This past June, the campaigns of Republican presidential candidates Ron DeSantis and Vivek Ramaswamy visited two of the nation’s most derelict neighborhoods. Their point: to connect the public disorder of San Francisco’s Tenderloin and Philadelphia’s Kensington neighborhoods with progressive governance. The visits raised expectations that street conditions would look better under a DeSantis or Ramaswamy administration.
The most direct way to address urban disorder is through a change in city leadership. With problems such as addiction, homelessness, untreated mental illness, and low-level offending, federal policymakers must work indirectly, mainly by sending resources to frontline providers. Still, Republicans like DeSantis and Ramaswamy are right to emphasize these issues, and some federal-level policy solutions are well worth pursuing.
For presidential campaigns, an orderly streets agenda should begin with repealing Medicaid’s “Institutions for Mental Diseases” exclusion. The IMD exclusion bars Medicaid reimbursement for specialized psychiatric hospitals that serve adults. It’s the main cause of the nation’s dire shortage of psychiatric beds. Questions about the legality of involuntary treatment—concerning who should qualify as “dangerous” or “gravely disabled”—get more attention than questions about how to pay for it. But the payment issue is now more pressing. There is no point in trying to make it easier to force people into hospital beds that don’t exist. The most straightforward way to expand the supply of psychiatric beds is by greenlighting Medicaid reimbursement for them.
Repealing the IMD exclusion would need to go through Congress, but presidential leadership could prove key, and Republican leadership would be particularly gratifying. Republicans are often accused of invoking mental-health policy only after mass shootings, in order to distract attention from guns. In fairness, Republican reluctance to raising Medicaid costs may be the greatest barrier to IMD repeal (which would cost the federal government $3–$4 billion per year). It may be even more formidable than pressure exerted on Democrats by disability-rights groups over re-institutionalizing the mentally ill. Inpatient psychiatric care is admittedly expensive. But repealing the IMD exclusion is the most important policy change the federal government could make that would meaningfully address public disorder, to the extent that untreated serious mental illness is causing it. Any presidential campaign that posts social-media videos about urban street mayhem and declines to call for IMD repeal will come across as performative.
The federal government should also eliminate Housing First requirements in federal homelessness grant programs, which prohibit funding for sobriety-oriented housing. That would help meet the constantly voiced demand for more treatment options for addiction. Many addicts need a place to live. Making housing contingent on sobriety, for some, can incentivize recovery. Even proponents of “low barrier” residential programs that don’t ask anyone to be clean concede that programs are necessary for people ready to take the next step toward a stabler life.
So-called recovery housing programs represent one sobriety-oriented housing model. These are self-governing homes run by residents. Recovery housing is highly cost-efficient, since staffing expenses are negligible. Housing First programs that don’t require their residents to be clean must shoulder considerable security and clinical personnel costs if they want to avoid warehousing their severely troubled clientele. No one can realistically claim that addiction is not now a leading cause of homelessness. And no one can realistically claim that they’re doing everything they can to expand treatment options, in the most cost-efficient manner, if they’re not working to expand recovery housing programs.
Bad ideas at the state and local levels remain the main driver of public disorder. Recent examples include spending Covid relief money on tarps and tents, giving literally anyone in the world a legally enforceable right to temporary housing, and overseeing the loss of cheap housing stock amid a raging homelessness epidemic. Big-city officials set the standard for performative politics, making them insensitive to public demands for less public disorder. San Francisco and Philadelphia are not electoral battlegrounds. If they were, local political systems would probably be more responsive to public concerns. But these cities’ challenges are not wholly unique and merit more dedicated attention from the national GOP than they have received.