The "housing first" narrative — that homelessness is purely an economic problem solvable by providing more housing — is well-intentioned but dangerously oversimplified. It conflates two distinct populations: people who are temporarily homeless due to economic hardship and the chronically homeless, who face far more complex challenges.

The chronically homeless — those living on the streets for extended periods — are disproportionately affected by severe mental illness and substance abuse. A 2023 report from the Substance Abuse and Mental Health Services Administration (SAMHSA) found that approximately 30% of the chronically homeless have severe mental illness and 50% have substance use disorders, with significant overlap between the two. A study from the University of California, San Francisco in 2023 found that 28% of unsheltered homeless individuals in California reported methamphetamine use and 18% reported fentanyl use in the prior six months.

If homelessness were purely a housing affordability problem, we would expect it to correlate primarily with housing costs. But the data tells a different story. Cities like Houston, with lower housing costs, have had more success reducing homelessness than San Francisco, which has spent over $1 billion annually on homeless services — roughly $100,000 per homeless person — with the problem continuing to grow. Between 2017 and 2022, San Francisco's homeless population remained roughly stable despite massive spending increases.

Housing-first programs, which provide housing without requiring sobriety or treatment, have shown mixed results. A landmark study in the Canadian Medical Association Journal found that while Housing First improved housing stability, it did not significantly improve substance abuse outcomes, mental health, or quality of life compared to treatment-as-usual. Residents were housed but their underlying conditions persisted.

The deinstitutionalization movement, which emptied state psychiatric hospitals beginning in the 1960s, is a critical and often ignored part of this story. State psychiatric hospital populations dropped from 559,000 in 1955 to fewer than 38,000 by 2014, according to the Treatment Advocacy Center. The promised community mental health centers were never adequately funded. Many of the severely mentally ill ended up on the streets.

A comprehensive approach to homelessness must include affordable housing — but also robust mental health treatment, addiction services, and in some cases, supported living environments that provide ongoing care. Pretending that housing alone will solve a multifaceted crisis ensures that the most vulnerable people remain trapped in cycles of suffering.