How Homeless Actions Thwart Medicaid Goals

California, the epicenter of the U.S. homelessness crisis, is cracking down on people living outside more than ever before. The country is taking an aggressive new stance on dismantling and clearing homeless encampments. That follows a landmark U.S. Supreme Court ruling in late June that makes it easier for government agencies to fine and arrest people living on streets and sidewalks, in broken-down vehicles, or in public parks, even if no shelter or housing is available.

From San Francisco to Los Angeles, communities are launching cleanups, enforcing existing anti-camping laws is being stepped up, and in some places new laws are being passed to prevent people from living outside.

Health care experts and homeless service providers say police crackdowns undermine taxpayer investments in evidence-based treatment and housing services that cities and states across the country are deploying as politicians aggressively push to get health care off the streets.

The sweeps, which began under Democratic Gov. Gavin Newsom, who issued an executive order in late July requiring state agencies to clear encampments and encouraging local governments to do the same, have created chaos for homeless people and severed crucial connections with health care providers, social services and housing navigators who try to help them get healthy and off the streets.

Newsom’s hardline stance undermines his flagship Medicaid initiative, known as CalAIM, which provides $12 billion over five years to help the homeless with health care, housing and social services, among other things.

The experimental program, designed to stabilize the most vulnerable and keep low-income patients out of expensive institutional care in places like hospitals, prisons and nursing homes, was launched in early 2022 with support from the Biden administration. It provides state and federal health care funding to street medicine teams, hospitals, health insurers, community clinics and other organizations that serve the homeless.

Newsom announced this month that his Health Secretary, Mark Ghaly, who led the effort to integrate homeless social services into the state’s health care system, would resign.

Clearing the camps also upends longstanding federal health policy that provides billions of dollars annually to frontline clinicians, case management teams and clinic workers, including through the national Health Care for the Homeless program. The program is also designed to help homeless people get healthy and find permanent housing.

Newsom has been vocal in saying that streets are not homes and that it is unsafe to let people live outside amid public health hazards like rats, drug needles and piles of trash. The second-term governor, who has threatened to pull homeless funding from communities that aren’t making enough progress, argues that his policies help people get long-term housing and services.

“There are simply no more excuses,” Newsom said in July.

Health care providers and homelessness experts say the result is a slow-burning health care disaster, caused by the very Democratic politicians who emphasize the need for care and services in California, which has more homeless people than any other state in the country.

Nowhere is the situation worse than in San Francisco, a decidedly liberal city that has long had a reputation as a place where the homeless can find refuge and good services.

Now, case managers, housing navigators and street medicine teams say vulnerable people are getting sicker because of the crackdown, and many of their patients have simply disappeared. Others have lost medications and vital documents like birth certificates and Social Security cards, thwarting efforts to stabilize people with housing, mental health services and addiction treatment.

Frontline aid workers say the city is a glaring example of policies gone wrong when it comes to the homeless.

“All the sweeps and arrests do is move people to the next curb and disrupt their continuity of care. It’s a huge waste of resources,” said Shannon Heuklom, a primary care provider and street medicine expert for the San Francisco Community Health Center, which has a clinic in the heart of the Tenderloin.

“Some of the people may end up in a shelter, but for the most part the city just moves them back and forth, which just makes them sicker, worsens their mental health, worsens their physical health,” she said.

Disrupted care

Frontline workers are now spending enormous amounts of time and resources helping people replace valuables like medications, Social Security cards and birth certificates that have been lost to sweeps. They are seeing patients skip routine health care and see increases in substance abuse, anxiety and depression.

“This just makes homelessness worse,” said Evelyn Peña, care manager at CalAIM at the Mission Neighborhood Health Center in San Francisco.

Taylor Cuffaro, a nurse practitioner and street clinician at the San Francisco Community Health Center, walked the streets of the Tenderloin on a bright August afternoon with Eli Benway, a licensed clinical social worker who provides talk therapy and other behavioral health treatments on the streets. They were looking for patients.

Some needed help managing chronic illnesses and mental health conditions. Others needed antipsychotic injections that work longer than pills. Some needed repeat prescriptions for HIV drugs.

“Health insurance companies are not going to just give you more drugs,” Cuffaro said. “That’s not how it works, so people are really at risk of dying faster.”

Part of what is being wasted is trust, which is essential to getting people off the streets. “These sweeps just make our job impossible,” Cuffaro said, as he searched in vain for a patient in an alley.

Politics of homelessness

The national response is taking place despite growing evidence that providing quality health care, along with social services and intensive case management, can effectively get homeless people off the streets and improve health, while saving taxpayers and reducing health care spending, which is too expensive for institutional care.

Democrats are embracing a hard-line approach as public patience wears thin over the intractable crisis. Newsom’s stance isn’t entirely new: During his tenure as mayor of San Francisco, from 2004 to 2011, he was a driving force behind controversial ideas about homelessness, including an ordinance known as sit/lie, which made it illegal to sit or lie on public sidewalks.

Newsom and local leaders, including Breed, say they must strike a balance between ensuring public safety and clean streets and a humane approach to clearing encampments as they try to get people inside. Breed administration officials say that while some homeless people accept shelter, many choose to remain on the streets and refuse treatment.

“People are not accepting shelter or getting treatment from doctors or psychologists or whatever, often because they have to stay and watch their belongings, some of which are filthy and a health hazard,” said David Nakanishi, a clinical social worker who directs the Breed administration’s Healthy Streets Operation Center, which conducts the raids.

Meanwhile, in Los Angeles, street medic Brett Feldman is losing patients to the raids. “It really undermines our housing efforts,” he said.

A city report released in May found that clearing encampments and enforcing anti-camping laws that prohibit people from sleeping, sitting or storing belongings on sidewalks in certain sensitive areas, such as school zones, parks or freeway underpasses, is not effective in helping people find housing.

After spending about $3 million on enforcing anti-camping laws between 2021 and 2023, the city placed just two people in permanent housing and 81% of its campsites have been repopulated, the report found.

In a central Los Angeles district that does not aggressively enforce anti-camping laws, the number of homeless people fell by about 38% from 2023 to 2024, said Indu Subaiya, interim CEO of the nonprofit Healthcare in Action, which houses and treats patients there.

“We are actually starting to see results and a decrease in unsheltered homelessness,” Subaiya said. “But in the Southern California counties that are aggressively enforcing Newsom’s executive order and clearing encampments, we are seeing our patients and their medical conditions deteriorate dramatically.”

2024 KFF Health News. Distributed by Tribune Content Agency, LLC.