Dr. Margot Kushel: West Coast a magnet for homeless

One-quarter of homeless people in the U.S. live in California, despite Californians making up only 12 percent of the population. The rest of the West Coast also harbors a disproportionate share, as do the inland neighbor states of Arizona and Nevada.

Homelessness is also more visible in this part of the country. That’s because a higher proportion of homeless people are entirely unsheltered.

In the U.S., 24 percent of homeless people sleep outdoors, or in vehicles or other makeshift substitutes not intended for human habitation. But that varies greatly from place to place.

California and New York contain the largest share of homeless people in both numerical and percentage terms. But 68 percent of California’s homeless are unsheltered, compared to just 5 percent of New York’s.

Even in the West, there are exceptions. The most notable is Utah, where the percentage of unsheltered homeless rounds to zero.

Visitors may be shocked to find tents lining cities hugging the West Coast, from San Diego in the south to Seattle in the north. Like a modern-day “Grapes of Wrath,” the tents are stark reminders of the suffering of the thousands of homeless making do outdoors.

Guest Writer

Dr. Margot Kushel serves as a professor at the University of California at San Francisco Medical School. She also maintains a clinical practice with the school’s affiliated San Francisco General Hospital and a faculty post with the school’s Center for Vulnerable Populations. Her research focuses on the causes, consequences and prevention of homelessness.

What’s to blame for such a large proportion of unsheltered homeless in the region?

Studies show it isn’t more drug use, more mental health issues or more favorable weather. It’s an extreme shortage of affordable housing.

As a physician and researcher specializing in extension of medical care to people experiencing homelessness, I have seen first hand how devastating homelessness is to one’s health.

Being unsheltered is terrifying, humiliating and isolating. People living without shelter lack access to toileting facilities, sinks and showers. They have no way to store or prepare food, and no protection from the elements. And they often go hungry.

Sleeping in makeshift beds, frequently on sidewalks and such, they get little sleep. They must contend with theft of their possessions. They must also cope with frequent forced moves, which disrupt relationships and make it difficult for family, friends or service providers to maintain contact.

People who are unsheltered are at high risk of physical and sexual abuse. If they struggle with addictions and dependencies, their drug and alcohol abuse occurs in plain sight, leaving them particularly vulnerable to arrest.

They have no place to store or refrigerate medications, receive appointment reminders or host nursing visits, no place to dress wounds or plug in an oxygen source. Without access to hygiene facilities, they are at high risk for communicable diseases like hepatitis A.

Some assume homelessness is common on the West Coast because people move here after the fact. But research data does not support this supposition.
Most people experience homelessness close to where they lost their housing in the first place.

My team’s research in Oakland found 81 percent of homeless senior citizens became homeless in the Bay Area. Only 10 percent had lost their housing elsewhere.

In fact, the high rate of homelessness can be attributed to lack of affordable housing. The West Coast suffers from rising rental housing costs, stagnant incomes and a sharp decline in federal support. For example, California has gained 900,000 renter households since 2005, but lost $1.7 billion in state and federal funding for affordable housing.

Extremely low-income households — those below 30 percent of the local median — are at greatest risk of homelessness. Nationally, there are only 35 units available for every 100 extremely low-income households.

In the West, these shortages are even more severe: California has just 21 units available for every 100 extremely low-income households, and Nevada only 15.

For the first time in 13 years, Los Angeles opened its housing voucher wait list last year. The city drew 600,000 applicants for 20,000 slots, highlighting the enormous unmet need.

These vouchers allow households to pay 30 percent of their income in rent. The rest is paid by the federal government, but only when lucky applicants reach the top of the list.

Why are people on the West Coast also so much more likely to be unsheltered than homeless people in other parts of the country? It reflects differing government priorities.

New York City, which has declared shelter a legal right, spends about $17,000 a year, per capita, serving the homeless. Boston isn’t far behind at $14,000 per year. But Los Angeles spends only $5,000.

With enormous numbers of people living outdoors, West Coast cities are scrambling for solutions.

Some cities, like Seattle, have created sanctioned homeless encampments, featuring hygiene facilities and other services. However, the U.S. Interagency Council on Homeless cautions this approach is costly and doesn’t served to solve the root problem.

Other cities are following San Francisco’s example by creating navigation centers, a form of homeless shelter with added services. These centers allow people to come in groups, bring pets and belongings, and stay all day.

Many areas have passed tax increases to expand service options. This effort produces some modest success, but the lowest income tier continues to struggle with the unfavorable housing conditions leading people to become homeless in the first place.

My research suggests there is only one real solution — affordable housing. Curbing homelessness will require a commitment to creating housing affordable to all, even those at the bottom of the income ladder.

For people who are chronically homeless, and often suffering from one or more disabling conditions, critical support services are also essential. This requires extending safety net services without a dealbreaking requirement that sobriety be maintained or mental issues treated.

In my experience, providing housing both permanent and supportive is the key to success.


Sal Peralta

This would have been even stronger from an Oregon perspective. We are 3rd in the nation in homelessness growth in the last 2 years, most of it in rural parts of the state.


This article makes no sense to me. The article states affordable housing curbs homelessness but the key problem according to what I’ve read and seen is people need help with mental issues and substance abuse to get off the streets. If what I gleen from this article is correct this lady expects the general public that works for a living to pay for housing for these people with no strings attached? That’s insanity.


Dr Kushel has a lot more expertise and has obviously given this a lot more thought than I have, so I really want to respect her conclusions. But I have a hard time understanding how the root cause could be unaffordable housing. If I lived in San Francisco and couldn't afford the sky high housing prices, I wouldn't get a tent and live on the street. I would get on a greyhound bus and move to small town South Dakota and move into a single wide manufactured home and work a blue collar job.


"Studies show it isn’t more drug use, more mental health issues or more favorable weather. It’s an extreme shortage of affordable housing."

I realize that a newspaper opinion piece isn't a place where you would have footnotes and reference the "studies" but I would love to read these studies she mentions to see how they were done and if they were published in credible peer reviewed journals. I have a hunch that if you gathered your data by walking around the streets interviewing homeless people they might be biased to site unafforable housing as opposed to drug use and mental health issues as the cause of their homelessness.

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