With homelessness rising in several US cities, some officials are considering a controversial approach: involuntary hospitalization of the mentally ill. The policy has risks, and to have any hope of success it requires ample funding and planning. But without bold action the problem will only get worse.
Officials aren’t wrong to warn of a crisis. New York City Mayor Eric Adams has described “people living with human waste, talking to themselves, drugs, paraphernalia, imagining things, hearing voices in their heads.” He proposes that a range of first responders and contractors should involuntarily hospitalize those who “are a danger to themselves.” In Portland, Oregon, Mayor Ted Wheeler said he has seen “people walking through the elements without appropriate attire, often naked, they are freezing to death.” He wants to lower the threshold for involuntary commitment.
The question is, what happens to these vulnerable people once they’ve been taken off the streets? Oregon’s shortage of psychiatric beds is so dire that patients have been left in community hospitals for months on end. Three of the state’s largest hospital systems have sued the Oregon Heath Authority, saying it has forced them to provide care they’re not equipped to give.
One barrier to essential funding should have been eliminated long ago. When Congress created Medicaid in 1965, it blocked federal money from supporting larger psychiatric institutions. Reports of abuse and neglect had led to the closure of facilities across the country and a push toward community care. Though well-intentioned, this shift has left the country short of psychiatric beds. The squeeze tightened abruptly during the pandemic, when hospitals converted hundreds of their remaining beds for Covid patients. Thanks to low reimbursement rates, they’re in no rush to convert them back.
States are left to apply for Medicaid waivers or rate increases to free up funding, which can take months. Congress should remove the Medicaid exclusion so they can get necessary resources faster. Longer term, state governments nationwide need to commit to expanding capacity and hiring more staff at the hospitals on the front lines of this crisis. (At one point, National Guard soldiers had to step in to fill a shortage at Oregon’s largest psychiatric facility.) New York is taking steps in the right direction: Governor Kathy Hochul will compel state-licensed hospitals to reopen more than 800 inpatient psychiatric beds lost during the pandemic, imposing steep fines on hospitals that don’t comply.
Patients also need a safe place to go when they’re discharged. New York has about 35,000 supportive housing units offering affordable, long-term residency with a range of services. Demand far outstrips supply, but many are sitting vacant, caught up in red tape. In Los Angeles, Mayor Karen Bass, who declared a state of emergency on homelessness last month, has directed city departments to speed up development and approvals for supportive housing. The measure follows California Governor Gavin Newsom’s new law that mandates treatment for the mentally ill.
Civil-liberties advocates have long voiced understandable concerns about involuntary treatment, and getting such policies right will require foresight and vigilance. With appropriate planning and financial support, though, a humane and effective answer to one of the country’s most intractable problems should be within reach.
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The Editors are members of the Bloomberg Opinion editorial board.
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