Research Will Be Integral in Evaluating the Efficacy of Executive Order Regarding Homelessness: Jack Tsai, PhD, MSCP

Jack Tsai, PhD, MSCP, regional dean and professor of public health at UTHealth and research director for the National Center on Homelessness Among Veterans, 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, Tsai noted that evaluating the changes over time in addressing homeless individuals after the executive order can help to understand the best course of action for homeless individuals moving forward.

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?

Tsai: The executive order directs federal agencies to reduce unsheltered homelessness by prioritizing public safety and mental health and substance abuse treatment. The order promotes involuntary civil commitment for individuals with mental health or substance use issues, redirects federal funding to support enforcement of public order laws (eg, bans on urban camping or loitering), ends support for harm reduction programs, and requires health data sharing with law enforcement. This marks a shift from current protocols in many jurisdictions that have focused on harm reduction, immediate access to housing, voluntary participation in mental health or substance use treatment, and limited data sharing across government agencies. Some jurisdictions already have existing statutes that align with the executive order (eg, civil commitment, sleeping on public property) and so the executive order is seeking to reinforce those.

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?

Tsai: The executive order directs the Attorney General to seek to enact or reinforce state and local policies so that people experiencing homelessness with mental illness “who pose risks to themselves or are living on the streets and cannot care for themselves” are involuntarily committed to appropriate facilities. The executive order is currently still unfolding and may take many months to take effect. But presumably, many state hospitals and long-term care psychiatric facilities will be needed. Given there is already a shortage of mental health providers and few long-term psychiatric facilities in many areas of the country, there will likely be challenges with finding institutions for some people experiencing homelessness that meet the directive’s criteria.

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?

Tsai: Many mental health care systems across the country are fragmented and not well-integrated with other health care and social service systems, so there may be patients that “fall through the cracks” with these changes. Moreover, civil commitment requires legal action and so that will add another layer of complexity as mental health care systems will need strong coordination with legal systems. It’s hard to predict what will happen with people experiencing homelessness who need mental health or substance use treatment but there may be inadequate resources or overcrowding in facilities.

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

Tsai: As a researcher, I think this is an important time for research as there are many areas that need evaluation and evidence to guide decision-making. For example, assessments of when and how civil commitment should best be used; natural experiments comparing outcomes of jurisdictions with different policies; and changes over time with the executive order are all areas that need study. It’s also important to not consider this executive order in isolation but also understand this order in relation to other executive orders, such as the changes being made to Medicaid, that may change the public health response to homelessness.