Last March, homeless shelter providers in Massachusetts found themselves confronted by a dilemma. Recommendations from the Governor and state public health officials that called for the implementation of social distancing protocols were impossible to execute in shelter settings. Facing consistently overcrowded facilities, shelter providers recognized that they faced an impossible choice: should they deny shelter to individuals in need, subjecting them to the risks associated with cold weather exposure, or continue to allow them into shelters where they would be susceptible to COVID-19, a quickly spreading and often deadly virus?

Fortunately, they discovered another option, and through Herculean efforts, depopulated their shelters by securing alternative spaces that allowed for social distancing and protected those who are among the most vulnerable to this highly contagious disease. The consensus among shelter providers was never again -- They cannot go back to the way things were.

With the rapid rate of transmission of COVID-19 within shelters, a harsh reality became clear -- by their very nature, traditional shelter sites could not meet the needs of the aging and often ailing population.

But the need for social distancing represents only one part of a larger problem of sheltering people experiencing homelessness with complex medical conditions. The COVID-19 pandemic also laid bare the failure of Massachusetts, as well as states across the country, to address the unique needs of people with complex medical histories experiencing homelessness. While the Commonwealth’s default approach to homelessness for the last forty years has been emergency shelter, the pandemic quickly revealed that congregate shelters are not the answer. The truth is that the emergency system has become the de facto housing option for some of the Commonwealth’s poorest and most disabled residents. However, this band-aid approach has proven time and again to be ineffective and expensive.

The evidence is clear. Housing providers report that permanent supportive housing produces significantly better results for both individuals experiencing homelessness and our health care system overall. But where to begin? For the last fifteen years, the Massachusetts Housing & Shelter Alliance (MHSA) has advocated for “Housing First,” an approach that reflects a real paradigm shift in how the Commonwealth addresses homelessness.

At MHSA, we view homelessness primarily as a housing issue. Once safe housing is secured, the “Housing First” model takes a comprehensive, tenant-focused approach, addressing health and wellness through a wide array of coordinated services. This model program emphasizes the establishment of successful tenancies rather than the cultivation of compliant “clients.” The “Housing First” initiative offers immediate housing followed by the delivery of a wide range of supportive services, such as mental health and substance use disorder counseling, all designed to engage clients in their own health care. These housing strategies have proven markedly better than traditional approaches to sheltering that leave individuals homeless for years.

MHSA administers two statewide initiatives under the “Housing First” umbrella: the “Home and Healthy for Good” (HHG) program, which has served more than 1,200 formerly chronically homeless individuals since 2006, and the “Social Innovation Financing Pay for Success” (PFS) program, which has served over 1,000 formerly chronically homeless individuals since 2015.

This past December, the Blue Cross Blue Shield of Massachusetts Foundation released results from a sponsored study, “The Preventive Effect of Housing First on Health Care Utilization and Costs Among Chronically Homeless Individuals.” This study combined MHSA and MassHealth administrative claims data, comparing MassHealth expenditures and healthcare utilization of members with a history of chronic homelessness before and after the provision of “Housing First” services (the “intervention” cohort) with expenditures and healthcare utilization for a matched group of members who are chronically homeless but have not received “Housing First” services.

This study clearly underscores the major differences both in cost and utilization between those who participated in a “Housing First” intervention compared to those who had not. The Blue Cross Blue Shield of Massachusetts Foundation noted, “[t]he study suggests that the preventive effect of permanent supportive housing may lead to a reduction in overall health care utilization and costs.” In addition, the study found that:

• Individuals enrolled in permanent supportive housing programs had significantly lower total per-person per-year health care costs, on average, than a similar group of chronically homeless individuals ($25,614 vs. $30,881, on average).

• Individuals enrolled in permanent supportive housing programs received significantly more mental health services than a similar group of chronically homeless individuals. However, the cost of the higher average utilization of mental health services among those enrolled in permanent supportive housing was more than offset by their lower utilization of inpatient and emergency department services relative to a similar group of chronically homeless individuals.

The study confirms what MHSA has long suspected: when linked with essential services, the provision of permanent housing results in better utilization of less costly outpatient medical care and a greater use of much-needed behavioral health services. Yet despite evidence that “Housing First” provides a proven alternative to the failed system of emergency shelter, the Commonwealth has not invested in the housing necessary to end homelessness. In fact, the Governor recently cut $1 million earmarked for the “Home & Healthy for Good” program highlighted in the Blue Cross Blue Shield of Massachusetts Foundation study that was originally included by the Legislature as a part of the Fiscal Year 2021 budget.

This drastic cut means that well over 100 new units of permanent supportive housing will not be added to the program over the course of the next two years. And worse, there will be no alternative for those who would have benefitted from the 100 new units —other than the streets or the inadequate system of shelters that has already shown itself incapable of meeting the long-term needs of this vulnerable population.

If the Governor’s cuts are restored, and the Commonwealth at long last prioritizes the most vulnerable among us, we will never again be forced to choose between health and housing for those facing the greatest risk -- an impossible choice we should never be forced to make.

About the Author:

Joe Finn is President & Executive Director, Massachusetts Housing & Shelter Alliance (MHSA). Joe has worked on homelessness issues for more than 30 years, serving as executive director of Shelter, Inc. (now Heading Home) in Cambridge and Quincy Interfaith Sheltering Coalition (now Father Bill’s & MainSpring) prior to joining MHSA in 2003. He concentrates on the expansion of permanent supportive housing opportunities for individuals, including people experiencing chronic homelessness -- the most expensive and disabled segment of the homeless population.

Joe is a 1978 graduate of Siena College. He earned a Master of Arts degree in Theology from the Washington Theological Union, a Master of Arts degree in Sociology from the New School for Social Research, a Juris Doctor from the New England School of Law, and an Honorary Doctor of Humanities from Bentley College. Joe also served as a City Councilor for the City of Quincy.