Where are They Now

BACKGROUND: The U.S. Department of Veterans Affairs (VA) has invested billions of dollars to address homelessness, but there has been limited analysis of long-term outcomes. OBJECTIVES: This retrospective study followed 2 cohorts of homeless veterans over 2 decades to identify long-term trajectories and predictors of mortality and continued VA homeless program use. RESEARCH DESIGN: National VA administrative data were analyzed from 2004 to 2024. SUBJECTS: A 2004 cohort of 85,533 homeless veterans and a 2014 cohort of 222,974 homeless veterans. MEASURES: Primary outcomes were mortality and continued use of VA homeless programs. RESULTS: A total of 50% of the first cohort died within 20 years (mean=63.9 y old) and about one-quarter of the second cohort died within 10 years (mean=65.3 y old). Of surviving veterans, 25% in both cohorts used VA homeless programs, and 32%-36% used VA emergency department/urgent care in 2024. In both cohorts, predictors of mortality included being older, non-Hispanic White, male, having medical comorbidities, and alcohol use disorder. Predictors of continued use of VA homeless programs included non-Hispanic Black, male, unmarried, low-enrollment priority group, military sexual trauma, and drug use disorder. In both cohorts, 61%-81% with substance use disorders received substance use treatment, but generally of short duration. CONCLUSIONS: In a homeless population with access to comprehensive health care, there is a long-term need to address premature mortality, substance use disorders, and pathways to independence. These findings signal the work that remains in the VA, and the broader challenges that may lie ahead in other national efforts to address homelessness.