Margot Kushel, M.D., speaking to journalists following her fall summit keynote address. Photo by Erica Tricarico/AHCJ
Expensive housing, inadequate wages, job scarcity in low-income areas, the impact of mass incarceration on families and the enduring effects of classism, racism, sexism, homophobia and transphobia on people’s opportunities in life lie at the root of homelessness.
Those were some of the factors revealed by the California Statewide Study on People Experiencing Homelessness, the centerpiece of Dr. Margot Kushel’s keynote talk at AHCJ’s 2023 fall summit, “Homelessness and Health,” in Oakland, Calif.
The day-and-a-half gathering of about 100 researchers, clinicians, activists, journalists and policymakers took place Nov. 2-3. The local host for the event was the California Health Care Foundation; it was sponsored by The Commonwealth Fund and the Robert Wood Johnson Foundation.
The study, which Kushel led, also provided insight into the consequences of homelessness in California and recommendations for policy changes to shape programs in response.
Kushel, who is a professor of medicine, division chief at the Division of Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center and director of the UCSF Center for Vulnerable Populations and Benioff Homelessness and Housing Initiative, used the analogy of musical chairs to illustrate the problem of the housing crisis. She explained that it often leaves people “sitting on top of each other” or “left standing” without chairs. But this is simply a byproduct of the chairs being intentionally pulled, she noted.
In the case of housing inequity, advocates emphasize the need to address affordable housing as a crucial measure to ending homelessness. The systemic causes of homelessness are directly analogous to the manner in which Kushel says chairs are “pulled” from people who are left unsheltered.
“People often wonder why homelessness is so bad in California,” Kushel said. “In California, we have 24 units of affordable housing available for every 100 extremely low-income households. So, you basically have 20 ‘chairs’ for every 100 people.”
The study surveyed adults ages 18 and older who were homeless in California. It incorporates the findings from nearly 3,200 administered questionnaires, along with 365 in-depth interviews with adults “experiencing homelessness” in eight regions of the state, representing urban, rural and suburban areas. The interviews were conducted in English and Spanish, with interpreters for other languages. The University of California, San Francisco Benioff Homelessness and Housing Initiative team, in partnership with a wide array of community stakeholders, collected data between October 2021 and November 2022.
The study highlights the interconnectedness of the structural and individual circumstances that lead to homelessness. “When we say, ‘Why are there so many people experiencing homelessness?’ These are really two separate questions: Why are there so many people in our region that experience homelessness? And why is this particular person experiencing homelessness?” Kushel said.
She explained that depending on which question you ask, you’re likely to get a completely different answer. The first question is structural, but people often end up answering it with factors that relate to people, which creates a misconception that personal reasons are solely responsible for homelessness.
Coupled with the structural factors working against many unhoused people, those with individual risk factors were more likely to remain homeless. Among the participants that were interviewed for the study, approximately 32% were in leaseholding arrangements immediately prior to becoming homeless, 49% were in non-leaseholding arrangements, and 19% were in institutional settings. Most participants received an average of five days warning time before losing housing.
Kushel shared the testimony of one study participant during her presentation:
“We were going to get an apartment together, but he died last month. So, now I’m up to paying full rent, which is $700, $800 to start with. I can’t pay that. I can’t pay that much. It’s a lot to pay PG&E and get groceries, too. It’s just not possible.”
According to the report, addressing homelessness requires a social justice perspective that ensures equal access to housing for all people. Homeownership is the main contributor to wealth building in the U.S. However, Black Americans are at a higher risk of homelessness, and the study indicates that approximately 35% of interviewees identified as Latino/x.
Furthermore, an alarming number of people, particularly older adults and those from marginalized communities, are on the precipice of losing their homes or have already fallen victim to this crisis. This trend is a significant contributing factor to burgeoning homelessness across the U.S.
Ultimately, homelessness is not a standalone issue. The conditions that leave families unhoused include the high cost of rent, low wages that do not keep pace with inflation, the steady disappearance of jobs from low-income neighborhoods, the consequences of mass incarceration on families, and the ongoing effects of classism, racism, sexism, homophobia and transphobia on people’s life chances.
“I’ve been really pleased with how [the study findings have] been reported. In general, I don’t think there’s been that much misconception. I would say the common thing that I think a lot of people get wrong is conflating unsheltered homelessness and homelessness,” Kushel said of journalists who have written about her research.
