This week, the President issued an executive order directing a few federal agencies (DOJ, HHS, HUD, and DOT) to “crack down” on unsheltered homelessness, substance use, and untreated serious mental illness in ways that feel more like policing than public health.
Ending Crime and Disorder on America’s Streets – The White House
You can read the Executive Order here, but here’s the quick version: the EO tells cabinet agencies to: 1) Support court-ordered treatment and institutional care for people who are homeless and “unable to care for themselves”; 2) Give grant priority to cities that enforce laws against camping, drug use, and squatting; and 3) Withhold funding from harm reduction programs like safe consumption sites.
One line even encourages the collection and sharing of health data with law enforcement, “where allowed by law.”
Note: While Executive Orders give agencies formal direction from the executive, they don’t give them any additional statutory authority. They still need to act within the boundaries in federal law set by congress. If agencies use an EO in a way that exceeds their existing statutory authority it’s relatively straightforward for the judicial branch to overturn those actions.
Most of the Power Lies Closer to Home
From a public health perspective, the EO raises more questions than it answers. First, most of the real levers that impact homelessness and behavioral health lie at the state and local level.
State law determines what qualifies as grounds for court-ordered evaluation or court-ordered treatment. Local governments control zoning, affordable housing incentives, and most eviction policies. States decide whether or not to preempt city NIMBY-informed and unreasonable zoning restrictions that prevent more affordable housing. Substance use treatment systems vary widely from one state to the next.
The Federal Role: More About Funding Than Policy
Yes, the federal government plays an indirect and limited role, primarily through funding. HUD’s Continuum of Care grants, SAMHSA block grants, and DOJ reentry funding can shape what local programs are available and how they’re run.
But the biggest federal lever by far is Medicaid, specifically the 1115 waiver that allows AHCCCS (our state’s Medicaid agency) to experiment with coverage for services like behavioral health, supported housing, and community-based crisis care, including their new H2O initiative.
Striking Absence: No Mention of CMS or Medicaid
And that’s where this EO gets oddly silent. There’s no mention of CMS, 1115 waivers, or how Medicaid policy might be aligned with this new federal posture.
That’s surprising, since Medicaid pays for a huge portion of behavioral health care in Arizona, including treatment mandated by the courts for members with a Serious Mental Illness.
If the President truly wanted to change how states approach serious mental illness, substance use, and homelessness, Medicaid waivers and Medicaid agency oversight would be the place to start.
Instead, the EO is silent on Medicaid and in my opinion reads more like a political message dressed up as policy (at least so far)… except for nebulous expectations for changes in HUD’s Continuum of Care and SAMHSA block grants (which are relatively small).
What HUD and DOJ Might Do (Eventually)
The National Association of Counties issued an objective summary, noting that the EO reflects a shift in federal posture toward institutional treatment and “public safety” requirements, but with few details and unclear implications for how it’ll be implemented.
Agencies like HUD and DOJ are instructed to prioritize enforcement-focused jurisdictions when awarding grants… but again, no specifics yet.
So, What Does This Mean for Arizona?
For now, probably not much. Unless CMS starts using its 1115 waiver authority to reshape Medicaid in ways that align with this EO (which the order doesn’t mention), the direct impacts will be limited in at least the near future. AHCCCS isn’t required to change how it funds COT or behavioral health services. Our housing programs that depend on HUD grants may face new strings attached, but we won’t know until those grant criteria are formally updated.
Public Health Needs the Right Tools, Not Just Tough Talking EO’s
Bottom line: this Executive Order may generate headlines, but it’s not likely to change much in Arizona, at least not yet.
For real progress, we need policy that’s informed by evidence, not just ideology, and that uses the right tools to support people living with serious mental illness, substance use disorder, and housing instability. These tools include Medicaid flexibility, community-based treatment capacity, and housing-first strategies, not just law enforcement crackdowns and institutional beds.
We’ll be watching to see how (or if) the cabinet agencies translate this order into actual policy… or whether a new EO extends this into the Medicaid world. In the meantime, local and state action remain the primary drivers of outcomes.
