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iAUDIT! - According to media reports and some members of the Board of Supervisors, the County of Los Angeles intends to model its new homelessness agency on its existing Housing for Health (H4H) program; LAist’s April 17 edition ran a story on it. According to the article, County officials claim H4H is more successful than other programs. I’m not sure the numbers support that.
What is Housing for Health? According to its website, H4H is a medically-based approach to homelessness. It has several programs covering street outreach, clinical services, interim housing, permanent supportive housing, and other support services. Its clientele are people most in need of medical and/or mental health care, and who could benefit from a stable housing environment. You could say it’s a supercharged version of Housing First, with intensive support services linked to individual clients in supportive housing settings.
LAist noted that in 2024, 37 percent, or 407, of the 1,100 people who left shelters via H4H were permanently housed, which is eight percent more than 29 percent who transferred to permanent housing from the general shelter network. H4H’s budget is $875 million (and is not included in County Homelessness Initiative’s budget, which is only $783 million). Assuming H4H’s goal is to permanently house its clients, that works out to $2,149,880 per client housed. The article is a bit confusing about the numbers. It also says H4H placed 5,000 people (as opposed to 407) into permanent supportive housing but gives no timeline or context for that number. Placing 5,000 people would cost $175,000 per client, but only if those people were placed in a single fiscal year. Most surveys show about 60 percent of LA County’s unhoused population have untreated mental illness and/or a substance abuse problem; that comes out to 45,180 people who could benefit from Housing for Health’s medically-based programs, based on LAHSA’s estimate of 75,312 homeless people in the 2024 PIT count. At $175,000 per person, the total cost to house and serve that number of clients would be $7,906,000,000—nearly 8 billion dollars. Since the housing is permanent, those costs would be incurred each year in perpetuity.
Some of the numbers the County gave LAist are questionable or don’t indicate systemic success. The County said it served 57,000 people in 2024. I looked at H4H’s website and its most recent semi-annual report for fiscal year 2023-24 and couldn’t find anything close to that number. It could be the County added all the clients in all its H4H programs and that may come out to close to 57,000. Although each program claims it serves unique people, there is probably significant overlap since, per an independent audit ordered by the federal court, clients can receive services from multiple providers who do not communicate with each other. The LAist article also notes that only six percent of the people contacted by H4H street outreach providers were “connected” with housing. This is actually worse than the 20% + or – average for all programs cited in the court-ordered audit of City homelessness programs. Also note “connected” doesn’t mean people actually entered housing or stayed when they got there. The six percent housing rate seems to match the annual report, which on page 7 says 647, or 5.7 percent, of the 11,218 people served by County Multidisciplinary Teams (MDT’s) were placed into permanent housing.
The semi-annual report also says 92 percent of clients were still in PSH after a year, and 85 percent were still housed after two years. That may sound impressive but consider two things 1) assuming a seven percent loss each year (92-85=7), after five years, 35 percent of the program’s clients would have left their housing. 2) the dropout rate increases over time. As reported in the April 2021 edition of Medical Care, the journal of American Public Heath Association, a study of Housing First in Boston found that only 36 percent of clients remained housed after five years, and almost half died while housed. Remember, H4H provides permanent supportive housing for those who will require lifetime support; it is not a program designed to help people reenter traditional housing modes. By limiting the lookback to two years, the County ignores the fact that housing rates nosedive after five years. H4H has been operating since 2012, so program managers could produce long-term housing data if they desired.
The County’s plan to use Housing for Health as a model raises serious questions about what the County and City may define as “reform”. If you scroll to the semi-annual report’s Appendix for capital projects, you’ll see many of the same players that are key providers in current programs: HOPICS, The People Concern, and LA Family Housing. These are the large corporate nonprofit organizations who have seen their bank accounts balloon over the past few years. There is very little likelihood they will support any proposal that threatens their cash flows. Compounding these concerns, Mayor Bass, who still opposes reforming LAHSA despite nearly 20 years of negative audits, has stated her desire to rehire anyone laid off from LAHSA as a result of defunding. Rehiring the people who managed years of failed programs is hardly a positive move.
In reality, Housing for Health isn’t a great success; it may just be less of a failure than other programs. In any case, it would be absurdly expensive to apply it to the majority of the unhoused population. If 60 percent of the unhoused population would benefit from it, then 40 percent could be served using much less expensive alternatives, but at nearly $8 billion, H4H would already equal two to four times the current total City/County expense for all homelessness programs. Housing for Health is just another program that may or may not have marginal success for a certain population among the unhoused. But its not a matter of improving one or two programs. LA’s failures are systemic and structural. They require fundamental restructuring.
(Tim Campbell is a resident of Westchester who spent a career in the public service and managed a municipal performance audit program. He focuses on outcomes instead of process in his iAUDIT! column for CityWatchLA.)
