, 2018.

Copyright 2018 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK519584


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