Homelessness is not a new problem. Since emerging as a policy priority during the early 1960’s War on Poverty, politicians, communities and other stakeholders have debated homelessness risk factors and solutions. However, this June in Grants Pass vs. Johnson, the U.S. Supreme Court ruled that municipalities can legally ban sleeping outside, essentially criminalizing homelessness. This decision is part of a larger trend wherein the Court rules against public health measures, often ignoring scientific evidence and decreasing states’ abilities to protect citizens. Recent examples include striking down vaccine mandates, invalidating firearm restrictions, walking back environmental safety regulations, and of course, ending Roe v. Wade. Even recent decisions like ending affirmative action in education have dire health consequences. Grants Pass is likely to have similar ramifications, potentially sending unhoused people to prison and further jeopardizing the health of already-vulnerable populations. Once again, federally qualified health centers (FQHCs) are on the front lines, serving nearly 1.4 million homeless patients in 2022 with innovative programs like mobile units and hotel lobby-based vaccination clinics. Therefore, here we explore homelessness policies and their implications, including the perspective of an FQHC clinician.
Health and Homelessness in the U.S.
On any given day, 600,000 people in the U.S experience homelessness. This includes those staying in transitional or supportive housing and those who are unsheltered, meaning they sleep in emergency shelters, cars, parks, sidewalks, abandoned buildings, or streets. Persons who are unhoused have unique health and social needs. For example, 67 percent of people experiencing homelessness have a current mental health disorder, including 44 percent with substance use disorder.
Policies can exacerbate these extenuating health issues. Grants Pass v. Johnson, wherein the Supreme Court granted the city of Grants Pass, Oregon the right to impose civil and criminal penalties on those sleeping outdoors, is the most significant ruling in history regarding the rights of homeless individuals. By criminalizing sleeping outside, Grants Pass could give the unhoused the choice of relocating or being placed in the justice system, potentially leading to debt, trauma, and convictions endangering future employment. Moreover, increasingly common “move-along” orders, when local governments raze communal homeless camps, are associated with increased hepatitis C and HIV incidence, interrupted substance use disorder treatment, and increased hospitalizations. These encampment sweeps, cost taxpayers millions, disproportionately impact minoritized populations, and lead to loss of belongings, worsening mental health conditions, reduced trust in care providers, and severance of social connections, all of which affect short- and long-term health outcomes.
Research shows that criminalizing homelessness can have a ripple effect on physical and mental health outcomes. Additionally, BIPOC individuals, who comprise around 60 percent of homeless populations, are more likely to experience homelessness and be targeted by police for enforcement than white individuals. Individuals experiencing homelessness who identify as LGBTQIA+ are also more likely to be marginalized by criminalization.
A Safety Net Clinic Perspective
FQHCs serve unhoused populations with innovative programs, meeting patients where they are. For example, the Center for Key Populations at Community Health Center, Inc. (CHCI) program Wherever You Are (WYA) offers mobile health care for Connecticut’s most vulnerable populations regardless of their ability to pay. As a CHCI clinician specializing in family medicine, HIV treatment, and substance use treatment, I (Hinojosa) work closely with a team of nurses and medical assistants to help patients reach optimum health. Our team uses a harm reduction philosophy when caring for our parents, many of whom are unhoused.
Often, those who visit the clinic have been out of health care for many years. They seek care for health issues which are often exacerbated by unsafe living conditions, malnutrition, loss of employment, uncontrolled substance use, and lack of knowledge about available resources. When treating homeless patients, my team considers the whole person and how best to meet all of their needs, fostering trust and motivating patients to practice self-care. This strengthens partnerships between us and our patients, and ultimately improves the health of our unhoused patients. Policies that criminalize homelessness will sever these bonds and further separate patients from healthcare and other resource networks.
Policy Considerations
According to Housing Not Handcuffs, policies that criminalize homelessness are defined as those that threaten or punish for engaging in activities such as sleeping, resting, or sheltering outside, (e.g., Grants Pass), asking for donations, sharing food, or simply existing in public places However, for advocates and health experts, this approach is seen as a form of cruel and unusual punishment. In her dissent, Justice Sotomayor called the decision “unconscionable and unconstitutional,” as people can be fined or arrested even when no shelter or other resources are available. Justice Sotomayor wrote, “Sleep is a biological necessity, not a crime. For some people, sleeping outside is their only option.”
Local policies criminalizing homelessness are also on the rise. According to the National Homelessness Law Center, between 2006 and 2019, city-wide bans on camping increased by 92 percent, on “sitting or lying” by 78 percent, on loitering by 103 percent, on panhandling by 103 percent, and on living in vehicles by 213 percent. These bans have occurred despite a 1,300 percent rise in homeless encampments across the U.S., clearly indicating the need for housing solutions.
Looking Ahead
Meanwhile, several states and local governments have enacted progressive policies that decrease homelessness and its effects on communities. The Housing First model, based on a harm-reduction, trauma-informed framework, prioritizes housing and support services without preconditions. California mandates all state-funded housing programs adopt this evidence-based approach, and Austin, Texas has funded and built over 700 Housing First-modeled units.
Connecticut, Hawaii, New Hampshire, Washington and others have adopted the Critical Time Intervention for Rapid Re-Housing model, which prioritizes finding fast supportive housing for vulnerable populations including those with mental illness and veterans. Another promising policy is the enactment of zoning changes supporting higher density housing. For example, Florida allows areas with single-family zoning policies to create high-density affordable housing for low or moderate-income residents.
It is also important that policymakers consider the impact criminalization will have on homeless youth, who are more likely to struggle with mental health issues, report suicidal thoughts and attempts, and engage in substance use than non-homeless youth. We must prioritize the funding, creation of, and access to housing for our most vulnerable populations, especially as those sleeping outside now risk criminal charges that will ultimately exacerbate health disparities.
The opinions expressed in this blog post are the author's own and do not necessarily reflect the view of AcademyHealth or of their respective affiliated employers/organizations.