New Executive Order Shifts Homeless Policy, Potentially Overwhelming Health Care Services: A Q&A With Kristen R. Choi, PhD, PMHNP-BC, FAAN

Kristen R. Choi, Associate Professor & Audrienne H. Moseley Chair in Nursing at UCLA Joe C. Wen School of Nursing & UCLA Fielding School of Public Health, spoke with The American Journal of Managed Care^® about the implications of the executive order signed by President Donald Trump aimed at addressing homelessness nationwide.

This executive order specifically centers civil commitment as a means of getting those who are mentally ill or addicted to substances off of the street. However, experts argue that this move is more responsive than targeting the root cause of the issue. According to the National Alliance to End Homelessness, addiction care specialists and mental health specialists are few in communities that are at highest risk of homelessness, ultimately threatening housing stability and potentially leading them to more severe outcomes.

In this Q&A, Choi highlights how this executive order could lead to overwhelming the health care and mental health care services across the nation, potentially leading to further problems in these spaces.

This transcript has been lightly edited for clarity.

AJMC: The Trump administration signed an executive order on July 24, “Ending Crime and Disorder on America’s Streets,” directing federal agencies to act to reduce homelessness on the streets. Can you explain what this executive order is and how it’s different than current protocol for homeless people in the US?

Kristen R. Choi: This executive order is a significant shift in federal homelessness policy away from a “housing first” approach to an approach of enforcement and institutionalization. In recent years, housing policy has focused on providing housing without requiring sobriety or treatment engagement, based on evidence that stable housing promotes better treatment outcomes for individuals with mental illness or substance use disorders. This order is a change in course, aiming to shift homeless individuals into institutional settings and treatment through civil commitment. It prioritizes federal grantmaking to states, cities, and counties that enforce prohibitions on drug use, urban camping, and loitering. It also ends federal support for "housing first" policies and redirects federal funding away from harm reduction programs toward treatment-focused approaches.

It is important to note that being homeless is not the same thing as having mental illness, and homelessness alone does not meet the strict legal criteria established for civil commitment. Only about 20% of homeless individuals have serious mental illness, and even fewer would meet legal criteria for civil commitment. Civil commitment requires demonstrating that someone poses an imminent danger to themselves or others due to mental illness. The majority of people experiencing homelessness cite economic factors, such as job loss, health care costs, or unaffordable rent, as the primary causes of housing loss, not untreated mental illness.

As a nurse who cares for individuals living at the intersection of homelessness and serious mental illness in Los Angeles, this order concerns me because I have seen first-hand how coercive treatment approaches undermine therapeutic relationships that are essential for recovery. While psychiatric care is important, alone it does not resolve the social, economic, and housing needs people living with mental illness or substance use disorders. The order frames homelessness primarily as public “disorder” rather than recognizing the underlying causes of homelessness. It also does not address the social determinants of health that diminish the effectiveness of a “treatment first” approach for people with mental illness or substance use disorders.

Kristen R. Choi, PhD, PMHNP-BC, FAAN

AJMC: One of the aspects of the executive order is the directive to send homeless people to mental institutions through civil commitment or other available means. What do you think the immediate effects of this aspect of the executive order could be?

Choi: Civil commitment for mental illness is a serious legal action that removes individual rights to self-determination. It has consequences and risks, and it does not guarantee long-term stability or resolution of a person’s psychiatric and social needs. The immediate effects of increased civil commitment could be overwhelming an already-burdened mental health system with spillover to emergency departments and courts. Many states have been closing psychiatric hospitals for decades and have severe shortages of treatment beds and mental health providers. For example, a 2021 report from the RAND Corporation on psychiatric beds in California estimated a shortfall of at least 7000 beds across all levels of care while also projecting increased demand for psychiatric beds through 2026. Over 160 million Americans—one-third of the population—live in a mental health provider shortage area and face severe scarcity of psychiatrists, psychologists, psychiatric nurses, and social workers. A sudden influx of more individuals requiring psychiatric evaluation and possible treatment would be very challenging for our mental health system to absorb.

With existing shortages in psychiatric care, there is risk for an unintended consequence of overwhelming emergency departments. Individuals with mental illness often must wait for days in the emergency department for psychiatric evaluations and available beds. This creates a bottleneck that diverts resources away from other emergencies and strains an overtaxed health care system. There is also risk for overwhelming legal systems. Civil commitment requires due process, including court hearings, psychiatric evaluations, and legal representation. The sudden influx of cases could overwhelm court systems and public defenders' offices.

From a research standpoint, evidence suggests that coercive treatments for substance use disorders and mental illness do not guarantee recovery or long-term stability. Individuals who receive involuntary treatment relapse at high rates and may be less likely to engage in treatment in the long term. Forced institutionalization often leads to deep mistrust of health care systems, and it does not automatically lead to long-term housing stability in the community. The order risks creating demand for services we are already struggling to provide to people who voluntarily seek treatment for mental illness or substance use disorders.

AJMC: Should this action be taken effectively, we could be seeing thousands of homeless people entering mental health or substance use rehabilitations. How do you see this influx of patients affecting care nationwide?

Choi: I want to reiterate that most homeless individuals in the US do not meet the legal criteria for civil commitment. Most people who are unhoused do not have serious mental illness, and civil commitment is only legally permissible under specific circumstances of imminent danger to oneself or others. However, if the order were implemented broadly, the mental health system could face challenges in treatment capacity that could spill over to other parts of the health system, as well as carceral systems. There are already high levels of need for mental health care among the American public in general. Approximately 46% of adults with mental illness have unmet need for treatment, and many desperately want care that they cannot access or afford. Overwhelming the mental health system risks poor quality of care, dangerous staffing ratios, financial strain, and provider burnout. It also risks creating additional barriers to mental health care for the many Americans who want and need treatment.

Based on my clinical experiences with involuntary treatment and civil commitment, I do recognize that involuntary care mechanisms can serve a legitimate purpose under specific circumstances. For example, when individuals pose an immediate danger to themselves—such as in cases of severe suicidal ideation—temporary intervention can be lifesaving and necessary. I have had patients in these circumstances who were grateful that someone intervened. However, the effectiveness and appropriateness of such interventions depend heavily on their implementation being targeted, time-limited, and focused on genuine emergencies rather than as a broad social policy tool for addressing complex issues like homelessness.

AJMC: What should next steps be in addressing this executive order? Are there other means of addressing homelessness that this executive order missed?

Choi: To address the homelessness crisis, an evidence-based approach that addresses root causes is critical. Homelessness is driven first and foremost by insufficient affordable housing. I would hope to see new policies that increase the supply of affordable housing across the US. There is also need for permanent supportive housing, which comes with social and health services and is especially beneficial for individuals with mental illness or substance use disorders. But because most cases of homelessness and housing instability are driven primarily by unaffordable housing and economic factors rather than mental illness, policy solutions must center housing first.

There is no doubt that investments in mental health care and substance use treatment are also essential. With high levels of unmet need and critical provider and bed shortages, the US mental health system needs significant attention in policy. The minority of homeless individuals who also have a serious mental illness would benefit substantially from increased treatment options, as would the American public in general. Policies to increase the behavioral health workforce, incentivize workers to go to underserved communities, increase access to care, and improve the affordability of care are needed alongside direct housing interventions. Investments in research on innovative treatments and new models of behavioral health care could also yield significant benefits for Americans living with mental illness or substance use disorders.

As we consider how to address the homelessness crisis and a parallel crisis of mental illness, I hope to see US policymakers center approaches that preserve dignity and autonomy. Coercive treatment can sometimes backfire, sometimes leaving people worse off or with new challenges that complicate their path to well-being. I have seen first-hand how mental health and housing services that are built on trust and respect are what enable recovery, and I hope to see these values reflected in future homelessness policy.