One resident of 5 Franklin Street, a boxy gray building with a flat top and a long wheelchair ramp, has lost his legs and his hands. Two were paralyzed in motor vehicle accidents. Several live with profound mental illness.

All 14 residents of this home in Northampton have complex medical challenges, and all had been homeless for years, living in shelters or on the street, until they moved into Independent Housing Solutions, a program founded in 2023 by Dr. Jessica Bossie, a primary care doctor who cares for homeless people in Western Massachusetts.

Bossie’s program serves the most vulnerable and medically needy, offering what she calls “ultra-supportive” housing with daily medical care.

But now, this program and dozens of others around the state may have to shrink or close — and some are already declining to accept new clients — because of a looming change from the US Department of Housing and Urban Development that up-ends a two-decade-old approach to housing policy.

The Trump administration wants to curtail “permanent supportive housing,” which was built on a philosophy called “Housing First.” The move jeopardizes some $91 million in federal funding that supports nearly 4,000 Massachusetts households, said Joyce Tavon, chief executive officer of the Massachusetts Housing & Shelter Alliance.

These programs emphasize getting a roof over someone’s head before requiring that they address their mental health or substance use issues, on the premise that people who have been homeless for years need the stability of housing before they can get better. Clients get their own apartments with no requirement to leave within a certain time period, and the agencies provide case management and counseling.

In an executive order on homelessness last year, President Trump denounced Housing First programs, saying they “deprioritize accountability and fail to promote treatment, recovery, and self-sufficiency.” The Trump administration favors “transitional housing” that sets requirements for entry, such as sobriety, and expects people to move on to their own housing and achieve self-sufficiency within two years.

“This idea that there’s this short-term solution and everybody will just be self-sufficient after two years is completely unrealistic,” said Janna Tetreault, associate director of programs for Community Action Pioneer Valley, an anti-poverty agency that manages housing applications in Berkshire, Franklin, and Hampshire counties.

HUD announced in November that it would reduce spending on permanent supportive housing from around 90 percent of federal homeless-housing money to 30 percent — requiring agencies to reapply under the new terms.

A court injunction in December put a temporary hold on this plan. And the appropriations bill that Congress passed in January slows down the changes somewhat. But HUD has filed a motion seeking to institute the new policies with agencies whose contracts are up for renewal in the second half of the year.

“The upshot is there’s continuing chaos and uncertainty,” Tavon said. “No one knows how to proceed.”

The changes come at a time of persistently high homelessness in Massachusetts. The 2025 “point in time” count — when volunteers across the country count the number of homeless people on a single night in January — found an increase in the number of sheltered and unsheltered adults in households without children in Massachusetts, from 6,912 in 2024 to 7,257 in 2025. The statewide results of the 2026 count have not yet been tabulated.

Meanwhile, even as they hope for further relief from the court, Housing First programs are bracing for the worst. “The long term plan of this administration is to get out of funding this kind of housing,” Tavon said.

The actions in court and Congress are “really just buying us time,” she said. “We’re collectively shifting into a huge project of contingency planning” trying to arrange alternative housing. While finding homes for their clients is the top concern, providers are also worried about losing housing inventory as those units come off line, Tavon said.

The uncertainty has also had immediate repercussions. You can see the evidence on the white board in Bossie’s office. It displays a list of 16 room assignments in pink ink — but room numbers 104 and 207 are blank. Despite a long waiting list, Bossie doesn’t want to admit residents only to have to evict them a short while later.

“We don’t want to promise them a program that’s going to provide support, but then have to eliminate that because we don’t have the funding,” she said, adding that her contract with HUD expired Feb. 1, and the department has yet to provide her with a new application, leaving her scrambling for stopgap funding.

Around the state, other agencies — though no one has an exact count in a fluctuating situation — have been leaving some apartments empty or not renewing leases.

“Do you take someone who’s extremely vulnerable, maybe been homeless a long time, put them in an apartment where you only have a lease for another year?” Tavon said. “All across the state, there are a lot of nonprofits that have entered into leases with private landlords, and they’re really going to have to wrestle with them as those leases come due.”

In Hampden County, at least eight slots for homeless youths are not being filled even though there are young people who need housing. The programs were unable to “find landlords who will participate with this level of uncertainty,” said Geraldine McCafferty, Springfield’s housing director.

Hampden County has 304 units of permanent supportive housing for chronically homeless, disabled people. But several housing providers have indicated they would stop offering such housing, telling McCafferty “we can’t manage this level of instability,” she said. Those programs will try to shift their residents “to some kind of public or subsidized housing and make sure that they are connected with every available service in the community to support them,” she added.

But ultimately, if HUD goes through with its plans, more people will be living on the streets, McCafferty predicted.

Action Inc., a Gloucester-based human services agency, has decided it will not fill any permanent supportive housing units that become vacant, said Erin George, division director of program services. The program gets funding for 57 permanent supportive housing units scattered around the North Shore.

So far, one slot has been left empty, after a person left the program in December. People stay for an average of three years, and one has been there for 13, George said. Action Inc. helps those who are poor, often disabled, and have lived much of their lives on the street. For many, this is the first time they’ve had an apartment of their own. “It takes them maybe the first year or two just to acclimate to having their own place,” she said.

The agency’s contract with HUD expires in December, and George is not sure what will happen to residents if funding is curtailed after that. There’s a long waiting list for Section 8 housing, and high rental costs in the private market.

“This isn’t necessarily a population that’s going to quickly stabilize, find a job, and be able to move on,” George said. “Even if there’s those folks that can, the reality of the housing situation that we are in does not even make that possible.”

The Housing First concept originated in the 1990s with the Pathways to Housing program in New York City. A study published in 2000 showed that people with severe mental illness in Pathways to Housing were more likely to remain housed for five years than those in traditional residential programs.

The concept quickly won support at the state and federal levels.

Massachusetts was one of the first states to promote it, Tavon said, with a 2006 pilot project called Home & Healthy for Good, which 20 years later continues to help pay for more than 1,300 housing units.

The administration of President George W. Bush also supported Housing First and it became a routine part of HUD funding, with bipartisan support.

When the Housing First model came along, “it was like a miracle,” said Dr. Jim O’Connell, president of Boston Health Care for the Homeless Program. Until then, the barriers prevented the most vulnerable of his agency’s patients from ever getting into housing.

Research shows that Housing First does help chronically homeless people get stable homes — and it’s been especially effective with veterans and people with HIV. But overall the evidence doesn’t show improvements in health or mortality.

“Housing First just hasn’t worked,” said Rachel Sheffield, a research fellow in welfare and family policy at the conservative Heritage Foundation. The foundation’s Project 2025, a source of many Trump administration policies, had called for the dismantling of Housing First.

Sheffield acknowledged that Housing First policies successfully keep people in housing. “But the downside to it,” she said, “is that it does not seem to effectively address deeper issues, like mental health and drug abuse, alcohol abuse.”

Permanent supportive housing “might be an option for some people, but it should not really be the primary focus,” Sheffield said.

She supports a shift to emphasizing short-term shelter in which people could “work their way up” to an apartment and “lose that privilege” if they can’t stay sober.

“The goal is to get people not just to be in [government-funded] housing forever and ever, but to actually move towards greater self-sufficiency,” she said.

O’Connell noted that most of the research into Housing First has looked at results after six months or a year or two, even though the individuals involved have conditions that have persisted for decades. It would make more sense to see how it’s working after five or 10 years, he said.

And, it’s “unfair” to expect housing alone to solve problems that originate in a person’s childhood trauma, untreated mental illness, long-term substance use, and years living on the street, which in turn emerge from broad societal failures in poverty, foster care, incarceration and education, he added.

“The government adopted Housing First as a way to go, but the emphasis was on the housing,” O’Connell said, “and the government did not really fund the degree of social and health services that people need once they get in.”

That reality, in fact, is what prompted Jessica Bossie to open Independent Housing Solutions, which is unique among permanent supportive housing programs for the level of medical care it provides.

As a primary care doctor who cares for homeless patients, she found herself facing one crisis after another, as her patients repeatedly got evicted from housing. One patient with psychosis thought the light bulb was talking to them and damaged the ceiling. Another was hoarding, while someone else had body lice that had infested the entire building.

“We would pour resources into these people who were just chronically homeless for years and years and years,” she said. But their needs couldn’t be met in nursing homes, rest homes, or independent supportive housing, and “they would just end right back up at the shelter.”

“It was very clear to me that chronic homelessness is a symptom of an underlying health condition — every single time,” Bossie said.

Bossie cobbled together private and government funding to buy a former office building and open Independent Housing Solutions in March of 2023, accepting 16 of the most vulnerable patients in the region — people who could not live anywhere else.

One of her residents ran up $800,000 in hospital bills in the year before he moved in, including an eight-month stay because no place would take him when he was ready to be discharged. In the eight months since, now living at Independent Housing Solutions, he’s had only one ER visit, Bossie said.

Some residents had been evicted from nursing homes. “One of them was using drugs. One of them raced his wheelchair. Just raced his wheelchair down the hall — that was enough for them to kick them out,” she said. Another was deemed “mouthy” and uncooperative.

In housing and caring for these complex patients, Bossie calculated that she spends $41 a day per resident. In contrast, she notes, a nursing home costs $316 a day, and a hospital visit more than $3,000. About two-thirds of her $242,000 annual operations budget comes from HUD. The rest is funded by the state plus small amounts in donations and rent. (Residents kick in 30 percent of their income.) This shoestring level of funding, she said, is “unsustainable.”

Bossie doesn’t collect a salary for her work at Independent Housing Solutions. She is a full-time employee of the Hilltown Community Health Center, which allows her to spend part of her time seeing patients at 5 Franklin St. A nurse from Hilltown visits weekly. Independent Housing Solutions has only three employees — one full-time program director and two part-timers who take care of the building and its residents at night.

The nurse and the staff are focused on making sure patients get what they need — administering monthly antipsychotic injections, dispensing other medications, signing people up for visiting nurses when they qualify, and working to connect patients with personal care attendants covered by their health insurance.

One of the residents, 65-year-old Bob Savard, worked in construction for 50 years, returning to the job even after a fall broke his ribs and injured his back. He eventually moved into arborist work, but soon learned that he suffered from Buerger disease, a rare condition, possibly caused by tobacco use, in which blood vessels in the arms and legs became inflamed and blocked. He had one leg amputated, then the other, then his hands.

At the time he was living in West Springfield with his girlfriend and daughter, but after his girlfriend was injured in a car accident she could no longer take care of him. He went to a nursing home but found it “unbearable,” with too many restrictions, flavorless food, and only one shower a week.

He left for the street, and lived on Main Street in Northampton for three years.

“I met a couple of guys, they really took care of me,” he said. “There’s some really good-hearted homeless people out there.” But he lived around the clock upright in his wheelchair, developed frequent infections, and started using heroin to deal with the constant pain.

When Bossie offered him a home three years ago, Savard was thrilled. Now he has his own room, a therapy dog named Lady, and a personal care assistant paid for by his insurance. He can get in and out of bed himself, and comes and goes as he pleases in his wheelchair. He said he stopped using heroin after he moved in.

“I love it here,” he said. “I have my freedom. … Before when I was on the street, I would have to cruise around and look for certain people to help me. I have somebody here all the time.”

Savard had always supported President Trump. But after learning that changes in HUD funding could force the program to close or to evict him, Savard had this to say: “You want to put me back on the street? I’ve worked and paid taxes most of my life. You’re gonna put me on the street again?”