The visible homelessness on American streets — the encampments, the open psychotic episodes, the people clearly unable to care for themselves — is not the same problem as a family losing their apartment after a rent hike. Conflating the two has made both harder to discuss honestly. One is a housing problem with a housing answer. The other is a severe mental illness and addiction crisis that the country dismantled the infrastructure for and never replaced.
We keep arguing about the housing piece because the other piece is politically harder.
What deinstitutionalization actually did
In 1955, U.S. state psychiatric hospitals held more than 550,000 patients. By 2015, fewer than 40,000 beds remained. The shutdown was driven by genuine reformist motives — the old asylums were often abusive — and by a bipartisan financial calculus, since states could shift costs to federal Medicaid by closing institutions. The community mental health centers that were supposed to replace them were funded for roughly a decade, then quietly defunded. The aftercare system never arrived.
The population didn’t disappear. Today, jails and prisons function as the largest psychiatric facilities in the country. The Los Angeles County Jail and Cook County Jail each hold more people with serious mental illness than any state hospital. The street holds the rest.
Housing First is necessary and not sufficient
Housing First — providing permanent supportive housing without preconditions of sobriety or treatment — is genuinely effective for the chronically homeless. The evidence base is real, and the cost savings against ER visits and incarceration cycles are documented. Cities that have implemented it well, such as Helsinki, have reduced visible homelessness substantially.
But Housing First was designed as housing plus wraparound services, including assertive community treatment teams, supported employment, and accessible psychiatric care. American implementations frequently get the housing and skip the services because services are harder to staff and fund. The result, in Los Angeles and San Francisco especially, is units filled but unstable, and a visible crisis that doesn’t budge.
The conservatorship debate, honestly
Civil commitment and conservatorship are uncomfortable topics on the left because of the genuine abuses of the asylum era. They are uncomfortable on the right because doing them well requires expensive, well-staffed psychiatric facilities and ongoing community treatment — public spending at a scale that contradicts small-government instincts.
The result is paralysis. People who are demonstrably unable to consent to treatment, who cycle through emergency rooms and jail, are left on the street under a definition of liberty that no clinician working with them recognizes. Reforming conservatorship — with rigorous due process, fixed durations, and mandated treatment capacity — is one of the few interventions the evidence supports for this specific subgroup. It also requires building the beds the country closed.
The takeaway
Street homelessness is not solved by zoning reform alone, even though zoning reform matters. It is solved by rebuilding inpatient and community psychiatric capacity, funding the services Housing First was designed around, and having an adult conversation about civil commitment with strong procedural protections. Every plan that skips the mental health half of the problem is a plan to manage the crisis indefinitely.
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