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To Fix Homelessness, Stop Fixating On Housing

homeless man in San Francisco
Image CreditBrandon Evershed/Flickr/cropped/Public domain

The homeless are often both mentally ill and addicted. Yet the government persists in treating homelessness as almost entirely a housing issue.

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Homelessness affects cities across the country, but it’s not just a local issue, though media cover it that way. Nor is homelessness mainly about housing; rather, it’s largely about untreated mental illness and drug addiction. Consistently misdiagnosed, homelessness is being wrongly addressed. And the policies that give rise to homelessness largely come from Washington, D.C., not localities. A bill called “Housing PLUS” has been introduced in Congress by Rep. Andy Barr, R-Ky., with 22 sponsors, to start to rectify these policies.

A national mental illness crisis has been building since the deinstitutionalization of the mentally ill began in the 1960s. Drug addictions also have increased and most surveys show that the “homeless” are often both mentally ill and addicted. Cases like the recent death of subway disrupter Jordan Neely in New York City underscore the frightening dangers of untreated psychotic behavior. Yet the Biden administration, Congress, and many regional officials have persisted in treating homelessness as almost entirely a housing issue.

Until now — maybe. “Housing PLUS” would redirect 30 percent of federal housing funds to mental illness, addiction services, and job training. North America Recovers, a new alliance seeking to reform government’s approach to homelessness and addiction, supports more sweeping changes, but sees Barr’s bill as a good start.

Eric Adams in New York City is unusual among mayors in budgeting for increased mental health and addiction treatment, not just housing. San Antonio has reduced street-level homelessness by 85 percent over the past 14 years by prioritizing long-term treatment. Voters in King County, Washington (Seattle’s metro area), recently approved a property tax increase to fund $1.2 billion for such purposes over the coming decade.

Federal Efforts Failing

But the big bucks for homeless programs come from the budgets of the departments of Housing and Urban Development, Veterans Affairs, and Health and Human Services, and from the National Institute of Mental Health. There they typically encounter relatively little interest, let alone congressional scrutiny.

HUD emphasizes housing vouchers, virtually as a cure-all, ignoring other strategies. Success is measured by how many housing vouchers are distributed, not by how many homeless people progress to greater independence. The “housing first” policy began under President Barack Obama, when it was predicted the policy could end homelessness by 2023. But here we are, it’s 2023, and while some improvements have been seen nationally, many communities have more street people than ever.

“Housing first” simply does not work well for folks who resist lodging that comes with rules against drug use or whose mental illness is made worse by isolation in housing that lacks services for their behavioral issues. The costs of new apartments, meanwhile, especially in California and other heavily regulated states, quickly eat up capital funds.

Is change possible? Barr’s proposal does not anticipate an increase of federal funding, just an adjustment of priorities. This is meant to make it palatable to Republicans. Limiting the non-housing percent of funds to only 30 percent is meant to make the bill palatable to Democrats.

Unfortunately, even Barr’s modest bill may go too far for Democrats. Many seem in thrall to the “homeless industrial complex” — the developers who gain from new housing subsidies,  progressive theorists and activists who perceive homelessness as an indictment of capitalism, and a civil liberties bar that resists efforts to push addicts and mentally ill people into treatment, even if they present a danger to themselves or others. “Bodily autonomy” and “harm reduction” are current statements of a strange laissez-faire social philosophy that in many cases now consigns addicts, effectively, to a slow death.

Lack of Demand for Action

But the general voting population, which obviously dislikes homelessness, has been unaware of the way legislative theories and federal funding helped generate and sustain the problem. One might expect more public demand for congressional action given the diseases, overdose deaths, and crimes against people living on the street; the untold costs to emergency rooms and jails where homeless people in crisis wind up; the shoplifting, car prowls, and random violence perpetrated by some street people to finance their addictions; the damage homelessness causes to downtown areas in places such as San Francisco; and the huge market helping suck deadly fentanyl into America from China via Mexico.

But most media and politicians have failed to explain the connections between federal policy and realities on the local street. Nearly every time someone pushes a stranger in front of a subway train, shoots up a school, or drives a car into a crowd of pedestrians, it turns out (usually well down in the news story) that the perpetrator has a long-established problem of untreated mental illness. Stories about border issues involving fentanyl are vivid on the nightly news but seldom show the end results in American cities: uncontrolled addiction and death.

Even in states with “Kendra’s Laws” that allow the involuntary treatment of people whose mental condition makes them a danger to themselves or others, some district attorneys and judges are loath to apply these laws. And if they do, there often are not nearly enough psychiatric facilities available to handle such cases.

Just a First Step

In this larger context of social disintegration, even the Barr bill seems like a mere first step. It would amount to only about $3 billion, spread nationwide, and it would entail limited services. At this point, Congress and the White House should be mobilizing a much larger federal response, and that certainly should include long-overdue reform of Medicaid.

Mental patient deinstitutionalization was itself seen as a reform in the 1960s. But at that time the promise of new drugs to treat mental illness was exaggerated, as was the hope that most patients would be better off in small community centers than in specialized state hospitals.

Such well-meaning hopes also were linked to a desire to cut expenses at the state government level, where mental health care had long been centered and funded. The Medicaid Act of 1965 intentionally offered payments for only a small share of most state hospital psychiatric care, while simultaneously offering to pay for less costly community services. That effectively encouraged states to cut their own financial commitments for state hospitals.

Deinstitutionalization has now proceeded to the point that we have only 5 percent of the number of psychiatric beds as at the time the Medicaid exclusion went into effect. As for small community-based treatment, it didn’t become a successful option, in part because caring for serious mental cases without adequate professional staff on hand and without the means to monitor drug treatment is seldom successful. Summarizing the situation, the recent director of the National Institute of Mental Health, Dr. Thomas Insel, acknowledged in his 2022 book, Healing, “We so overcorrected the problematic state of institutions in the 1960s that we effectively created an enormous deficit in psychiatric beds.”

The Congressional Budget Office estimated this year that it would take $38 billion over a decade to refund the nation’s mental hospitals. Obviously, that figure scares everyone, though there doesn’t seem to be any economic estimate of what not dealing with America’s mental illness problems is costing society today.

Cities and states, for their part, should stop releasing without bail or jail time drug addicts and mentally ill people who commit crimes, and they need to use the threat of punishment as a way to induce street criminals to accept treatment. States need to step up their own funding for mental hospitals. The federal authorities are not the only level of government to fail the homeless and society, though Washington, D.C., has much more responsibility than it has been shouldering.

Meantime, the question arises, can Congress even get a start on reform of these erroneous and debilitating federal policies? The Housing PLUS bill of Barr is a test.


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