Episode 62: Who Experiences Homelessness, and Why with Margot Kushel (Pathways Home pt.2)

Shane Phillips 0:04
Hello, this is the UCLA Housing Voice podcast and I'm your host, Shane Phillips. This is the second installment in Pathways Home. Our series about what research can tell us about the causes of and solutions to homelessness. This episode features Margot Kushel, a physician and the lead researcher on the California Statewide study of people experiencing homelessness, the largest representative study of homelessness in the United States since the mid 1990s. Our previous conversation with Gregg Colburn focused on the housing market factors driving the wide disparities in homelessness rates between cities and metro areas in the US why places like Los Angeles and Seattle have such higher rates of homelessness than places like Detroit, Chicago, and Houston. Housing remains front and center in this episode two, but this time, we're also digging into the statistics and stories that start to explain individual variation, who becomes homeless, at least in an expensive state like California, the circumstances that led to their loss of housing, and the experiences of being homeless and what they can tell us about the barriers to returning to stable housing. To many people's understanding of homelessness and the people experiencing it is based on anecdote that leads to ineffective and even counterproductive prescriptions for solving it. The work of Margo and her colleagues is helping improve our understanding of these issues. And as I think you'll hear in this episode, it's also hopefully fostering a little more empathy for the people experiencing homelessness and the toll that experience takes on their lives. The housing voice Podcast is a production of the UCLA Lewis Center for Regional Policy Studies. With production support from Claudia Bustamante, Gavin Carlson, Jason Sutedja and Divine Muttoni. If you have questions or comments, you can send them my way at Shane phillips@ucla.edu. With that, here's our conversation with Margot who shall we Margot Kushel is professor of medicine at UCSF division chief of the Center for Vulnerable Populations, and director of the Benioff Homelessness and Housing Initiative at Zuckerberg San Francisco General Hospital and trauma center. And she's here today to talk about findings from the largest representative study of homelessness in the United States since the mid 1990s, for which she was the principal investigator. Margot, thank you for joining us, and welcome to the Housing Voice podcast.

Margot Kushel 2:37
Thanks for having me.

Shane Phillips 2:38
And my co host today is Mike Lens. Hello, Mike.

Michael Lens 2:41
Hello Shane. Hello, Margot. Great to have a chance to discuss this very, very important study with somebody who is now a collaborator of mine on a recent grant that we received. So this is very exciting.

Alright, Margot, at the top of every episode, we ask our guests to give us a quick tour of a place they know. Well, I think you're going to be talking about Berkeley.

Margot Kushel 3:04
Yeah, I'm going to talk about my current hometown of Berkeley, California, a small place that sort of looms large in the public imagination, and a place that I think particularly among housing doesn't really live up to its ideals. Berkeley, in the early part of the 20th century, was, in some ways at the forefront of single family zoning with all of its racist implications, it was pretty clear that it was done in the interest of, you know, segregation. And as much as Berkeley likes to think about itself as a place committed to justice. It has really struggled on the issue of housing. Interestingly, so you look around Berkeley, lots of single family housing has had a massive displacement of its black community. You can see the numbers dropping, even from my kids public school from their kindergarten until their senior year. It was like you could see it happening in real time. But recently, there has been some changes. Wonderful city council member Vice Mayor really led the charge in 2021 to get rid of single family zoning that was in fact voted in. But it's a place where people are really having a lot of agony around it. Not that far from our house, there is the North Berkeley BART station, a really empty parking lot filled with crabgrass and lots of cars, in which there has been a huge fight over development. As my husband said, the reason why he couldn't take me to any dinner parties because I would lose my cool. But finally finally, after lots of community aggravation, dueling lawn signs and lots of angst, I'm happy to say that they should break ground and about 2025 on some at least moderate density housing a lot of if it will be affordable in what is currently a really ugly parking lot.

Shane Phillips 5:05
I gotta say, this is a podcast that welcomes people who cannot keep their cool when talking about housing. So you're, you're in the right place. Right. So the report that we're talking about today is titled toward a new understanding the California Statewide study of people experiencing homelessness. It came out in June of this year 2023, and was co authored by Dr. Kushel, who is a physician and Tiana Moore, more the other kinds of doctor who has a PhD in developmental psychology, and is policy director at the Benioff homelessness and housing initiative. This survey is important for a bunch of reasons, but to package them all into a single big one. It's important because it gives us a much clearer window into the lives of the more than 170,000 people who experience homelessness in our state on a given day. And hopefully that can help us do a better job of helping those individuals back into housing and preventing others from becoming homeless in the future. There are a lot of misconceptions about who is homeless and why. And we're very unlikely to fix a problem that we don't understand. But I will save further exposition on the purpose and value of the study for Margo. The study itself took place over a year from October 2021 to November 2022. And it was designed to be representative of all adults 18 And older experiencing homelessness in California. It surveyed nearly 3200 people and includes 365, in depth interviews with adults experiencing homelessness in eight regions of the state, really all regions of the state. The survey and report explore the experience of homelessness in four parts, starting with who experiences homelessness, followed by how people became homeless, the experiences of being homeless, and then barriers and facilitators of returning to housing. Before we get into your findings, Margot, tell us about the motivation for this project. I mentioned that this is the largest representative survey of homelessness since the 1990s. And certainly a lot has changed in the housing and homelessness landscape since that time. So what did you feel was missing from our understanding of homelessness and people experiencing homelessness in California? And what is your team hoping to accomplish by deepening that understanding?

Margot Kushel 7:24
So the origin story for this study happened in September 2019, when Secretary Mark Galli, who's the secretary of the Health and Human Services Agency for California texted me and said that the governor's office was planning to make big investments in homelessness, and they thought we needed some research to help answer some key questions. How did people become homeless who was actually homeless, and acknowledging that so much we know about homelessness is sort of done on people's hot takes, you know, someone looks in their neighborhood and makes assumptions or there's a tiny study, I have to fess up that I had some skepticism. And I actually said No, three times. I kept saying, No, you know, I love doing research. But I kept saying, with all due respect, do we really need this? This is going to be hard and expensive. And don't we already know this. And so we had a few months of dueling memos, where Secretary Gali and his team would send me a list of questions and said, Can you answer this? And generally, I would be able to answer about half of them. And the other half, I would say, Well, I think I think I'm pretty sure and that his office would push me like, how do you know that? Why are you sure. And so we developed a list of things that actually we realize we didn't really know. And that the population in the world has changed so much since the last really well done study. You know, there has been a big shift to unsheltered homelessness, a lot of folks not getting any services, the population is aging, there has been an expansion of Medicaid, there's been a lot of changes, sort of both good and bad. That left us a little bit at a loss of what was happening. We agreed to do it, then the pandemic hit. And so it got delayed, I was doing a lot of work with the agency around the pandemic and homelessness. And I said to the secretary, you know, I don't know halfway through sort of maybe beginning of 2021, do we still want this? And the answer was actually we need it more than ever, because we know that the pandemic led to big shifts, and we really don't know what's going on. So that's basically the origin story.

Shane Phillips 9:31
So we I don't think we need to spend a lot of time on methodology. But is there anything our listeners should know about how representative These findings are of the population of adults specifically experiencing homelessness? Any limitations or disclaimers?

Margot Kushel 9:47
Absolutely. And you know, we will have sort of really geeky methods papers coming out for those interested in the weeds. The first thing to say is, overall, we're really confident. You know, the people who didn't like our results made all sorts of accusations And I cannot begin to tell you how careful we were in getting a representative sample to reflect the diversity of California rural areas, urban areas, areas with higher and lower amounts of homelessness, making up for whether there were some people who couldn't participate for a variety of reasons we were able to adjust for that on the back end, I will say the one big caveat is we were obviously only looking for people 18 And over so we weren't including children. But really importantly, young adults 18 to 24, who are part of the homeless youth population 12 to 24, without a grown up with them, and without minor kids with them are a very distinct population, who tended not to be able to be found, we used additional methods to find them, we knew this would be a problem. But we also didn't have the resources to focus exclusively on them. And we feel like we underrepresented them. And so we are not making any claims that the proportion of them in our study is their true proportion in the 18th. And over. So I would say it's the young adults that I'm most concerned about people drawing Miss conclusions about. Otherwise, I think we did a pretty good job.

Shane Phillips 11:15
And I know as researchers, we're going to want to be cautious here and not over generalize or miss apply this work. And I think in this case, that could mean taking these findings, which are about California, and people experiencing homelessness here. And assuming that the same is true for people experiencing homelessness in Colorado or Texas or Washington, DC or anywhere else. But I have to I would like to at least imagine that there are lessons here that policymakers and advocates outside of California can learn from. Most of our listeners are not in California. So how should they think about the findings from this study?

Margot Kushel 11:51
First of all, there's some things about the nuance of the experience. You know, we paired surveys about one in eight people who got a survey also got an in depth interview. And I think that's going to be very helpful throughout the country. Homelessness is very contextual. You know, it has everything to do with housing affordability. And certainly states and localities can have different rules and practices, I would say that what we found is likely very generalizability to most of the western United States, you know, Oregon, Washington, Arizona, who and to a certain extent Texas, Colorado who have very similar patterns to California, low cost regions are quite different. And then actually the Northeast DC, Boston, New York have very different local housing policies, leading to the vast majority of their population being sheltered, which is a big difference. So their experience is quite different, in many ways.

Shane Phillips 12:46
Alright, jumping in here, the first chapter of the report tackles the question of who experiences homelessness in California. I'll start with a few big picture numbers just to kind of get us started here might be helpful context. Of the 3200 respondents, 90% of the participants were single adults, 7% were adults in families, and 3% were transition age young adults, which means age 18 to 24, and not living with children. I think, as you said, it's only 3%. Here, you think it might actually be higher proportion. In actuality, 39% of participants indicated that their current episode of homelessness was there first. And the median length of the current episode of homelessness for all of the respondents was 22 months. Your study also confirmed what other surveys of unhoused individuals have found, but I think it bears repeating, which is that most people are homeless in the same community in which they were last housed. So community maybe broadly defined, but to be more specific about that 90% of participants became homeless in California, and 75% lived in the same county where they were last housed. So I think in other words, this is a homegrown problem and not something we can just, you know, point the finger at someone else. Margo, could you fill out that picture a bit more for us, you know, at a high level, looking at both personal and structural factors, where and among whom do we see above average rates of homelessness or, you know, however you want to answer this question about who experiences homelessness, summarizing, kind of generally, yeah.

Margot Kushel 14:19
And in their terrific book In the Midst of Plenty, Jill Khadduri and Marybeth Shinn pointed out that when we ask that question who experiences homelessness, we're really asking two different questions. One is why is there so much homelessness in this region? And the other is why is this particular person experiencing homelessness? Why is there so much homelessness in this area is almost always driven by the structural factors, the biggest of which is the accessibility or the access to affordable housing and on that score, California does really terribly, only 24 units of housing available and affordable for every 100 extremely low income household. This Second question, though, is really like among in those communities who's most at risk, and is quite an older and and Greg Colburn talk about the difference between the drivers or the underlying factors that drive homelessness, which is really housing, housing, housing, housing, housing, and then I would add in structural racism as our, you know, firsthand reasons. Yeah. And who within that is pushed into homelessness, obviously, in a tough housing environment, people with certain disabilities, certain sort of barriers, things like personal exposure to racism, mental health and substance use disabilities, things would make them lose out in a tough housing market are going to be way over represented. So we definitely found that a huge over Representation of Black folks and indigenous folks, Pacific Islanders, you know, this is an aging population, which I hope we'll have time to talk about. And people who have had lots of trauma in their lives, people with higher rates of mental health problems, substance use problems, medical problems, these folks are over represented, in part because those leave people less able to compete in a tougher housing market. And also because frankly, those problems get a lot worse once people experience homelessness.

Michael Lens 16:21
Right.

Shane Phillips 16:22
I think you mentioned age, and I think some listeners may be surprised to learn that 44% of the adults in this survey were at least 50 years old. I personally was very surprised to learn that 41% of those older adults had never been homeless before age 50. And I feel like that really turns on its head some of these popular conceptions of homelessness and the people experiencing it. It seems to me that if people are able to get by for at least 50 years before ever becoming homeless, then it's it's really difficult to chalk this up entirely to kind of personal choices, personal failings, that kind of narrative that comes out a lot of times. But do we have any idea if this finding is unusual? That's such a large share of people experiencing homelessness are both older and an older and experiencing homelessness for the first time is this new to see so many people becoming homeless for the first time so late in life?

Margot Kushel 17:18
So first of all, it's nice when you do a really huge representative study, and it bizarrely completely matches prior work that you've done. We've been observing this aging of the homeless population. Now for quite a while I started to work on this issue in the early 2000s, when I started to make the clinical observation that folks seem to be aging. And at that point, we pulled up some studies that we had been working on in my research group over the years even before I started, and we realized that in 1990, in San Francisco 11% of folks were 50 and older. In 2003, it had gone up to 37%. We were super interested in this wrote a study on it. In fact, we couldn't get it placed in any journal, we finally got into a brief report in a tiny journal. And the next day, it was like banner news in the San Francisco Chronicle showing journals don't always know what's important. And then I spent the next about 10 years trying to get grant funding to look into it. After 10 years, literally, of writing for grant funding, it finally got funded. And we started the study in 2013 2014 in Oakland. And there we found that 44% of people who are 50 and older had first become homeless after the age of 50, which, you know, using confidence intervals is the same finding we found here in our study among single homeless adults, because obviously youth can't be over 50. And you know, parents of young kids aren't going to be over 50 among single homeless adults. 48% of them were 50 and older. And as you said, 41% were first homeless after 50, both in the study in Oakland, and then confirmed in this study, we found that the pathways to homelessness really differed for those older folks who are first homeless after 50 and those who are first homeless before 50. Those first homeless before 50, in a lot of ways confirmed what we generally think of as risk factors for homelessness, lots of mental health crises, substance use, you know, not really in the in the workforce, lots of imprisonment as a risk factor, etc. Those first almost after 50 are very different. They tend to be people who are the working poor, generally a non unionized physically demanding low paid jobs, they tend to have work their whole lives, usually more than one job at a time. And we're sort of hanging on by their fingernails to housing, and then they could identify a discrete crisis. You know, they were able to say us, I was housed until, you know, I lost my job. My wife lost her job, I got sick, my wife got sick, my marriage broke up or my wife died or someone in the household died, husband died, or a parent died, you know, 52 year old men living with 78 year old mom, mom dies, their name isn't on the lease or are on even on a house that their family had owned for years. Suddenly, in their grief in their trauma, they realize that they have no legal rights, their housing, and they're displaced into homelessness.

Shane Phillips 20:10
Wow,

Michael Lens 20:10
Those are really incredible insights. I mean, I think a couple of things stand out to me, you know, first, the way that you're able to, through a mixed methods approach here, you know, having not just survey data with numbers, but also interviews with a lot of contextual information, you're able to kind of explain what we're seeing. The other thing that just the numbers stand out to me or it kind of this change over time, is, you know, this points directly to me to rent burden being at least one massive contributing factor here. And, you know, you've already laid out that case, I think, if rent burden is going up so substantially in California, and in its major metro areas, as it has in the last, you know, I'd say 30 years, then it makes sense that you would see a lot of people that have been employed a long time in their lives and are kind of working poor, as you describe them, just that little extra bit of you know, rent burden, and boom, like their 20 year experience have been relatively stable the house, it's relatively stable, the employed blows up, sometimes in the face of a lot of these other contextual factors that you, you know, certainly raise in terms of changes in household etc. But just to me, like if you become homeless for the first time, at the age of 55, like, so much of that has to be wrapped up in just the cost of housing.

Margot Kushel 21:48
Absolutely. I mean, I would say for everyone, even the folks with lots of mental health and substance use problems, it comes down to Rembert. And you know, and there are all these really interesting studies like Pew just put out this interesting report showing that in cities where there was slow rise in rent, not even rents coming down, but a slower rise in rents, homelessness went down. And in cities where rents are rising, quickly, homelessness goes up. And we found that for sure, like, you know, amongst everyone in our study, the median monthly household income in the six months before they became homeless was $960 a month. And the single biggest reason why people became homeless across the leaseholders who became homeless, or the people who were doubled up before they became homeless was a loss of household income. And I think about it, you know, folks, 50 and older renters 50 and older in this country are the most likely to have severe rent burden. And in a way I think of it as poor people are really like running on a hamster wheel desperately trying to keep up with their rent, and any small perturbation can push them over the edge. And when you're over 50, you it's harder to take on that third job, right? When your jobs are physically demanding, it's harder to work, you can't work three jobs, you know, hauling boxes, when you're 50. And you've had lousy access to health care, and you're, you know, body sort of broken down from a lifetime of hard work. And you're just much more likely to have those perturbations, you know, your spouse is more likely to get sick or die. And it's just harder to make up for it. So I think that these older adults are really a priority population. Something I know from my other research, and not from this, because we weren't set up to do it in this study. But in my other research, we've been following people for a decade, and the mortality rates were excruciatingly high. But those first homeless after 50, as opposed to those first homeless before 50, were at almost twice the risk of dying.

Michael Lens 23:51
Wow.

Shane Phillips 23:52
So Margo, a lot of people believe homelessness is largely a problem of drug abuse. And the survey results could be read in a way that supports that conclusion, you found that 65% of participants reported using non prescribed amphetamines, cocaine or non prescribed opioids at least three times in a week, at some point during their lives. So how do you think about this intersection of homelessness and drug use both as a homelessness researcher and as a physician? I think, you know, my personal view is that focusing on drug use and mental health, these kinds of things can tend to take attention away from structural factors like housing affordability, and the safety net. And at worst that can be used as an excuse to further victimize people rather than helping them. But for many folks, it is, I think, pretty clear that this is a sincerely held conviction. I don't think it's purely just, you know, a desire for a punitive approach. So what is your response to people who are concerned that this is really at route a drug problem or a mental health problem for that matter?

Margot Kushel 24:59
First of all, I want to have some empathy for people who have that position, which I don't agree with, which is that I totally understand why you would think that that you know, when you walk down the street, you can see people visibly suffering from substance use and mental health problems. Second thing I'd like to say is, you know, substance use and mental health problems or health problems. There are health problems that are very contextual, right? They're related to trauma, they're related to suffering, they're related to genetics are related to the environment. But what they are not is moral problems. Thirdly, I'm a physician. They don't scare me. You know, there's certain things that scare me pancreatic cancer scares the living daylights out of me substance use and mental health problems we know how to treat. And as a physician, I can tell you, we cannot do that when people are homeless, our hands are tied behind our backs. These are related crises, but they're not in any way the same people with substance use and mental health problems. These are highly stigmatized conditions, conditions that by definition, interfere with people's daily function that is kind of what they do and how we define them. So not surprising that folks are more likely to become homeless when they have these conditions. But most people with these conditions are housed. There is nothing about having these conditions. That means that you can't be housed, I did nothing at all. The opposite though is a little bit true is it's very hard for us to get treatment to people when they are on housed. And it's very hard for people to heal when they are unhoused. We found that about a third of people, it was pretty much exactly it was 35%. I think we're actively using one of the illicit drugs, cocaine non prescribed opioids and unprescribed methamphetamines three times a week or more while they were experiencing homelessness. This was mostly by the way driven by methamphetamines, that is the main drug out there, about 11%. We're using opioids regularly, and almost all of them are also using methamphetamines. But people in those in depth interviews, talk to us really clearly, that while they might have been using these drugs before they became homeless, they're using them while homeless was a coping strategy. You know, methamphetamines are almost perfectly designed for a world in which people are homeless, what do they do, they keep you wide awake and alert, and they keep you from being hungry. And people spoke about those effects of them as being useful to them. One of the principles as a physician, when we're dealing with substance use is to help people identify their motivators, you know, for saying, like, what is this doing for you must, it's doing a lot of bad things for you. And they list out all the bad things it's doing for them and like, well, but you're still using it, what is it good, good for you. And it's actually helpful to get people to pinpoint that because it actually gives us a hook to reframe the conversation. People were really clear what these drugs were doing for them while they were homeless. I think the other thing to know is that of people who were using drugs heavily or alcohol, commonly about 9% of people were binge drinking at least once a week, among the people who are either using drugs regularly or binge drinking. 35% of them told us that they wanted treatment, and we're trying to get treatment but hadn't been able to access it. And I think that that also should give us some pause for all the discussions about forced treatment. As a physician, I can tell you forced treatment doesn't work terribly well, your best chance of substance use treatment working is in people who want it. And so that's who I would start with just as a limited resource. And we are not nearly getting to everyone who wants it. And that's where our focus needs to be. But the other principle, and this has been shown empirically in studies I've run and other people run is when you get people who are using into housing, they can still be housed when they're using a lot. And we have lots of success keeping people housed for years and years and years, even though they're using heavily. But the other thing that happens is once they get housed, then they engage in treatment. So getting people housed is not only you know the right thing to do because it gets them house, it's actually our best chance at getting them to stop using.

Shane Phillips 29:06
It sounds like in a way the drug use, you know, substance abuse treatment is mirroring the homelessness, shelter housing problem itself, in that we are blaming people and telling them, you know, we need to force you into these things. And yet we don't actually provide the resources and the resources just like we're not providing the treatment to people yet when they want to seek it. And we're not providing you know, we're saying get off the street, and yet there's not enough shelters. The shelters of course, are inadequate anyway. And so there's certainly not enough housing. So it feels like this is a common theme. Absolutely. Yeah. Moving on to chapter two, which is pathways to homelessness or how people became homeless. You asked participants to report on their experiences during the six months prior to becoming homeless, which strikes me as a time in people's lives that we released seemed an No way too little about. And yeah, it is really crucial knowledge if we want to help people avoid becoming homeless in the first place. So what are some of the findings about pathways to homelessness that you'd like to draw people's attention to?

Margot Kushel 30:12
Yeah, so first of all, you know, people's entrances into homelessness, a whopping 19% came directly from an institution. This was primarily prisons or long term jail stays, although the next biggest after those was drug treatment, I will add, because if you don't have housing combined with a drug treatment, people either relapse, which people do anyway often, and then they're kicked out of the drug treatment and on the street, where they complete drug treatment, and there's still no place to go. So but you know, prisons and jails, I think, offer us a really big intervention opportunity. Because we know who those people are, we know we are discharging them into homelessness, and we could actually stop that if we care, too.

Shane Phillips 30:53
Because we asked them, you know, where do you plan to live? Right? And a lot of people, yes, a shelter or something? Because they know, they don't actually have anywhere to go.

Margot Kushel 31:02
Yeah, it's really shocking. And actually, you know, those numbers are a conservative estimate, because we also asked had they been released from prison in the prior six months, and many people who are released from prison get short term housing, and what we heard from them is it just wasn't long enough. So if we actually phrase it a different way of like, where you release from prison or long term jail stay in the last six months, it's even more than 19% of the population. Huge, huge opportunity to intervene there. But interestingly, of everyone else, you know, 49% of the whole population came from what we call the non lease holding environment. This meant that they were already doubled up, they were already staying with friends or family or some other way where they didn't have any legal rights to where they were 43% of those folks were paying no rent. So imagine what standing you have, when you are sort of staying in an overcrowded, you know, 10 people to in a one bedroom apartment, things fall apart pretty quickly. And we saw that they only had one day warning on median before they became homeless. 32% came from what we called using shorthand, at least holding arrangement. Most of those were renters. 3% Overall, were people who came from mortgages. But those were folks who were evicted or threatened with eviction, and they went right to homelessness, they made a little more money that the non leaseholders median household income was 950 a month. Of those who paid rent, it was about $450 a month. And again, 43% of them didn't pay rent of the lease holders, median household income was $1,400 a month, but they'd been paying $700 a month of rent. And I would say two things about the $700 a month one is if your household income is $1,400 a month, $700 a month is too high, you can't you can't pay for that you're going to fall behind at some point and wind up out of there. But the other point is, we're in California, can you get back into the rental market for $700 a month, so it was both too high and could not be replicated. Those folks had a median of 10 days warning in a state with relatively strong eviction protections. That says to me one of two things, and this is what we heard in the in depth interviews. Most of those folks were threatened with eviction and left before the eviction went through, they did not have legal counsel, they either weren't aware or were too afraid of that eviction on their record. So they just packed up and left and had nowhere to go, or they were getting three day pay or quit orders. I think one of the really important findings is almost nobody in either group sought help before they became homeless. Of course, it's possible that the people who sought help never became homeless, but another huge area that we could work on to improve. And then finally, like, if we're focused on prevention, we should actually put a lot of resources into people leaving institutions. But the other thing is, if you're looking at people who are currently housed, the highest risk folks are probably those who are already doubled up who many of whom, you know, two, three years before had been just like the lease holders. Their difference was they had someplace else to go, but it just wasn't sustainable.

Shane Phillips 34:13
Yeah, the share of people experiencing homelessness, who in their last housing situation had been non leaseholders, was really surprising. I mean, it was half. And I think even more surprising was that the median household or person had a notice of one day, or the media notice was one day for having to leave. And, you know, that also strikes me as a potential area of intervention. I think it probably a very difficult one. But just thinking about like, if you're trying to target resources at folks, waiting until someone gets a one day notice is almost guaranteeing that they're going to spend some time homeless, and you know, possibly unsheltered. And I'm sure you've thought about this, but like, Are there efforts to kind of identified those people specifically or, you know, I'm sure there are very large barriers, it's just hard population to track.

Margot Kushel 35:06
I mean, the you know, the biggest problem with homelessness prevention is actually trying to identify those at high risk, because there are a lot of people who are at high risk, and only some of them will become homeless. So you're sort of looking for the needle in the haystack, you know, people who are doubled up, they're not going to get like you have to leave in one day, things just explode. So I like to think structurally, in our in depth interviews, people talked about how charged those environments were, you know, they've gotten evicted tears before. In fact, we saw this slow slide, like we heard again, and again, like I, my family was renting a two bedroom apartment, someone lost their job, we got evicted to them, we rented a room, and then you know, something there went wrong. And so then we were doubled up with my brother, it was usually like a long, you know, long lead in before they got to this point. But one thing it really makes me think of is, can we uncharged, some of those experiences, like what people told us is, you know, their social networks, we're not living in five bedroom houses in the suburbs, right? These are black folks, indigenous folks, folks whose whole social networks are facing the upstream effects of racism, poverty, all of that. And they talked about the tension of being like, you know, when you've got 10 people in a one bedroom, apartment, money is really tight, you don't have money to contribute. Everyone's on tender hooks. And so considering how expensive homelessness is, and you know, people were really optimistic about small financial interventions, preventing it wouldn't have changed the tension there. If we had provided support to that whole household, you know, would it have made it easier for tensions to be lower, if we could have made money less tight in that household if we could have somehow otherwise intervened, even to just buy some time. But you know, I think the bottom line is people living in overcrowded households where they're not really able to contribute income, because a lot of people like when they moved into that brother's house, they lost their job, because their brother lived 100 miles away, or whatever it was, can we help support that whole household so that things don't fall apart?

Shane Phillips 37:07
I think it's really worth reiterating how difficult it is to target resources preventatively, just because at any given time, you know, we have a state of 40 million people, there's probably a few million at least who if the wrong set of circumstances arises, they could be homeless for some amount of time. And you can't just like freely give all of them $500, you know, that kind of thing every year, you would just run out of money way too quickly. So you have to have a better way of figuring out who is either most likely to experience those negative circumstances or maybe think there are efforts to kind of like, as those circumstances arise as people the first time they apply for some kind of safety net program, like kind of digging in a little further. But it's a really, really difficult challenge that still no one has solved, and I'm not sure there's ever going to be like a perfect solution to that.

Margot Kushel 38:01
There's not a perfect solution. But there are ways to target right. I mean, our friends at Cal Policy Lab at UCLA have used AI to help predict. And there's lots of research done in New York, you know, the single biggest risk factor, first of all, you have to sort of look already at people, right, who are extremely low income who have certain other risk factors, single biggest risk factor is having been homeless before, there are certain life events. So there are strategies, but I agree with you, it's not as easy as just throwing $500 a month at everyone at risk, Homeless Prevention, the success of it is all about targeting.

Michael Lens 38:35
Do you think that a more a broader and deeper safety net does some of that work? In that, you know, we don't worry about the targeting so much. And we just say, like, let's just have the pool of people at risk be a lot smaller

Margot Kushel 38:51
100%, like, you know, when I think about and I tend to think about prevention, like wearing my physician hat, right, like, having people stop smoking is the first line of prevention. And then the second line of prevention is sort of identifying people at risk for, you know, smoking is risk factor for cervical cancer, so you're doing pap smears or whatever, right. And so in the same way, if we can really go upstream, you know, in communities where there is less expensive housing, there's less homelessness, you know, I really liked the frame put forward in the early 1990s by Marty Burke and Irani of like homelessness is an interaction between structural factors like the cost of housing, individual factors, you know, things that place individuals at risk, like mental health problems, such as these problems, you know, having been in prison, etc. And the presence or absence of the safety net. So, you know, you go to Northern Europe, which has really strong safety, net flat income structures, a lot of social housing, you still will see some people homeless, but there are people with really severe individual risk factors and California 2023 Lots of people are at risk. So if you brought down the overall risk, if we brought down the cost of housing, if we increased housing choice vouchers, you know, homelessness would decrease completely. And then there's sort of the secondary prevention of like, when those conditions are bad, how do you actually get resources to people right before they became homeless, and that's where the targeting comes in. But if we raised our 24 per 100, amount of ELI housing to 30 to 100, we would have many fewer people, homeless, you know, if we decrease the average rental costs and increase the average income, we'd have many fewer people homeless. That's the real prevention.

Shane Phillips 40:35
Moving on the reports third chapter discusses the experiences of homelessness. And before we get into specific questions on this section, give us again, that general overview what's the summary version of the experience or experiences of homelessness in California?

Margot Kushel 40:52
Homelessness is absolutely devastating. Like there's no other way to say it, it is it is absolutely catastrophic, was so catastrophic, that we had to bring in lots of extra resources for my staff who just hearing the stories day in and day out, were suffering, that's how bad it is, you can imagine how bad it is to actually experience it. You know, in California, most people who experience homelessness do so in unsheltered settings. 90% of everyone experiencing homelessness had been unsheltered at some point during their homelessness. And you know, about three quarters were primarily unsheltered either living in cars or more commonly outside during their experience. The experience is one of constant trauma, some really, you know, little trigger warning here about sexual violence, but 10% of everybody had been sexually assaulted during this episode 36% had been physically assaulted, if you narrow the sexual assaults down to women, or trans and non binary folks, it was much much higher than that. And also the perpetrators were half of the perpetrators were strangers, which for people who sort of think about violence all the time, that's very unusual. You know, despite the public idea, most violence is perpetrated by people known to them. When you're homeless, and you have no door to lock, the switch flips and you're really exposed to random violence, people were getting no sleep, the effects of you know, what are commonly called sweeps or displacement was intense. And frankly, we saw that while researching where, you know, we were, we did all these complicated things to identify where people were. And then we would do one last Scout, within 36 hours before sending the team out, let's say to an encampment, and even with some insight information from the counties, even with that last check, we would go 36 hours later, and there'd have been 200 tents there, you know, two nights before and it would be empty and walled off. Lots of sweeps happened while we were interviewing. So we'd be interviewing, and you know, armed in some communities, like armed police and sort of military outfits would come and start throwing everyone's stuff away. 36% of people said that they had had all of their things thrown out by some official body during this episode, people were exhausted, they were scared, and they really felt abandoned. Like there's all this talk in California were spending so much money we're doing so much, but from the experience of people experiencing homelessness, they felt abandoned. The rates of discrimination that people were experiencing, we used all of these standardized measures of discrimination, whether it's in stores or in healthcare settings, or you know, by others, was really, really intense. It is a life changing, devastating experience. people's health was terrible. They were using the emergency department and being hospitalized at astronomical rates, it is a catastrophe.

Shane Phillips 43:53
One thing that stood out to me about the health was among people in the survey age 50 or older 53% reported fair or poor health and in the general noninstitutionalized population, the share of people 65 And older reporting fair or poor health is 22%. So it's like 40% as much despite being an older cohort. So there's a big, big difference there, on forced, you know, displacements on sweeps, confiscations and, you know, maybe criminal justice involvement and other things that are kind of also pose these immediate threats. What did folks say about the barriers that impose the additional kind of obstacles that created to returning to housing,

Margot Kushel 44:34
So 30% of everyone had had a short jail stay. These are mostly like a week or less during their episode of homelessness, and they told us in the in depth interviews that their experience was constant surveillance like they were, you know, police would come in and sort of like, Hey, you have an outstanding warrant, what's on you search them for drugs, you know, whatever, and they just felt like they were constantly being thrown into jail. This presented a huge barrier because people's cars Real records when they actually if they wanted to rent an apartment, they were getting blocked because of that. So we're undermining ourselves. 50% of people noted that they didn't have documents that that presented a big barrier that that had obstructed. They're getting house, when we asked, Well, why don't you have documents? We asked in a nicer way. But like, why don't you have documents? You know, some of it was sort of the chaos of homelessness, some of it was weather, you know, rain, etc, some of those things got stolen. But mostly it was all people just keep coming in throwing out all my stuff. So you know, we've got like one branch of government desperately trying to get people housed, while the other branch is sort of getting in our way and causing these further obstructions. Of course, the single biggest barrier to people getting housed was the cost of housing.

Shane Phillips 45:47
You also found that pregnancy was very common among unhoused people who were assigned female at birth 26% had been pregnant at any time during their current episode of homelessness, which again, the median overall, at least I don't know, for the female at birth population, what this looked like, but was 22 months was the median current episode of homelessness. But again, 26% had been pregnant at any time during a current episode. And that number rose to 40%. For younger adults aged 18 to 24. What can you tell us about these pregnancy rates in the first place, and the experience of being homeless while pregnant? And then you know, what kinds of unique barriers do pregnant people or people with young children face when trying to get back into permanent housing? And, you know, I think there are probably some advantages isn't the word I want to use. But I think there's a little bit of priority in some cases, like, does that work in practice? What is what does that look like?

Margot Kushel 46:40
So this statistic took my breath away. And actually, when I first ran it, I had one set of system run out, when I saw it, I actually sent the request to all the other statisticians on their team independently and asked them all to run it because I wanted to double check it, but have people assigned female at birth 45 and under 26% pregnant during this episode, I think it points to a couple things. One is that pregnancy itself is a huge risk factor for homelessness. It has been shown that pregnant people face this inordinate risk of being kicked out of the house or, you know, losing their housing for whatever reason. So I think that's an important point. People who are experiencing homelessness have really poor access to reproductive health care and to agency, you know, to be able to make choices about pregnancy or whatever. You know, ostensibly, people in homeless families are in a in a different system is not quite the right word, but sort of are prioritized differently. They're viewed differently by the system, they have access to different resources. And they should have enhanced resources, although not nearly enough. But one really interesting thing we found is that among people read a single homeless adults, you know, homeless as 25, and don't have a kid with them. 10% of them had a kid in CPS Child Protective Services, some of that was likely directly related to their homelessness, we know that when people lose their housing, they get even more surveilled, and their kids are taken away. And that came through in the interviews, people with kids were terrified of their kids being taken away. But 9% The only reason they weren't with their kids was because they were homeless, meaning that they lost their housing, they were actively parenting their kid, their child was not in Child Protective Services. And they were able to park their kids somewhere and had to endure child separation, not imposed by the state, but imposed by their current condition. They told us something that they recognized that they were being read by the system as a single adult having very low priority to housing. And if they were ever offered any shelter or housing services, it was going to be without regard to their children. And they basically said we're not going to move anywhere that our children, they were being misread by the system,

Shane Phillips 48:56
Snd to get that priority would require them to bring their child into this, you know, into homelessness, basically

Margot Kushel 49:03
Into homelessness where their child was at incredibly high risk to be taken away by Child Protective Services, extraordinary risk of

Shane Phillips 49:10
Doing the responsible thing in

Margot Kushel 49:12
100%.

Shane Phillips 49:13
Yeah,

Margot Kushel 49:13
Just an impossible Catch 22 situation.

Shane Phillips 49:18
We often hear that mental health problems and other issues increase the risk of homelessness, but they also are exacerbated by homelessness. And I'm curious what you heard on that front, sort of the distinction between those things and just how people thought about problems that they might have already had getting worse during homelessness or problems that they may not have had kind of being triggered by homelessness.

Margot Kushel 49:43
So overall, 27% of our participants had at some point in their lives had a psychiatric hospitalization. This is through the roof number. About a third had had a suicide attempt not just due to suicidal ideation, that's a breathtaking number and speaks to the suffering of people 56% of those who had had a psychiatric hospitalization, their first hospitalization had happened before their first episode of homelessness, mental health conditions in this country continue to be highly stigmatized and difficult conditions. And so they do increase people's risk of homelessness. But you know, I think when we reported it, we knew that this statistic would get misinterpreted a lot. 66% of everyone had serious symptomatology, or symptoms of a mental health problem, we asked about symptoms rather than diagnoses. Because if you don't have access to, you know, medical care, you don't get a diagnosis, you just have the symptoms. But those symptoms were primarily depression and anxiety, about almost 50% of everyone had depression and 50, almost 50% had anxiety symptoms. Now, if I were living outside, you know, getting at risk of sexual assault or getting sexually assaulted, seeing what I saw, I would be pretty depressed and anxious to, and people definitely spoke about that. And we've shown empirically from our other work that when you house people, their depression gets better, even absent, even absent treatment. So mental health symptomatology was high for sure. When we looked at other indicators, for instance, hallucinations, about 14% had ever had hallucinations 12% Were currently experiencing hallucinations. After we published the report, we develop this metric of sort of who is having behavioral health conditions. So we basically said, if either you were using illicit drugs three times a week, or more drinking heavily, one time a week or more experiencing hallucinations, or had a recent psych hospitalization, 5% of people had been in a psych hospital in the past six months, 47% of the population had one of those four conditions. And I think that that is really important for us to know, for targeting resources, we have shown empirically that folks with those problems, not only can be housed successfully, but have to be housed successfully, that's their only chance at treating those problems. But we need the resources to do that they need the supports that go along with housing, we again, we know how to do this, but we need to make sure that we have those supports, that these folks need to help them thrive in housing.

Shane Phillips 52:17
This is sort of making me think about, you know, the amount of resources needed. And I guess where I'm going with this is, it seems that because we have let this problem gets so out of hand, there are a lot of people who need really intensive support, maybe you know, permanent support, who if we had never allowed them to become homeless, or at least stay homeless for so long, they might not need such intensive support

Margot Kushel 52:45
100% that these conditions, mental health problems, substance use problems, they're definitely risk factors for you know, losing out in this type housing market. But what people don't understand is by not intervening by not preventing their homelessness, or by leaving them out there. So long, people deteriorate terribly, their mental health gets worse. You know, when you think about it, when I think about it as thinking of wearing my physician hat, you know, what you want to do for people with a mental health problem is not only get them formal treatment, but you want to sort of stabilize their environment, get them sleep, get them social support, you know, all of the things, you know, increase meaning in their lives. People who are experiencing homelessness have exactly the opposite of that. They're terrified. They're sleep deprived, they're getting victimized, they're not getting any access to treatment, we saw ridiculously low rates of anyone getting any treatment for mental health problems,

Shane Phillips 53:41
Which is ironic, because people end up in the, you know, emergency room and things like that is exactly what I hear about. And yet it's not actually exactly treatment.

Margot Kushel 53:50
Again, we're like talking about forced treatment, but only 18% of people who had these really significant mental health symptoms, were getting any treatment. And we were pretty liberal in what we counted. You know, if your primary care provider had thrown some Zoloft at you, we're like, we'll have a count. If you were in a peer support group, we're like, Sure, we'll count the people. We're just not getting any help for the symptoms. But I think your point is so well taken is that we're taking folks already at risk, and we're making things so much worse. And so a lot of those folks, if we had intervened quickly and not left them out there for two years, they might have just needed a little bit of subsidy to get them back into housing, but because they've gotten sexually assaulted because they're gotten physically assaulted, because there have been so exhausted and helpless and you know, all these and hopeless and all these other things. Now they're going to need quite a bit of support to get stabilized again, that they wouldn't have needed had we intervene faster,

Michael Lens 54:51
Maybe pulling together a couple of the things that we've talked about and also looking for some glimmers of positive Every year hope here like we talked about sweeps in. And I think that one of the dare I say positive objectives of sweeps, at least according to the rhetoric of some of the local governments that engage in this, you know, specifically reading things that Los Angeles, la casa other agencies specify here is that they're trying to use sweeps as a mechanism to get people into housing to provide offers of housing, did you uncover any success and an image? I guess it doesn't have to be really just attached to sweeps. But like, any success from at the local level of intervening on the street, getting people connected to housing, is there anything going well, on that front?

Margot Kushel 55:51
Absolutely. I think a couple things, you know, like 41% of people in the study told us that at some point, they'd wanted emergency shelter and hadn't been able to access it. Like we don't have enough emergency shelter, you know, like, but the other part is a lot of people talk to us about their hesitation about emergency shelter. There are lots of rules, they're, you know, they're really crowded, they're scared of COVID. They're scared of violence, they don't want to abide by really sort of dehumanizing rules, whatever. Nobody didn't want housing. And I think that people allied those things. And they misunderstand that someone's saying, I don't want to go into huge congregate shelter. They then abstract from that, that people don't want to go into housing. People told us they wanted to be housed every it was almost like an absurd question. They looked at us like we had two heads, like, of course, I want to be housed. And again, empirical evidence have shown that there's also lots of evidence that people can go right from an encampment into housing, I like to say that the system can't handle it. Because you know, you need to get all your paperwork in order. And you need to fill out all these forms. And you know, and all of this, but individuals can. One really interesting thing that LA is doing is that Mayor bass just got a waiver from HUD from the federal government to allow LA to move people into housing without having all of their paperwork in order sounds like a small thing. But it's a huge thing. She got I think, I think it's 90 days, where the promises look, if we can't get their paperwork in order in 90 days, then we'll kick them out. But they know that they can get people's paperwork in order once their house. And they have shown that they've pulled a lot of people right from encampments right into housing. And there's, by the way, lots of other studies have shown that like we get in our own way here, I just don't think that you know, having police come and throw everyone things out, including their medications and their documents is helping us get there. And the best practices, there are best practices for what's called encampment resolution, or sort of getting rid of encampments is to offer people first of all to come in as a community people build really close attachments in those encampments. By necessity, they're watching out for each other, they don't want to leave people behind. There's like enormous survivor's guilt if one person gets in and not. So cities that have done this, well, like Houston, basically brought entire encampments inside gave them privacy and the ability to bring their partners in and their pets in and their belongings in, brought them inside as a community, and then quickly got them all housed, and then they moved on to the next encampment. So my fear about force displacements is that we're just moving people from one bad place to another place. What what has been shown empirically is if you go you spend some time you build some trust, and you have something to offer people that they want, which is housing, you can, you know, get people that really quickly. And so I was thrilled to see La get that change from HUD, HUD is aware that lots of other people will be asking for it. Obviously, we don't have enough vouchers, we don't have enough housing supported by HUD, that's the biggest problem here. But the least we can do is get out of our own way and make it easier. And then they've shown proof of concept. We also saw, you know, during the pandemic, when we had to move huge numbers of people into project room key wasn't nearly as good as housing, but at least it was non congregate shelter. It was like hotel rooms and stuff. It was really easy to get people to accept that housing is even easier.

Shane Phillips 59:14
So just to flag for folks, we are we are now in chapter four, which is a about barriers to and facilitators of returns to housing. Another one that I wanted to ask about was people's experience with case management and housing, navigation, these kinds of services that are often provided at the place that people are living in an encampment or otherwise, what were some of the things that people experiencing homelessness had to say about these different service providers, both positive and negative.

Margot Kushel 59:45
So first of all people recognize it is a barrier that they not having it they said was a barrier. And the flip side was that people thought having a housing navigator would be very helpful. We didn't use that term because that's kind of jarring. going on, but we sort of said, you know, having someone who will help you identify housing helped negotiate with the landlord help get your paperwork together. A huge portion, people I think was 94% said that having something like that would be a huge help and getting them housed. So that's the good news and people who had had, we're working with housing navigators generally like them. The flip side was that people just hadn't been getting help. Only 46% of people had had any contact with anyone like a housing navigator during their whole episode of homelessness. And then we asked, like, how about in the past six months? Have you had anyone? And if you had, how often have you seen them? Because you can imagine that for housing, navigation to work, it needs to be pretty intensive, you know, you need to meet with people constantly, you need to be like showing them apartments, negotiate with landlords, you know, getting everything together. Only 26% of people had had monthly are more often contacted the housing navigator in the last six months. And, you know, monthly is not enough, but we needed something.

Shane Phillips 1:01:01
Did you? Did you see a lot of variation regionally in that, you know, I we're just investing so much here in Los Angeles in services over the last five or six years. And I would hope that we're doing better than average. But of course, a lot of places have not made those same investments.

Margot Kushel 1:01:16
Yeah, I mean, I would say La has made so many investments, but it has such a huge number of people, the scale of the crisis in LA and, and I'll say for everyone, you know, we weren't eight counties, we're keeping all the counties secret, except for LA, because LA was its own region. So it was definitely included. And we're allowed to say that, which is why we're talking about it. But LA, you know, we didn't so much notice a difference between regions, as we noticed a big difference between people who are sheltered or unsheltered. And that just goes to the fact that like, you know, if you're in a shelter, it was a lot easier for housing navigators to find you. And folks in shelters were relatively happy with the services that they were getting. And people outside of shelters either had had bad experiences or didn't think they would help. Or maybe it was just because they knew they could never get into shelter. But what people unsheltered told us is that people who had had one, but now weren't in touch with them, said, you know, like, I had this guy really helpful, it was great. And then you know, and then I don't know, I got swept, my phone got turned off, I lost my phone, my phone number changed, I don't have a phone, you know, they just can't find me and I lost track of them. It's just another way in which having people move from place to place to place is really hard. And, you know, people told us in depth interviews, like really poignant stories, like they are like, I'm sitting out here, nobody has come to help. And like, I have no phone, no car, no access to the internet, no way to take a shower. No, you know, what am I supposed to do? Like? How would I ever How am I ever gonna get out of here.

Shane Phillips 1:02:55
Another barrier that you call out is hopelessness. And I want to highlight this quote from a participant, quote, they tell us, you're on the waiting list and all this, it's been three years, how long can the waiting list be? We should be priority according to what the news says all the time, we should be priority to get us off the streets, and they don't. Some of these guys have been out here for 20 years. I understand you get the elderly and those out of the way health conditions, but they tell us the same thing all the time. Your next your next is just stressful. Unquote. What role do wait lists and feelings of hopelessness that can result from that kind of thing and other things, play and all of this both as you know, a general stressor in people's lives, but also specifically in their efforts to get back into housing?

Margot Kushel 1:03:44
Yeah, I mean, I think this is where there's this big public disconnect. You know, there's a sense like, Oh, we're spending so much money. But I want to remind people, we're spending a lot of money. And we're not spending nearly enough, right that like that the crisis, the scale of this crisis and the hole that we're in, by both not having created sufficient housing in California, and not having rental subsidies or other ways. You know, it's like, we've been fighting for $15 an hour. I love that movement. And it's so great that we have a $15 an hour minimum wage, but in most of the state that housing wage is like $40 an hour, right? We just like there's no amount of money you can throw at a homelessness crisis, to make up for that fundamental, deeply ingrained gap. And once again, how it disproportionately affects people of color, right, like we've got a call out the role of racism here. This is like this is all tied up as one. But I think the weightless point to the fact that, you know, the public likes to think like, Oh, these people don't want housing, we need to force them to get housed. That is just not true. There is no housing. This is a problem of scarcity. And so people are sitting on weightless and they're losing hope out there and frankly, they're dying out there. or, like people are very aware that the public is angry at them, they are very aware that they are being blamed. They are very aware that they are seen as, you know, less than human or terrible or causing all these problems. They feel those sentiments on a daily basis. And they're also trapped. Because they're like, what more can I do like there, there is no housing, I've been on waitlist. Now, you know, most people can't even get on weightless, and then you're on waitlist. And so and then they're being told to move you can't be here. And their question to us is like, where am I supposed to be. And so it really this pressure cooker of both that hatred thrown at them and the resentment thrown at them, the displacements and the negative interactions, and just the lack of any realistic options. You could imagine what that does to a person's mental health to their sense of hope for the future.

Shane Phillips 1:05:59
I mentioned to you that this is going to be part of a series and the later episodes are going to really focus on different interventions and how effective they have been or have not been. So we don't have a whole lot of time anyway, to get into policy recommendations. But I do want to give you the chance just to kind of give some maybe bullet points, in addition to what we've already talked about, like what are the high level priorities on policy to address this

Margot Kushel 1:06:23
The first priority like I joke like the first 20 priorities have to be housing, right? The way out of homelessness is housing, we talk a lot about not only increasing the supply, but also increasing the subsidies, we're going to need the federal government to get involved here. And then we're going to need to be smart about how we use them, right, you need to housing subsidies don't help if you don't have the housing to put people in. But they also don't help if property owners are allowed to discriminate against people who carry vouchers. Because those discrimination laws aren't enforced. You're going to need housing navigators, housing navigators with no housing to navigate to is less helpful. But housing without housing navigators isn't going to work, either. So we talk a lot about housing, housing, housing, and then we'd like throw out some ideas about like things like shared housing, maybe not everyone can get their own studio apartment, we asked people a lot would you accept housing with someone else. And what they basically said is, I would need to be able to choose who that was, I would need to have some ground rules, I've needed my own bedroom. That seems pretty reasonable to me. But I think we can be more creative and how we do it. We have recommendations around prevention, people were pretty optimistic about small amounts of money, three to $500, a month, a five to $10,000, one time subsidy, but we raise the caution that it's all about targeting. And so those need to be piloted, although focusing on people leaving institutions, to me seems like a no brainer. We talk about the need for appropriate behavioral health treatment, a lot of these folks are suffering terribly. And we need to make sure once we have the housing that we have the behavioral health support, but frankly, we need to keep people alive while they were out there. We need to be getting into the encampments, bringing people treatment preventing them from overdosing, like, we know how to do this, but we need to kind of do it. And finally, we really need to think about this all through a racial equity lens. Like we cannot have conversations about this crisis. You know, we I feel like we talked about mental health and substance use almost as a way to ignore the elephant in the room, which is that, you know, 6% of people in California, I think six or 7% identify as being Black or African American and 26% of those experiencing homelessness do. indigenous folks, we did not go onto tribal land in this study. And even without being on tribal land, native folks were just vastly, vastly over represented in the study, like we need to really grapple with those issues and make sure that our solutions take that into account and are addressing those disparities.

Shane Phillips 1:08:54
Last question here, anyone who's ever worked on a survey knows that no matter how much work you put into it, and it sounds like you all put more work into this than just about anyone has ever done a survey you're gonna come up with people are going to answer things in ways you didn't anticipate you're going to regret not asking certain questions. What do you wish that you had asked in the survey that you didn't?

Margot Kushel 1:09:16
Oh, yeah, we have Google Docs and was just a mistake. Like, somehow the question on whether you'd ever been in the child welfare system accidentally got turned off, and it didn't get asked, I was like, Oh, no. Some of it was things, you know, we wished we'd ask people who are doubled up about how long like were they evicted or threatened with eviction? And like, when did that happen? Like? So we wish you would ask a little more about that. We actually did not ask people directly, maybe because we thought it was so obvious, but I sort of regret just not saying yes or no. Do you want housing? It's, you know, I think people would have laughed at us. But we didn't actually ask that. We did lots of the in depth interviews and we asked in different ways, but we didn't just ask that. And I wish we had gone into more depth on the pregnancies. I wish we had And asked about where those carry to term. Did people receive health care? Were they electively terminated? Do they have a you know, miscarriage? Was it the result of sexual assault? Or, you know, we wish we had gone a little more into that because we think that's really important.

Shane Phillips 1:10:17
Well, this has been outstanding. I think it's going to be really great context for the rest of this series. So Margot Kushel, thank you so much for joining us on the housing voice podcast.

Margot Kushel 1:10:25
Thanks so much for having me.

Shane Phillips 1:10:31
You can read more about Margot's work on our website. lewis.ucla.edu. Show Notes and a transcript of the interview are there too. Mike and I are on Twitter and you can find the UCLA Lewis Center all over social media. Thanks for listening. We'll see you in two weeks with part three of pathways home