Executive Order on Homelessness Includes Several Policy Shifts: Katherine Koh, MD, MSc

Katherine Koh, MD, MSc, a practicing psychiatrist at the Boston Health Care for the Homeless Program and Massachusetts General Hospital, discussed the different components of the executive order signed by the Trump administration on July 24, “Ending Crime and Disorder on America’s Streets,” that would shift the approach to homelessness in the country.

This transcript has been lightly edited for clarity; captions are auto-generated.

Transcript

What are the components of the executive order signed in July aimed at getting homeless people off the streets?

The current Executive Order focuses on ending crime and disorder on America's streets. Its starting premise is that people experiencing homelessness are violent and dangerous and that public safety measures need to be implemented in order to protect communities. Yet the fact of the matter is that the vast majority of people experiencing homelessness are not criminals. They are kind, courageous, resilient individuals who have been through unimaginable trauma and yet still strive for a better life. Evidence suggests that people experiencing homelessness are more likely to be victims of crime rather than perpetrators of crime.

The executive order includes several major policy shifts. The first is encouraging states to use involuntary commitment more broadly and to lower the threshold for involuntarily committing people with mental illness. Psychiatrists and other professionals who have the capacity to use involuntary commitment typically use it as a last resort, given the risk of taking away people's autonomy and civil liberty. And while it can be indicated for the sickest of the sick, it always must be considered carefully for each individual, rather than using it as a blanket, widespread tool. Furthermore, it's not just the initial commitment, but what happens in the aftermath that determines whether or not people are able to get off the streets and to achieve stability. And the executive order says nothing of a plan to increase housing and the community-based supports necessary to encourage people after they leave the hospital from an involuntary commitment to achieve that path of stability.

The second executive order policy focuses on shifting federal funding priority to states and municipalities that forcibly remove people from the streets. However, not only are these directives inhumane, but they are also unlikely to keep people off the streets without a plan to increase housing and to connect people to temporary or permanent shelters or housing. Furthermore, evidence suggests that encampment sweeps increase overdose risk, increase violence, increase health care spending, and decrease access to treatment. This policy is very likely to keep people on the street rather than reduce the number of people who live on the street.

The third executive order [policy] aims to defund harm reduction programs, yet harm reduction programs have been shown to decrease mortality, to increase treatment engagement, and to be cost-effective for people with substance use disorders. Defunding harm reduction programs is likely to only fuel a worsening of the substance use disorder and opioid use disorder crisis and to increase homelessness.