The U.S. Supreme Court's watershed decision on homelessness Friday will make it easier for elected officials and law enforcement authorities nationwide to fine and arrest people who live on streets and sidewalks, in broken-down vehicles, or within city parks — which could have far-reaching health consequences for homeless Americans and their communities.
In a 6-to-3 ruling in City of Grants Pass v. Johnson, the justices in the majority said allowing the targeting of homeless people occupying public spaces by enforcing bans on public sleeping or camping with criminal or civil penalties is not cruel and unusual punishment, even if there are no alternative shelter or housing options available for them.
The case, the most consequential on homelessness in decades, comes amid widespread public frustration over the proliferation of homeless encampments — especially in Western cities such as Los Angeles, San Francisco, Phoenix, and Portland, Oregon — and the unsafe and unsanitary conditions that often fester around them.
An estimated 653,100 people were homeless in the United States in 2023, according to the most recent federal estimates, the vast majority residing in shanties, broken-down recreational vehicles, and sprawling tent camps scattered across urban and rural communities.
In the majority opinion, Justice Neil Gorsuch argued that the homelessness crisis is complex and has many causes, writing, "With encampments dotting neighborhood sidewalks, adults and children in these communities are sometimes forced to navigate around used needles, human waste, and other hazards to make their way to school, the grocery store, or work."
In a dissenting opinion, Justice Sonia Sotomayor wrote that the decision focuses on the needs of local government and "leaves the most vulnerable in our society with an impossible choice: Either stay awake or be arrested."
Elected officials, both Republican and Democrat, have increasingly argued that life on the streets is making people sick — and they should be allowed to relocate people for health and safety.
"If government offers people help and they can't or won't accept it, there should be consequences. We have laws that need to be used," said Sacramento Mayor Darrell Steinberg.
"I'm comfortable telling people that you can't camp in public, but I would not criminalize it," he said. "Some cities will fine and arrest people."
Advocates for homeless people say constant relocations will further imperil the health of this population and magnify public health threats, such as the spread of communicable diseases.
"Some cities have decided that they want to fine, arrest, and punish people for being homeless, and the majority opinion tells communities that they can go ahead and do that," said Steve Berg, chief policy officer for the National Alliance to End Homelessness.
"It just is going to contribute to more death and higher mortality rates," said Jim O'Connell, the president of Boston's Health Care for the Homeless Program and an assistant professor of medicine at Harvard Medical School. "It's tough, because there's a public safety versus public health" debate cities are struggling with.
As homeless people become sicker, they will get more expensive to treat, O'Connell said.
"Stop thinking about the emergency room, which is cheap compared to what we actually see, which is homeless people being admitted to the ICU," he said. "I've got 20-something patients at Mass General today taking a huge amount of money to care for."
In Los Angeles, which has one of the biggest homeless populations in America, street medicine provider Brett Feldman predicts more patients will need emergency intensive care as chronic conditions like diabetes and heart disease go untreated.
Patients on anti-addiction medication or those undergoing treatment to improve their mental health will also struggle, he said.
"People are already getting moved and camps swept all the time, so we already know what happens," Feldman said. "People lose their medications; they lose track of us."
Homeless people die at rates two to six times higher than residents living in stable housing, according to a May report from the Los Angeles County Department of Public Health.
The Biden administration has pushed states to expand the definition of health care to include housing. At least 19 are directing money from Medicaid — the state-federal health insurance program for low-income people — into housing aid.
The Supreme Court decision could interrupt these programs, said Margot Kushel, a primary care doctor and homelessness researcher at the University of California-San Francisco.
"Now you're going to see disconnections from those case managers and housing navigators and people just losing touch in the chaos and the shuffle," she said.
Kushel said the ruling would make homelessness worse. "Just having fines and jail time makes it easier for a landlord to reject you for housing," she said.
At the same time, Americans are increasingly frustrated by encampments spreading into neighborhoods, ringing public parks, and popping up near schools. The spread is marked by more trash, dirty needles, rats, and human excrement on sidewalks.
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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