July 22, 2022. Health Affairs Forefronts. By Tamar Chukrun Julian Xie Donna Biederman Trisha Dalapati

Lorraine’s homelessness began in 2017 when she was evicted from her public housing apartment for drug use. In addition to chronic housing insecurity and substance use disorder (SUD), Lorraine was living with type 2 diabetes and high blood pressure. With her fixed income, she couldn’t find another affordable place to live and ultimately landed at the nearby homeless shelter.

Lorraine’s first priority became finding a home. She spent her days meeting with the shelter’s case managers, doing odd jobs to save up for rental application fees, and visiting places available for rent. With her primary focus on stabilizing her acute lack of housing, she had to push her own health and health care to a lower priority, despite chronic conditions in need of regular attention. The substantial stress of housing instability combined with missed health care appointments resulted in dramatic increases in her blood sugar and blood pressure. As more basic needs took precedent, medication-assisted treatment for her opiate use disorder would have to wait too.

While the shelter offered a place to sleep, shelter residents were required to leave from 6 a.m. to 2 p.m. to allow time for cleaning. Every day, this rule forced Lorraine back outside, away from her medications and the few belongings she could store under her single bunk bed. Without a safe place to be, she continued to struggle with her substance use disorder.

In five subsequent years searching for stable housing, she faced numerous systemic roadblocks erected by Congress and the Department of Housing and Urban Development (HUD), the very federal entities meant to aid her. Lorraine’s story illustrates how federal public housing eligibility rules perpetuate cycles of poverty and how reforming these rules could improve health equity and address structural racism.

Who Gets Housed: HUD Policy Today

HUD eligibility criteria make it difficult for people with SUD to qualify for public housing programs. Specifically, all local public housing authorities (PHA) who manage public housing and rental subsidy programs (including Section 8 vouchers) must deny any applicant who has been “evicted from public housing in the last three years for drug-related criminal activity,” or who is using a controlled substance or alcohol that the PHA deems a risk to “the health, safety, or right to peaceful enjoyment of the premises by other residents.” These rules apply not only to individual applicants but also to any household with a single member meeting one of these criteria.

These mandates are only the beginning; a 2013 study of a sample of 40 PHAs (those serving entire states or the most populous cities in each state) found that nearly all were enforcing these rules beyond what HUD requires. In some localities, anyone with a drug-related conviction was banned from public housing for life. Furthermore, there are no federal guidelines around the burden of proof required for PHAs to deny housing because of drug-related criminal activity. The result is great variability in how PHAs interpret and enforce HUD regulations.

Beyond eligibility criteria, HUD explicitly excludes SUD from their definition of disability. This is seemingly misaligned with Section 504 of the Rehabilitation Act, the Americans with Disabilities Act, and Section 1557 of the Affordable Care Act, which classifies SUD as a disability “when the drug addiction substantially limits a major life activity.”

According to HUD laws, a person with a mental illness qualifies for specific types of public housing when their mental or emotional impairment impedes their functioning, while “a person whose disability is based solely on any drug or alcohol dependence” does not. This exception raises yet another question: If HUD believes people with mental health disabilities should have carved-out affordable housing opportunities, why isn’t SUD included among the other psychiatric conditions?

The War On Drugs: Racism At The Root Of Current Housing Policies

HUD’s current SUD-related eligibility criteria stem from “War on Drugs” policies of the 1980s and 1990s within public housing. These policies’ “just say no” rhetoric was based on the belief that addiction was a product of poor individual decisions made by dangerous criminals deserving strict punishment. Policy makers passed these laws with the explicit intention to disrupt Black communities and to mobilize White voters to the polls. Arrests for drug law violations tripled, with more than four-fifths of these being for possession. In 1996, Congress passed laws that established today’s HUD policy, which systematically excludes people with SUD.

Unfortunately, the War on Drugs achieved its intended purpose; today 80 percent of people in federal prison and almost 60 percent of people in state prison for drug offenses are Black or Latinx. Increased incarceration of minority communities as well as historic redlining and current housing discrimination means that Black and Latinx households are more likely than White households to be extremely low-income renters and experience housing insecurity. This trend is borne out in public housing, where, despite representing 12.4 percent of the US population, Black people make up 46 percent of public housing residents. Since these communities are forced to rely more heavily on the public housing system, they are also more likely to become homeless when the public housing system fails them due to restrictive SUD-related eligibility. Therefore, anti-SUD public housing regulations originating from the War on Drugs have contributed to disproportionate homelessness rates for Black people in particular. In other words, reforming public housing eligibility is a racial justice issue.

The Medical Case For Reforming HUD Eligibility

The idea popularized during the War on Drugs that addiction results only from individual choices is harmful and medically false. Addiction physiology is underpinned by chronic neurological changes that impair judgment and decision making. Furthermore, according to the National Institutes on Drug Abuse, preexisting genetic factors account for 40–60 percent of a person’s risk for addiction. Beyond biological factors, environmental factors such as traumatic experiences, interpersonal conflict, and unstable home environments put people at risk for addiction. The SUD rate in homeless populations is triple that of the general US public. Substance use is not a result of inherent character flaws but rather a complex network of psychological, physiological, and environmental factors.

Restrictive housing eligibility proponents argue that those who don’t qualify for public housing due to a substance use disorder can rely on substance use treatment facilities and recovery houses. But this undervalues the agency of individuals with SUD. Like any person with a chronic illness, people with SUD should be able to make their own choices about pursuing addiction treatment regardless of housing status. While sober houses can be an excellent setting for some, they should not be the only option.

Housing-first programs prioritize affordable housing access without sobriety as a condition for participation. Studies have shown that individuals living in housing-first programs have the same SUD outcomes as individuals living in sobriety-contingent housing, while maintaining better long-term housing outcomes. This is consistent with the growing evidence that supports a longtime rallying cry among advocates: Housing is health care. In other words, prioritizing housing instead of imposing SUD restrictions could be the best path to improve the health of numerous people with SUD.

The American Medical Association, National Institutes of Health, and World Health Organization accept that SUD is a medical illness. Therefore, systematically excluding people with SUD from public housing is discrimination based on a health condition. These rules not only reinforce SUD stigma but also perpetuate cycles of poverty that keep our most vulnerable community members unhoused. According to research by the National Health Care for the Homeless Council, “people who are homeless have higher rates of illness and die on average 12 years sooner than the general US population.” Denying people housing based on a medical condition makes SUD recovery and rehousing less likely, while also exacerbating other comorbidities.

Lastly, anti-SUD restrictions undermine HUD’s mission to “create strong, sustainable, inclusive communities and quality affordable homes for all,” which are “free from discrimination.” HUD houses people who cannot get a place to live through the largely profit-driven private-housing market. But if our housing social safety net deems people with SUD as undeserving of assistance, then who will house them?

HUD secretary Marcia Fudge’s recent effort to eliminate public housing barriers experienced by people with histories of incarceration is a first step to reforming anti-SUD eligibility rules within HUD. Moreover, we have a long way to go in expanding the affordable housing supply, eliminating discrimination in housing, and carrying out critically needed public housing repairs.

Nonetheless, if we believe that housing is a human right and that SUD is a legitimate medical condition rather than a choice, then we should agree that HUD needs to enact SUD-inclusive criteria to reflect their mission of providing “quality, affordable homes for all.”

Lorraine’s Journey Reimagined

Imagine if instead of being evicted for her substance use, Lorraine received referrals from her HUD caseworker to services that would help her stay housed and safely manage her substance use. She would be connected with medical counseling that could equip her with clean needles and a naloxone kit for safer substance use. She would know where to go if and when she decided to pursue SUD treatment, and she would have more cognitive space to manage her other chronic health conditions. With a stable roof overhead, Lorraine could not only meet her basic health needs but also live out what home means to her: focusing on the things that bring meaning to her life.

Authors’ Note

All names used in anecdotes are pseudonyms, and stories are shared with permission. The authors would like to acknowledge our patients. Thank you for allowing us to be a part of your housing journeys and for sharing your lived experiences with us. Your resilience and strength are what inspired this piece. The authors would also like to acknowledge the following people who supported our work with WellNest and informed our perspectives: Sally Wilson and Julia Gamble and the rest of the Project Access Durham Homeless Care Transitions Team; Leah Whitehead and Toya at Community Empowerment Fund; The WellNest Leadership Team. Skye Tracey, Ian George, Maddie Brown, Ella Belina, Justin Chan, Kishen Mitra, Linus Li, Justin Zhao, Julie Thamby, Esme Trahair, Zoey Suarez, and Barbara Hefner; and Trisha White of the NC Albert Schweitzer Fellowship.

Tamar Chukrun and Trisha Dalapati are 2021-22 A. C. Reid Schweitzer Fellows.