Health and economic impacts of stable housing provision for older adults

IMPORTANCE: The population of adults experiencing homelessness in the US is aging, with 20% now 55 years or older. Individuals who are unhoused, but especially those who are older, experience substantial morbidity and mortality and incur the high costs of acute health care. 

OBJECTIVE: To assess the health outcomes and cost of providing stable housing to older adults experiencing homelessness in the US. 

DESIGN, SETTING, AND PARTICIPANTS: This was an economic evaluation using a model-based cost-effectiveness analysis of adults experiencing homelessness in 2025 in the US. Two simulated cohorts of 1000 adults were used to compare those aged 55 years and older to those aged 18 to 54 years. 

INTERVENTION: Provision of stable housing, with no requirement to enter treatment for opioid use disorder. 

MAIN OUTCOMES AND MEASURES: Overdoses and deaths during a 5-year period, lifetime per person discounted quality-adjusted life-years (QALYs) and costs, and incremental cost-effectiveness ratios compared to the status quo (no housing provision). 

RESULTS: The analysis assessed and compared 2 simulated cohorts of 1000 unhoused adults each: an older cohort of those aged 55 years and older (mean [SD] age, 62.6 [7.5] years; 321 females [32.1%], 679 males [67.9%]) and a younger cohort of those aged 18 to 54 years (mean [SD] age, 39.2 [9.5] years; 319 females [31.9%], 679 males [67.9%]). Among the older cohort, under the status quo, 218 (95% CI, 209-229) deaths occurred over 5 years, with 5.64 (95% CI, 5.11-6.20) lifetime QALYs and $308 598 (95% CI, $299 000-$318 000) in costs per person. With the stable housing intervention, 184 (95% CI, 176-194) deaths occurred over 5 years, with 7.52 (95% CI, 6.82-8.26) lifetime QALYs and $460 673 (95% CI, $438 000-$485 000) in costs per person. The intervention cost $80 700 (95% CI, $67 900-$96 100) per QALY gained. Among the younger cohort, under the status quo, 72 (95% CI, 60-90) deaths occurred over 5 years, with 9.60 (95% CI, 8.65-10.67) lifetime QALYs and $391 976 (95% CI, $367 000-$415 000) in costs per person. With the stable housing intervention, 62 (95% CI, 50-78) deaths occurred over 5 years, with 12.13 (95% CI, 10.94-13.37) lifetime QALYs and $530 492 (95% CI, $496 000-$564 000) in costs per person. The intervention cost $54 800 (95% CI, $44 200-$68 500) per QALY gained. In sensitivity analyses, the housing intervention for older adults experiencing homelessness consistently cost less than $100 000 per QALY gained. 

CONCLUSIONS AND RELEVANCE: In this economic evaluation, investing in stable housing for adults of any age who were experiencing homelessness saved lives, improved health outcomes, and was cost-effective. As the homeless population continues to age, meeting the housing and care needs of older adults in vulnerable conditions is an increasingly urgent national priority. These findings strengthen the evidence demonstrating that permanent supportive housing for older adults experiencing homelessness is a health intervention with strong humanitarian, clinical, and economic justification.