Homelessness continues to get worse. Should Seattle, and the U.S., still embrace 'Housing First'?

Over three decades, Housing First grew from a fringe practice in cities like Seattle to the U.S. government’s guiding philosophy for responding to homelessness — one that focuses on moving people directly off the streets into their own apartments as quickly as possible, without requiring mental health or substance use treatment.

"The Housing First Approach: A Documentary" covers the homelessness crisis and the Housing First model. Listen to the full, in-depth story by Will James below, on the KUOW app, or your favorite podcast app.

But, as President-elect Donald Trump prepares to take office, all that could be about to change. Trump’s second term stands to culminate a fight over the future of Housing First, a debate that’s brewed for years, threatening to upend how the federal government tackles one of the nation’s most high-profile and persistent problems.

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U.S. Sen. JD Vance, the incoming vice president, has questioned Housing First’s emphasis on moving people off the streets without requiring treatment, saying it doesn’t address “the root causes of homelessness.”

Over the past several years, conservative activists and influencers have rallied Republicans to question decades of research supporting Housing First’s effectiveness, eroding bipartisan support and building a case for a return to Treatment First practices.

Project 2025, the conservative Heritage Foundation’s blueprint for Trump’s second term, calls on the U.S. Department of Housing and Urban Development to “end Housing First policies so that the department prioritizes mental health and substance abuse issues before jumping to permanent interventions in homelessness.”

A new KUOW audio documentary uses Seattle as a lens for understanding this backlash, drawing on Seattle’s history as home to some of the earliest and most enthusiastic adopters of Housing First — and, now, to some of its most passionate critics.

We Heart Seattle

For opponents of Housing First, Seattle serves up potent examples of the philosophy’s shortfalls.

Among them: the persistence of homelessness in King County, where volunteers counted a record 16,000 people living in shelters and on the streets on one night in 2024, despite decades of local interventions built around Housing First.

There are also reports of problems inside buildings where Housing First is practiced, where some tenants continue to struggle with mental health crises, substance use, and adapting to life indoors.

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“It's practical, boots on the ground evidence that has told me that by housing somebody without treatment or psychiatric care first is a recipe for disaster,” said Andrea Suarez, who founded the Seattle nonprofit We Heart Seattle in 2020.

Suarez, along with her staff and stable of volunteers, applies a Treatment First approach to helping people get off Seattle’s streets. The nonprofit’s outreach efforts focus on meeting people in encampments, building relationships with them, and then transporting them to substance use treatment centers.

“I've talked to eight different people today going through different steps of recovery,” Tim Emerson, who leads outreach efforts for We Heart Seattle, told KUOW one day last year.

Emerson said his support for Treatment First stems from his own experiences with homelessness and methamphetamine addiction.

“Ten years straight I didn't have an address,” Emerson said. “I lived like boat to boat, job to job, couch surfed. Sometimes just sleeping in the woods under a tree. My life has been saved for finding my purpose. And my purpose is helping our community.”

We Heart Seattle’s work has put staff in contact with tenants like Michelle Huckaby-Vierk, who moved out of homelessness into housing only to discover some of the same dangers awaited them indoors.

Huckaby-Vierk said that, about two years ago, a wave of overdose deaths swept through her building, where about about 60% of the units are permanent supportive housing, a form of Housing First. Overdoses claimed about six of her neighbors, Huckaby-Vierk said. Afterward, she felt so unsafe she began to hoard and build barricades in her apartment.

"There was people dying around you, so you hoard things, you make walls," Huckaby-Vierk said. "... I never in my life lived like that. I mean, they died in their apartments. I felt like no one was safe, not even me. I just kind of basically left and I camped out across the street. I was really scared."

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For Emerson, of We Heart Seattle, anecdotes like this have deepened his belief that Housing First is hiding people's problems behind four walls without doing enough to address them.

“What we're finding are people are overdosing and dying, people are being kicked back out and banned because they're not thinking right,” he said.

Origins of Housing First

When Housing First emerged in the 1990s, it was a radical approach to a stubborn problem.

Back then, the default approach was Treatment First, which insisted that people living on the streets needed to prove their readiness for housing by reaching certain milestones, including treatment and sobriety.

The problem was, Treatment First always left a subpopulation stranded on the streets: those who would not or could not live under these rules. They often had serious mental illnesses and substance use problems. In many cases, they had been offered help so many times, unsuccessfully, that they had stopped engaging altogether.

This is the population Housing First was invented to help. In the 1990s, Sam Tsemberis, a psychologist working for an organization called Pathways to Housing in New York City, started to experiment with ideas that would later be dubbed Housing First.

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“You can't imagine the level of anxiety,” Tsemberis told KUOW.

In Seattle, a nonprofit called the Downtown Emergency Service Center also started dabbling in this approach around the same time.

“We were thinking we should expect all kinds of chaos,” said Daniel Malone, who runs DESC today and oversaw these early experiments in the 1990s. “And that might mean somebody starts knocking holes in the walls, we're going to have to be prepared to fix the holes and not kick the person out of housing.”

But chaos did not ensue. In fact, Tsemberis’ data showed that, in nearly 90% of cases, when someone got an apartment through his program, they remained still housed five years later. Under Treatment First, his data showed, more than half of people ended up back on the streets.

“I thought, ‘We have just figured out how to house everybody in the United States,’” Tsemberis said.

Years of academic studies confirmed these results. First George W. Bush’s administration embraced Housing First, then Barack Obama’s. At one point, the Obama administration felt it was possible to end chronic homelessness altogether, in large part by expanding Housing First practices.

Federal grants incentivized agencies to adopt Housing First, helping scatter nearly 400,000 permanent supportive housing units across the U.S. In 2021, two thirds of the federal government's competitive homelessness grants went to these projects — more than $1. 75 billion.

In King County today, there are more permanent supportive housing units than emergency shelter and transitional housing combined.

An episode from Seattle’s history was key to overcoming lingering doubts about Housing First, adding fuel to its spread across the U.S.

In 2005, DESC opened 1811 Eastlake, a permanent supportive housing building for people who had lived on Seattle’s streets for years with severe alcoholism. The project generated a surge of backlash among people shocked that residents would be allowed to drink in their rooms and wouldn’t be required to undergo treatment. For these reasons, the project remains, arguably, the most famous and controversial example of Housing First in U.S. history.

But a 2009 study showed it was cheaper to house the tenants than to allow them to continue cycling among emergency rooms, sobering centers, and jails. And, once inside, residents curbed their drinking slightly. Even without any requirements around treatment or sobriety, they went from consuming an average of 16 drinks a day to 11.

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“To this day, I think probably there's not a single supportive housing program in the country that is better known than that specific project,” said Malone, of DESC. “And it helped build some of the momentum for Housing First becoming a priority compared to the old way that said people really needed to improve before they had the chance to move.”

The 1811 Eastlake project demonstrated how Housing First’s supporters and opponents have radically different visions of success.

While critics of Housing First say the goals of housing programs should be sobriety, employment, and self-sufficiency, Housing First practitioners argue that isn’t realistic for much of the population they’re serving. On average, the earliest 1811 Eastlake tenants had tried abstinence-based treatment 16 times without success.

“We're talking about men and women that have been living on the streets of downtown Seattle for 15, 20 years and have gone into conventional treatment multiple times and have not succeeded with it,” Bill Hobson, who led DESC in 2005, told KUOW at the time.

Hobson, who died in 2016, promoted a more modest vision of recovery.

“We believe that once you eliminate the chaos of homelessness from somebody's life, they can more effectively and meaningfully go through the stages of change that they need to go through in order to become a bit more clinically stable and much more socially stable,” he said.

What Housing First looks like in Seattle

Across 30 years, Kenny Taylor has lived all that is good and bad about Housing First.

Taylor was one of the first residents to move into DESC’s first residential building, the Union Hotel, in the 1990s. Now in his 60s, he remains there today, in a one-bedroom apartment he shares with his rescued cat, Treasure.

"I was homeless for about five years before I moved in here," Taylor said. "And it was rough. I slept in doorways, I slept on the street, I slept in tents ... at the missions, and stuff like that. It's not fun. Being homeless is not fun at all."

Like everyone here, he pays 30% of his income in rent. For Taylor, that’s about $400 a month, which comes from Social Security payments.

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The hard-to-bear realities of Housing First, for Taylor, include living alongside neighbors who continue to use substances and go through mental health crises. A next-door neighbor, he said, bangs on his wall in the early morning and has knocked holes in it. He said he keeps his distance from neighbors because he feels many of them want money from him.

But, despite opportunities to move, Taylor has chosen to keep living at the Union Hotel anyway.

"This is my home," he said. "I'm going to keep my home as long as I pay my rent. I just feel happy here. You know, I wouldn't trade it for nothing in the world."

One thing proponents and critics agree on is that execution matters and, in some cases, Housing First could be better.

Tsemberis, who created the Housing First philosophy, worries that, as the federal government hyped the model for years, some important tenets got lost. He said, in particular, he’s concerned some organizations don’t pay enough attention to delivering services for mental health and substance use. Even though Housing First doesn’t require treatment, it does call on practitioners to artfully move tenants in that direction.

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“Everybody wants to be Housing First because it's popular, you get funded,” Tsemberis said.

He said some organizations seem to want to “take a little Housing First powder and sprinkle it on everything” so that it “looks a little bit like Housing First” even if they’re not adhering to the model. (Tsemberis praised DESC and said it wasn’t among the organizations he was criticizing).

But those who practice and study Housing First also acknowledge some built-in limitations — realities critics have latched onto as evidence of failure.

Housing First, for instance, can both work at moving individual people off the streets while, at the same time, not budging overall homelessness numbers, said Stefan Kertesz, who studies addiction medicine at the University of Alabama at Birmingham.

Kertesz has published academic papers weighing the assets and limitations of Housing First. He said Housing First acts at the individual level and has nothing to do with broader economic forces that continue driving new people into homelessness.

“I can house five people and keep most of them stable, but I can't stop the fact that the rent is too high in my community,” Kertesz said.

Even in well-run Housing First programs, mental health crises, relapses, and overdoses continue to happen, said Malone, of DESC. He added that is the reality of a model designed to take in people with the most serious and complex problems.

“There is no magic treatment car wash that we can round people up and shove them through and have them come out clean and shiny on the other end,” Malone said. “What I'm here to tell you is that there are people in our community who have already experienced virtually every imaginable consequence of how bad it can get, short of death, and yet continue to engage in behavior, to use substances.”

Despite the messiness of life at the Union Hotel, Taylor said this is where he got sober from drugs about 10 years ago and from alcohol about two years ago.

"I was determined that the drugs or the alcohol wasn't gonna destroy me. I come this far, might as well go all the way. That's how I felt about it."

He said it wasn’t any sort of pressure that got him there — just recovery progressing on its own slow, uneven schedule.