Sirens blaring, ambulances rushing in, people grieving the loss of a loved one, beds filling up immediately after someone is discharged — this is the environment in San Francisco’s emergency rooms. An unhoused person in the midst of a mental health crisis can sit for days waiting for a bed and even be taken as far away as Sacramento for temporary psychiatric care.
A presidential executive order issued in July could make these conditions worse. The order pressures local governments to crack down on those experiencing homelessness, with millions of federal dollars hanging in the balance for local governments. San Francisco’s health care facilities and jails are already over capacity.
The order directs federal and municipal departments to take steps to loosen standards for involuntary institutionalization, and aims to prioritize funding for cities that ban camping and open drug use, as well as those that expand the use of involuntary psychiatric holds for unhoused or mentally ill people. Further, it threatens to slash grants for cities using evidence-based programs San Francisco has long relied on to help people struggling with homelessness and drug use. Politico recently reported that federal funding for permanent supportive housing also is expected to be drastically cut next year.
Experts said it’s unclear how the administration will determine compliance with its broad directives at this stage and thus hard to predict how San Francisco would respond to the order. Health care workers, service providers, researchers and advocates said the approach the administration is calling for could worsen homelessness by trapping people in cycles between jail, hospitals and the streets. Potential funding cuts, including those punishing evidence-backed practices that the administration disavows, could also spread existing resources thinner and upend successful policy interventions. Some sources warned of negative outcomes if the city ramps up enforcement or involuntary commitments, and if the federal government withholds funds, which they said could lead already overextended facilities to shoulder even more burden without any increase in capacity.
“The American system of emergency departments is already facing so much overflow. It’s just gonna absolutely worsen that.”
Chris domanski
The practices the administration is targeting include housing first, which prioritizes getting people off the streets and into long-term housing, even those with untreated mental health or substance use disorders. The order also punishes harm reduction, which emphasizes health interventions that save the lives of drug users over strategies that mandate abstinence or involve law enforcement. Research has found these strategies effect reduced overdose deaths and fewer emergency department visits in the case of harm reduction, and people remaining stably housed longer in housing-first programs compared to treatment-first approaches. Both have been part of the city’s approach for years.
The city Department of Homelessness and Supportive Housing and Department of Public Health were reviewing the order but declined interviews.
Sources called on leaders in San Francisco and California to take actions toward long-term funding for supportive housing and a behavioral health system that invests not just in emergency or involuntary care but also in homelessness prevention and community programs.
“It’s difficult to know how an executive order actually translates into practice. There’s so much space between that and the day-to-day work on the ground, but we know that criminalization is not effective,” said Robyn Miles, a clinical social worker at Citywide Case Management. “State and local institutions are gonna be the ones that have to invest in workers, in the community, services, treatment, because we’re just not going to be getting any help from the federal government.”
The order directs the Office of the U.S. Attorney General and the federal departments of Health and Human Services, Housing and Urban Development, and Transportation to prioritize funding for municipalities that adhere to the administration’s policy agenda.
Right now, San Francisco relies on approximately $325 million from the Department of Health and Human Services to assist people experiencing homelessness and mental illness or substance use disorders, low income and foster families, and other vulnerable residents. It receives another $240 million from the Department of Housing and Urban Development to reduce displacement, prevent homelessness and house those living on the streets.
It is unclear how much money these departments might withhold or the exact mechanisms for doing so.
Crackdowns could worsen problem
San Francisco police are already cracking down on public drug use and encampments. California has expanded the criteria for 72-hour involuntary psychiatric holds, also known as 5150s. While the exact implications of the order for the city remain unclear, sources were deeply troubled by its stigmatizing rhetoric and feared implementation would deplete funding for strategies that help people exit homelessness.
“It focuses all of the energy on institutionalization and criminalization, to be very blunt about it, without any mention of the whole spectrum of care that’s really needed to address people’s needs,” said Tara Gamboa-Eastman, director of government affairs at the Steinberg Institute, a California research and advocacy nonprofit focusing on mental health policy
Increased crackdowns on homeless encampments will only make the issue worse, sources said.
“Just moving people around doesn’t mean that they have actually gotten the treatment and the housing placements that they need,” Miles said. “If we’re not creating more housing, if we’re not actually helping people link and engage with treatment, with providers who meet them where they’re at, the problem is not going away, and, in fact, the problem is going to get worse.”
She worries that if the focus of law enforcement shifts even more to policing people for being on the street or using drugs, social workers’ jobs will shift from doing therapy with clients, getting them to their doctors appointments and helping them into new housing to taking people to court dates and other “legal stuff that doesn’t actually help people move toward any meaningful recovery,” Miles said.
The drive to criminalize homelessness, aided by a Supreme Court decision last June that allows cities to jail people for sleeping in public even if no other options are available, also threatens to further strain the city’s already over-crowded jails.
“Prisons and jails are not behavioral health providers even though they are often put in a position of being that,” said Gamboa-Eastman.
Emergency room overflow
Similarly, increased psychiatric institutionalization of unhoused people is “not a solution that actually accomplishes anything,” said Chris Domanski, a psychiatry resident who works in a San Francisco hospital emergency department. While making it easier to commit someone might temporarily get them off the street, if someone is unhoused for a reason not related to mental health, such as losing a job, “that’s not something psychiatrically I can fix, right? Like I can’t talk therapy their way into a job.”
Funneling more people into an overburdened mental health care system, including emergency departments, will only stretch existing resources thinner, sources said.
“The American system of emergency departments is already facing so much overflow,” Domanski said. “It’s just gonna absolutely worsen that.”
Without a “release valve” where people experiencing mental health crises can go, Domanski said, people could be confined to emergency departments for days on end in successive involuntary psychiatric holds, filling up limited beds needed for myriad medical conditions. As a result, he said, “everyone’s going to wait in longer lines just to be seen in the emergency department.”
Stabilizing someone in the emergency room is also far more expensive than helping them secure preventative care and other resources, Domanski said. “It’s like going and exchanging your roof all the time versus doing the basic maintenance, or getting a new car every year because you ran out of gas.”
High-cost interventions
To avoid system overload in San Francisco, the city would have to massively expand jails and locked hospital wings, which is incredibly expensive, said Jennifer Friedenbach, executive director of the Coalition on Homelessness.
Jennifer Esteen, a psychiatric nurse at the city Department of Public Health, said she is always taken aback by moves to put people in controlled settings like jails or locked psychiatric wards because they strip civil rights and work opportunities, which would enable paying for housing.
Exactly how the executive order could be implemented remains to be seen, but experts worry about threats to existing evidence-based programs like harm reduction, which studies have shown reduce risk of infectious diseases and save lives.
Amid the ambiguity of the order, Gamboa-Eastman said she worries that the “really valuable evidence-based programs in the community that California is currently funding will be more limited because dollars will be stretched really far in the absence of federal support.”
Experts agreed that cuts to harm reduction would be a huge mistake, noting that data shows forced treatment and abstinence-only policies can lead to worse outcomes. When people practicing an abstinence-only approach relapse, their tolerance can drop and they can overdose, sometimes fatally.
Solutions: long-term investments
In the face of uncertainty, providers, advocates and policymakers emphasized that the best path forward is long-term investing in evidence-based programs that help people into housing and treatment. They called on the city and state to fund resources that help people exit homelessness. Miles, the social worker, said her employer, the University of California San Francisco, should also invest in workers, treatment and services.
“We have seen time and again: We can’t arrest our way out of this problem. We have to invest our way out of it,” said Joe Wilson, executive director of the service provider Hospitality House. “Yes, that takes longer, but the results actually last longer.”
He recommended long-term investments in housing affordability, like land trust models. Friedenbach said the state should fund supportive housing and treatment in perpetuity instead of the one-time investments it currently makes.
“When people are actually offered housing and able to be successful in housing, it costs our taxpayers so much less,” Esteen said. “People are then able to become productive members of society and have jobs and contribute and pay their own taxes, not to mention have fuller lives.”
Funding prevention also is important, Friedenbach said. “It’s just much more cost-efficient to give people the help they need early on to prevent them from going into psychiatric crises to ensure people with mental illnesses don’t lose their homes,” she said.
California is in a place of dreaming big, said Gamboa-Eastman with the Steinberg Institute, citing recent efforts to transform the state’s version of Medicaid and to centralize community-based behavioral health care.
“We are really trying to come from a place of not giving in to anticipatory compliance and preserving that vision until we’re told otherwise,” she said.
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