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Why Homelessness is a Public Health Crisis

A recent Supreme Court ruling has granted local officials the authority to arrest homeless individuals found sleeping in public spaces.

According to the U.S. Department of Housing and Urban Development, the number of homeless Americans has risen to over half a million and shows no signs of slowing down.

With homelessness growing nationwide, what will be the impact of this decision?

Will it effectively reduce homelessness by directing unhoused individuals to local resources?

Or does it represent a harsh and unusual punishment that criminalizes homelessness?

In this week's episode of CareTalk, hosts David E. Williams and John Driscoll explore the implications of this landmark ruling and its far-reaching effects on affected individuals and communities nationwide.

Episode Transcript:

David Williams: Welcome to CareTalk, America's home for incisive debate about healthcare business and policy. I'm David Williams, president of Health Business Group. And I'm John Driscoll, senior advisor at Walgreens. Join the fast growing CareTalk community on LinkedIn, where you can dig deep into healthcare business and policy topics, access CareTalk content, and interact with the hosts and our guests.

And please be sure to leave us a rating on Apple or Spotify. While you're at it, 

John Driscoll: we love those ratings, David, can you just kind of lay out what the 

David Williams: Supreme court decided, John, the Supreme court has been busy. And so this isn't just a one, this is just one decision among a, a lot of landmark decisions, overturning precedent and so on in this case, uh, there, there's a, there's a case where, uh, a jurisdiction in Oregon is trying to clear people off of public land and they were told they couldn't do it.

So. The Supreme Court ruled that they can, in fact, arrest homeless people, even if there's no shelter available to them. [00:01:00] And that was overturning some previous rulings that said you can't arrest somebody if they have nowhere else to sleep. Uh, so that's the majority says it's really just about, you know, camping outdoors without a permit.

It's not about banning people from being homeless. 

John Driscoll: But it was a six three decision conservatives against liberals, uh, with Neil Gorsuch writing in it. It is kind of an anti homeless decision. This is all about whether, I mean, the, the, the law is pretty clear there it's, it's there. They're, they're using enforcement of a.

Of a ban on public camp, uh, on, on camping on public grounds to kind of, uh, enforce some order on the homeless. But this is really, don't you think at its base, kind of an anti homelessness. Decision? Sure. 

David Williams: I mean, John, it's hardly surprising to see what the decision was. And I think what it says is that, you know, we're, we're leaving it to the Supreme Court in particular, this Supreme Court to address homelessness.

That's not where we want to be. 

John Driscoll: I mean, don't you think that if the, if the, if the question, uh, for the majority conservatives was can homeless, mentally ill people be armed, that there would be a nuanced conversation where some of the conservative justices might actually think there's a legitimate, uh, Second Amendment right?

And then look for some sort of justification there. This is a very, very conservative court. 

David Williams: No doubt about it, John. And it's a 6 3 supermajority. And I think we have to remember that Mitch McConnell has a lot of responsibility for allowing this to happen. Uh, yeah, and that's, I won't say a whole different topic, John, because I think we're going to have a lot of topics like this.

Um, in fact, I mean, just with the, uh, the overturning of the Chevron draft deference on the same day or in the, in the same week, you know, there's also, that means that, uh, the federal agencies really don't have the ability to interpret the laws and actually put forth a policy. So there's, there's major, major things for the, for the court.

John Driscoll: That one's that, that one is probably worth a second, a second, you know, a second episode, but the Chevron deference. Effectively was the, uh, the room that the Supreme Court has historically respected of agencies to interpret the rules that led the Congress has laid down. And effectively what the Supreme Court said is that no more deference.

It's got to either go through the courts or be very specific. Defined by the legislature, which is impractical, which means it's basically a power grab on the part of the Supreme Court. But getting back to this, what's effectively a homelessness decision. I I'm somewhat sympathetic to the needs for mayors and governors to manage public space, particularly given the fact that there are some, you know, some, some public health implications, um, of.

Uh, managing the space in terms of people, you know, needing to kind of go about their, their daily lives in a, in a, in a healthy way at a public space. But it, you know, what bothered me, David, is there doesn't seem to be any concomitant expectation on the part of these jurisdictions that they're actually going to care for people who in many cases can be very, very sick.

And that creates public health problems. It beyond the incivility of it, but the potential incivility of it, uh, some public health problems on the other end for homeless folks who actually need care. 

David Williams: Yeah. So let's talk about that for a minute. Um, and then come back to this, this nuanced question about the cities and towns and their ability to enforce the laws.

So interestingly, of course, uh, homeless people, many have mental illness, many have a physical illness or have both a lot of chronic conditions and They are, uh, maybe unhoused, but it doesn't mean that they're completely uncared for. And in fact, there's a lot of outreach, uh, within cities in particular, uh, for healthcare and people that have chronic conditions and are homeless.

Many are actually getting treatment. One of the things that will happen if you, but that counts on, of course, people knowing where they are in general. So there's, there's workers that go out and find them, but if they're not, if they're not there because they've been arrested or sent somewhere else, that's a problem.

John, one interesting thing I was reading about this beyond kind of the obvious that there's, you know, more costs from, uh, people going to the emergency room is that there's a bigger cost. And I haven't seen it quantified to be interesting to do that, which is that you have homeless people with chronic conditions who end up in the intensive care unit.

For long periods of time. So at Mass General Hospital, there was someone cited, I believe, in the New York Times or Kaiser Family Foundation article talked about have 20 plus homeless people in the ICU. And that has tremendous costs and implications for the capacity. Uh, for the rest of us. 

John Driscoll: Well, I mean, I think with, with Jim O'Connell from the, you know, I think the Boston, you know, healthcare for the homeless was really referring to there.

And he's a real expert. Is that, is that if you make it harder to find people and to care for people, uh, where they are, you're going to get very, very sick people who will only want to You know, we, we talk about ER use and them hitting, crashing into the healthcare system, but once they crash into the healthcare system, we got to take care of them.

I mean, you know, the, the, the, the homeless folks, um, uh, unhoused people, um, who can't get care. Uh, you know, are, um, you know, two to three, at least two to three times more likely to have cardiac problems to have a whole series of other chronic conditions. And if they're, if you can't find them and they can't get care, they are going to hit the hospital.

They are going to hit the intensive care unit. They're going to be very, very sick. And again, I, the thing that's appalling to me in this Supreme court decision, um, is this notion that somehow we can move folks around, but, but there's no apparent responsibility for it. Um, governments to really care for those folks who are being moved out of public space.

David Williams: So, the Supreme Court is, you know, not requiring anything to be done about homelessness. They're sort of saying, hey, that's not our problem, the states need to solve it. Let's talk about some of these nuances that you were mentioning from before, John, which is that there is actually somewhat of a consensus among, you know, local officials that they should have the right to relocate people for their own Health and safety and also that they don't want to seed public spaces to homeless, you know, unhoused people and there have been some fairly brazen, uh, activities that even, you know, poke into the sensibilities of people like you and I in places like San Francisco, Los Angeles, Phoenix, Portland, as examples are very aggressive kind of, uh, activities that actually do impinge on people's lives.

Uh, you know, law abiding citizens' ability to go about their business to get, 

John Driscoll: you know, and again, thinking purely from a public health perspective, the, you know, there's, uh, there's an LA study that there, there are folks that, one, one of the health conditions that harm unhoused homeless folks is drug overdoses.

And there are, there are, there are multiple in, you know, incidences. Where there's, you know, drug paraphernalia or people, uh, overdosing. We've got a fentanyl epidemic in the United States. Uh, and you, you, I I'm, I'm very sympathetic to the jurisdictions, uh, well, pretty much exclusively those that are willing to take care of homeless folks, their need to actually regulate the public health of public space and making sure they're, they're safe for transit, that they're safe from.

From individuals and frankly, that there is some element of public order. I mean, I think all of those are reasonable, um, responsibilities of the part of public officials to make sure that there is, there is order and that they have a, a tool to incent, uh, the unhoused, uh, at some level. To actually, you know, play by the rules and make sure that public spaces are healthy.

But what drives me, what, what worries me about this decision is there doesn't appear to be any responsibility to take care of and actually engage in the healthcare of, of these very, very vulnerable populations of the unhoused that are, you know, two to six times as likely to be very, very sick. And I don't think, I don't think moving them.

Um, should be confused with caring for them. 

David Williams: Well, I think what you see, and maybe this is part of the broader context for this race, you know, conservative Supreme Court is with this ruling, what may happen, some are speculating, is that more, you know, conservative so called locales may use it as a way to just push people out, period.

By criminalizing street camping and transfer people essentially to those jurisdictions that are more compassionate and spend more on public health. So it's sort of a dumping, uh, or almost literally a dumping of people. Well, that's, 

John Driscoll: that's, that's exactly, that's exactly, I mean, where, where, where I think my, my fear is of this decision is that we're not forcing the responsibility of governments to, to, to, uh, to transport them, but not actually care for them.

I mean, it's troubling. And I under, I understand the advocates for the unhoused, why they're so. Agitated on this because there, there is a, there is a fear and it has been, and there are examples of jurisdictions where local leaders are much more focused on, uh, making sure folks are out of sight, um, and, and often, uh, disconnected from care.

John, how big 

David Williams: of a problem are we talking about here? How many homeless, uh, do we currently have in this, in this country? Do you think 

John Driscoll: we're, we're talking about, uh, potentially millions. If you look at folks who are unhoused, I mean, often families that are going through crises of losing their space will be homeless for a short period of time, and you need to make the distinction between folks who have short term housing crises and the long term individuals who are really living on the streets.

Who are often the, the, the target of, uh, of, of conservative agitation. And, um, you know, I don't, I don't have those numbers, but we do have a growing challenge because, you know, stepping back a second, we're, we're, I don't know, four to 5 million housing units short as a country. Uh, and so, and rents have been skyrocketing across the country.

Um, the cost of housing has gone up with the rise of interest rates. And so you've got some. Structural economic pressures from a housing perspective matched to a really strained public health system that only become became more stretched and and who's who's need to be patched and fixed was exposed during COVID.

So I think we've got a. We've got a problem on the streets that reflects, honestly, I think, a problem in our public health system that's not going to go away, uh, if we just move folks who are unhoused and ill, it's, I fear, only going to get worse unless there are jurisdictions where folks engage in caring for them.

I mean, there is a 12 billion, I think it's allocation in the California budget, um, to actually invest in. Care support and supportive housing for the chronically ill and the chronically individual homeless folks. I think that's the kind of responsible government where this decision potentially can lead to more solutions, but that's not matched.

In many, many of the jurisdictions, um, but every jurisdiction, every place in the country is, is, is, we're running out of housing units and, and, and certainly even more so affordable housing units. 

David Williams: We talked a lot on the show, John, about social determinants of health and certainly things like food and housing would qualify.

There is a move within the federal government anyway, to consider classifying housing. As healthcare, and I know we're going to talk about Chevron deference in a different show, but how does, you know, it's, it's, it's housing healthcare and, you know, how does this relate to, you know, the, the ability of the current administration and others to be able to.


John Driscoll: I think you're right, uh, but you've just, you just haven't, haven't framed it correctly. Social determinants are those things are in society that can really drive control or influence healthcare, healthcare, you know, conventional healthcare is. You know, provided by folks in white coats and in institutional settings.

Um, and we've, we've defined it pretty narrowly as, as, as, you know, specific clinical interventions. I think the whole social determinants movement has an, if you're a hungry individual, someone who, you know, you can't get access to, to affordable nutritious food is, you know, three to five times as likely to get diabetes.

Three to five times as likely to have a cardiac. Chronic cardiac disease, and those create problems at the other end on the clinical side. We're going to look at them as social determinants. There's no question at, um, you know, you can take 3 or 4 major health care categories, um, ranging from mental health to cardiac health and folks who have Who are unhoused or two to six times as likely as someone who has a roof over their head to be sick in those chronic disease category.

So I would argue that absolutely housing is an input to one of the social determinants. And if we don't deal with the fact that we need more affordable housing units, we will have Um, in, in, you know, expensive healthcare and that, that's what Jim O'Connell was talking about in terms of the ICU. If you don't deal with these chronic health issues like cardiac care, if you can't get access, um, to the patients and the patients can't get access, uh, or uh, uh, easy access to care, to consistent care, they're going to hit the healthcare system, but they're gonna be much sicker and we're gonna end up paying for it.

And so the social determin of. of housing is definitely, definitely a super important input. John, last 

David Williams: topic, uh, and I just want to speculate here a little bit. Uh, it's pretty clear that this decision wasn't intended to help the homeless. And in fact, the decision itself essentially says that. It's not their problem.

That's very generous. Under what, under what conditions could this ruling be used To end up helping the homeless by those of goodwill. 

John Driscoll: I think you saw it in some of the coverage, David. I mean, particularly the coverage in California, um, where the governor and some of the mayors where, again, it's, I think California has, you know, uh, roughly 25 to 30 percent of all the homeless.

Individuals, uh, downhouse individuals that we can measure, um, in the country and, um, mayors and governors are, have programs available that they can now use the pressure to move out of a public space without support to, uh, encourage, uh, Uh, the unhoused to actually get care in places where they can get support and housing.

So I think, you know, responsible mayors and governors need that. I mean, unfortunately we are absent of a Congress that works. We are deferring some of these really hard social issues. To a court that will make decisions, but has no responsibility to actually care for or support the folks that the laws actually impact.

But, um, certainly in for jurisdictions where they're actually looking to care for the unhoused, um, this, this, this, this decision could help them. Actually enforce the public laws and get the best of both worlds, safe public spaces and easy access, uh, to or better access for care and housing for the unhoused.

David Williams: John, I like that in the episode here on a positive note, especially on this 4th of July week where we're celebrating America's independence and greatness. That's it for yet another episode of CareTalk. We've been talking about the Supreme court's recent decision on homelessness. I'm David Williams, president of health business group, and I'm John Driscoll, 

John Driscoll: senior advisor at Walgreens.

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Watch the full episode on YouTube:



CareTalk is the only healthcare podcast that tells it like it is. Join hosts John Driscoll (Senior Advisor, Walgreens Health) and David Williams (President, Health Business Group) as they provide an incisive, no B.S. view of the US healthcare industry.



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