President Donald Trump has taken a sudden interest in California’s homelessness crisis. Last week, he and several senior White House advisers, including Housing and Urban Development (HUD) Secretary Ben Carson, visited the state to discuss federal intervention to address homelessness. But some state lawmakers registered deep suspicions about the White House’s interest, arguing that the policy options put forth by the White House Council of Economic Advisers (CEA) neglect key drivers of homelessness.

Before Trump’s visit, the CEA released a report titled The State of Homelessness in America (PDF), which documents variation in homelessness across the country and discusses Trump administration proposals to reduce it.

In a conference call with journalists, acting CEA chairman Tom Philipson “repeatedly highlighted homelessness in California, particularly in Los Angeles, and blamed it in part on state and local policies,” the Washington Post’s Jeff Stein reported. Philipson also said that “policing may be an important tool to get [people] off the street.”

Several state lawmakers said that “the president’s positions on homelessness are more about trolling California than attempting to find actual solutions,” according to Liam Dillon and Benjamin Oreskes in the Los Angeles Times. “If the president really cares about solving this crisis, he wouldn’t be talking about criminalization over housing,” said Los Angeles mayor Eric Garcetti in a statement to the Los Angeles Times. “He’d be making dramatic increases in funding for this country’s housing safety net.”

Research Misstated, Ignored

The CEA report estimated that deregulating the housing market would reduce the homeless population in San Francisco by 54% and in Los Angeles by 40%. But an expert whose work is repeatedly cited in the report, Columbia University economics professor Brendan O’Flaherty, PhD, told Dillon and Oreskes the CEA not only vastly overstates the potential impact of deregulation, it ignores research showing public subsidies can help get people off the streets and into housing.

Governor Gavin Newsom, the California State Association of Counties, the California League of Cities, and mayors from the biggest cities in the state agree that ensuring affordable housing is an important factor in combating homelessness. In a letter to the president (PDF), the group called attention to the administration’s proposal of “significant cuts to public housing and programs like the Community Development Block Grant.” They requested 50,000 additional vouchers from the administration through a combination of Housing Choice Vouchers and Veterans Affairs Supportive Housing vouchers. “Mr. President — shelter solves sleep, but only housing solves homelessness,” the group wrote.

On September 18, two days after the letter was sent to the president, HUD Secretary Carson rejected the request for additional housing vouchers. In a letter to the group (PDF), Carson argued that “California cannot spend its way out of [its homelessness] problem using federal funds.” The state must address its “overregulated housing market,” strengthen the ability of police officers to intervene in homelessness, and invest in mental health treatment to “help address this catastrophe,” he wrote.

Housing — an Important Component of Health Care

In addition to the need for more affordable housing, frontline providers say health care must be prioritized for people experiencing homelessness. In a commentary for CalMatters, Coley King, DO, director of homeless services for Venice Family Clinic, wrote, “While housing is a powerful form of health care, seriously ill patients . . . would likely die on the streets without proper medical care.”

In Los Angeles County, where Venice Family Clinic is located, the population of people experiencing homelessness “has grown by 39% over the past five years, but deaths among those experiencing homelessness rose almost twice as fast, 76%, over the same time period,” King wrote.

People experiencing homelessness have higher rates of premature death and greater disease burden than people who have shelter. A 2018 study of homeless adults entering permanent supportive housing found that 90% reported having at least two chronic physical or mental conditions, 68% reported at least two chronic physical health conditions, and 56% reported at least two chronic mental health conditions.

A recent study about hospital visits by New Yorkers experiencing homelessness suggests that closer collaboration between the health care and homeless services sectors would indeed help patients. The study, published in Health Affairs, found that hospitalization can precipitate homelessness when patients at risk of losing their home enter the hospital. Additionally, hospitals often struggle with a lack of adequate discharge options for patients who already have no home. “Hospital use preceding homelessness presents an opportunity for interventions to prevent homelessness,” the study authors wrote. “Our findings highlight the necessity of collaboration between homeless services and health care systems to best address the needs of their shared client-patient population.”

Los Angeles County supervisor Mark Ridley-Thomas, a cochair of Newsom’s Homeless and Supportive Housing Advisory Task Force, has called for better physical and mental health care for people experiencing homelessness. According to the Los Angeles Times’s Steve Lopez, Ridley-Thomas said that the county needs “more psychiatric emergency services, more addiction rehab, and more recuperative care so that homeless patients don’t go from hospitals straight back to the streets.”

Los Angeles County has been involved in several initiatives of Medi-Cal, California’s Medicaid program, to improve health care for people experiencing homelessness. One is the Health Homes Program, in which health plans coordinate physical health, behavioral health, and social services, including housing, for Medi-Cal enrollees with complex health conditions. The county also participates in the Whole Person Care pilot program, which in Los Angeles targets people who are homeless or at risk of homelessness (among other populations) and tests whether coordination across health care and social services can improve health outcomes while reducing medical costs.

CHCF Briefing to Focus on California’s Mental Health System

California’s homelessness crisis is just one of the reasons the state’s public mental health system has drawn attention in recent years. Join CHCF today, September 23, from noon to 1:45 PM for a briefing on California’s public mental health system. Register to watch via webcast or listen by telephone. A video of the briefing will be available on the event page by Wednesday, September 25.

Two Key Newsom Appointments

Governor Newsom has announced the appointments of two directors of key state health care agencies. Sonia Angell, MD, MPH, was appointed director of the California Department of Public Health. Angell was an assistant clinical professor of medicine and an assistant attending physician at New York Presbyterian / Columbia University Hospital. She also served as deputy commissioner for prevention and primary care at the New York City Department of Health and Mental Hygiene.

Newsom also named David R. Duncan Jr., MD, as director of the Emergency Medical Services Authority. Duncan was the medical director and executive medical officer at Air Medical Group Holdings and REACH Air Medical Services. He also served as medical director at the California Department of Forestry and Fire Protection.

Do you think the Trump administration’s interest in homelessness will help California solve the issue? Tweet at me with #EssentialCoverage or email me.

Xenia Shih Bion

Xenia Shih Bion is a communications officer at CHCF, where she helps to lead communications around the foundation’s work to create health equity. She is the founding author of the “Essential Coverage” column in The CHCF Blog. Read More

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