State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a Ñî¹óåú´«Ã½Ò•îl Health News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat — or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price — both in the cost to taxpayers and coverage losses — according to state documents obtained by Ñî¹óåú´«Ã½Ò•îl Health News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly will lose access to monthly cash assistance for food, including those with children.

In five states alone, for state officials and reviewed by Ñî¹óåú´«Ã½Ò•îl Health News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting company Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will . Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company that operates the state’s eligibility system.

Optum — which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act — to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, . And in Illinois, will cost at least $12 million.

A Historic Mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules — .

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements — about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was as of October.

of adult Medicaid enrollees nationally are already working, according to KFF. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the .

In Wisconsin, state officials estimate could lose coverage after work requirements take effect. Not covering those people would in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP — known as CARES — in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New Hurdles for Vets and Homeless People

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults — doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year . , initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government — that is, taxpayers — to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems — as D.C. is —­ I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to Ñî¹óåú´«Ã½Ò•îl Health News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” Ñî¹óåú´«Ã½Ò•îl Health News found that Deloitte, a global consultancy that generated in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 Million Bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a .

Adding the ability to verify work status would cost up to $7 million, . By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions . Accenture’s analysis said the federal law necessitated . Making employment a condition of Medicaid benefits could cause an estimated 32,000 Iowans to lose coverage, according to a

Cutting 32,000 people from coverage in one year, a fraction of the Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level — currently .

“There is no benefit to this population,” Lock said.

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that — priced at $12 million — is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” , the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time — supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 — Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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January’s extreme cold has put a spotlight on the conditions homeless people face. They get sicker and die younger than housed people, often because health problems go untreated. The Trump administration’s removal of homeless tent encampments in Washington, D.C., has made it more difficult for health workers to reach that vulnerable population this winter.

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Angela Hart takes WAMU “Health Hub” listeners to Washington’s streets to hear how homeless people are juggling their health and shelter after the Trump administration’s crackdown.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Los residentes comparten habitaciones diseñadas para personas con problemas de movilidad. También hay baños privados, algo muy importante para aquellos que lidian con la incontinencia.

A diferencia del MVP, la mayoría de los refugios para personas sin hogar no están preparados para ayudar a adultos mayores, especialmente a quienes tienen 65 años o más. Se trata del grupo que más rápido está creciendo dentro de la población sin hogar en Estados Unidos, explicó , investigador de la Universidad de Pennsylvania.

No solo están envejeciendo quienes han vivido por años en situación de desamparo, sino que muchas personas mayores están perdiendo su vivienda por primera vez en sus vidas.

Subir y bajar de literas, tomar los medicamentos correctamente y llegar a tiempo a un baño compartido son algunos de los principales retos que enfrentan estas personas en los refugios. En algunos tradicionales, el personal les pide que se vayan si no pueden cuidarse por sí mismas.

MVP es un refugio inusual porque ofrece atención médica en el mismo lugar para poder atender mejor a sus residentes a medida que envejecen.

La primavera pasada, Jamie Mangum, de poco más de 50 años y con cáncer de pulmón, tropezó y se cayó en su habitación. Para ver a una técnica en emergencias médicas, solo tuvo que bajar la escalera. Le vendaron rápidamente la muñeca inflamada y pudo regresar a su cuarto. Dijo que eso no habría sido posible en otros refugios donde ha estado.

“En otros lados, tendría que esperar horas. Aquí solo entro y me atienden”, dijo Mangum.

Agregó que en otros refugios probablemente habría tenido que buscar por su cuenta una clínica de urgencias o pedir una ambulancia. En MVP, además, trabajadoras sociales especializadas la han ayudado a recibir tratamiento para el cáncer.

“Tenemos clientes que necesitan cuidados de memoria. Tal vez antes vivían de manera independiente, pero ya no pueden y fueron desalojados debido a la demencia u otras razones”, explicó Baleigh Dellos, quien administra el refugio MVP para , una organización local sin fines de lucro.

En el refugio trabajan gestores de casos médicos especializados. También hay doctores de atención primaria y terapeutas que visitan semanalmente. Los residentes incluso pueden recibir fisioterapia en espacios privados dentro del mismo refugio.

Un camino hacia la estabilidad

MVP se asoció con para ofrecer atención médica.

Lo primero que la mayoría de las personas nuevas necesitan es ayuda con sus medicamentos, explicó Matt Haroldsen, de Fourth Street Clinic, que brinda servicios de salud dentro del refugio.

Para quienes viven en la calle, simplemente conservar sus medicamentos ya es un gran desafío. “Cuando están en los campamentos, les roban las medicinas”, dijo.

Las personas con diabetes que no tienen vivienda muchas veces entierran su insulina para mantenerla fría. Según Haroldsen, pueden olvidar dónde la enterraron o las ampollas se pueden calentar demasiado y echarse a perder.

Ayudar a las personas del refugio a recuperar sus medicamentos permite estabilizar sus afecciones de salud, lo que a su vez les permite concentrarse en otras prioridades, como obtener una identificación u otros documentos necesarios para solicitar discapacidad, Seguro Social y diversos programas que pueden ayudarlas a conseguir vivienda.

Gobiernos locales y organizaciones sin fines de lucro han abierto refugios similares en Florida, California y Arizona para responder a las necesidades de adultos mayores sin hogar.

Tener acceso a refugios especializados puede significar la diferencia entre la vida y la muerte, señaló , subdirectora del National Health Care for the Homeless Council.

En estados con climas fríos, negar una cama a personas mayores debido a problemas de movilidad u otras condiciones médicas puede ser especialmente riesgoso. En 2022, un hombre mayor sin hogar , Montana, después de que lo sacaran de un refugio por incontinencia.

Las necesidades médicas complejas también pueden representar un riesgo para otras personas en los refugios, quienes muchas veces no están preparados para manejar esas situaciones.

“Un refugio típico no permite que alguien entre con oxígeno porque representa un riesgo de incendio”, explicó.

Synovec dijo que brindar acceso a la atención médica dentro de los refugios es la mejor forma de ayudar a las personas mayores a mantenerse estables una vez que logren obtener una vivienda. Según explicó, los problemas de salud son una causa común por la que muchas personas mayores no pueden pagar o mantener una vivienda.

Modelo en expansión

El modelo MVP está mostrando resultados prometedores, tanto en Utah como en otros lugares.

“Más del 80% de las personas que pasaron por nuestro programa el año pasado lograron mudarse a una vivienda estable o permanente”, dijo , vicepresidente de programas del Task Force for Ending Homelessness en Fort Lauderdale, Florida. Esta organización sin fines de lucro administra un refugio llamado .

El refugio MVP, ubicado cerca de Salt Lake City, también ha tenido éxito. Hasta finales del año pasado, había logrado ubicar de forma permanente a 36 personas mayores.

Sin embargo, hay más personas que necesitan refugio de las que el lugar puede recibir. Dellos, la encargada del lugar, dijo que la lista de espera del MVP se mantiene en unas 200 personas. Agregó que se prioriza a quienes tienen más necesidad médica, no por el tiempo que llevan esperando.

Para quienes logran obtener una habitación, la experiencia puede cambiarles la vida.

La primavera pasada, Jeff Gregg, de 62 años, jugaba a lanzar la pelota con su perro Ruffy, justo más allá del jardín frente al refugio MVP.

Una antigua lesión en la espalda lo obliga a encorvarse al lanzar la pelota. También lo llevó a una adicción a los opioides que duró décadas. Dijo que romper ese ciclo fue muy difícil.

“Luchando con eso, teniendo un trabajo, seguro médico, luego perdiendo el trabajo, sin seguro, terminando en la calle y otra vez en ese infierno. Y volvía al mismo lugar”, contó.

Gregg dijo que mantenerse sobrio pasaba a segundo plano frente a necesidades más urgentes como encontrar comida o una cama donde dormir. Afirmó que el MVP fue el primer lugar donde pudo relajarse y concentrarse en su recuperación.

“Pude dejar las drogas. Me tomó un par de meses, pero fui avanzando poco a poco”, contó.

Dijo que esa experiencia le abrió el camino para operarse de la espalda. Espera que, con menos dolor, eventualmente pueda conseguir un trabajo y pagar un apartamento.

Este artículo es parte de una colaboración con  Ìý²âÌý.

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Scattered visits to free clinics notwithstanding, Guevara hadn’t had a full medical checkup in years. She required dental work. She wanted to start looking for a job. And she was overwhelmed by the maze of paperwork needed simply to get her off the street, much less to make any of the other things happen.

But Guevara had help. The Jamboree Housing Corp., an affordable-housing nonprofit that renovated the former Stanton, California, hotel Guevara now calls home, didn’t just move her in — it also provided her a fleet of wraparound services. Jamboree counselors helped Guevara navigate the health care system to see a doctor and a dentist, buy a few things for her apartment, and get training to become a caregiver.

“I was years on the street before I got the kind of help I needed so I could help myself,” said Guevara, 68.

Amid the Trump administration’s apparent opposition to using Medicaid funding for such social services, staffers at Jamboree and similar affordable housing providers in California have been worried about losing federal money, particularly as the experimental waivers that provide the primary funding for the program they rely on expire at the end of 2026. But as it turns out, the state had the foresight several years ago to designate certain nonhousing social services, such as mental health care, drug counseling, and job training, as a form of Medicaid spending that will continue to be reimbursed.

Catherine Howden, a spokesperson for the federal Centers for Medicare & Medicaid Services, confirmed that California’s use of the “in lieu of services” classification for these wraparound programs is allowed under federal regulations.

“It is starting to sound positive that we will, at the very least, be able to continue billing for these services after the waiver period,” said Natalie Reider, a senior vice president at Jamboree Housing.

During President Donald Trump’s first term, states were permitted to use Medicaid money for social support services not typically covered by health insurance. But the second Trump administration is reeling that policy back in, saying that the intervening Biden administration took the supportive services process too far. Howden said in a statement that the policy “distracted the Medicaid program from its core mission: providing excellent health outcomes for vulnerable Americans.”

Through CalAIM, a five-year experimental build-out of the Medicaid system, programs like Jamboree were able to leverage federal funding to offer the kinds of nonhousing social services that experts contend are essential to keeping people permanently housed.

However, these wraparound services are only one component of the CalAIM initiative, which is attempting to take Medicaid, known as Medi-Cal in California, in a more holistic direction across all areas of care. And when CalAIM launched, California officials gave the programs the Medicaid “in lieu of services” designation, known as ILOS, effectively putting them outside the waiver process and ensuring that even when CalAIM sunsets, money for those social initiatives will continue to flow.

“California has tried to future-proof many of the policy changes it has made in Medi-Cal by including them in mechanisms like ILOS that do not require federal waiver approval,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News. “That allows these policy changes to continue, even with a politically hostile federal administration.”

The designation allows these social services to be funded through Medicaid managed-care plans under existing federal laws because they are cost-effective substitutes for a Medicaid service or reduce the likelihood of patients needing other Medicaid-covered health care services, said Glenn Tsang, policy adviser for homelessness and housing at the state’s Department of Health Care Services. The state could not provide an estimate of the annual funding for these wraparound services because they are not distinguished from other payments made to Medicaid managed-care plans.

“We are full steam ahead with these services,” Tsang said, “and they are authorized.”

Although California was the first state to incorporate the designation for such housing and other health-related social support, Tsang said, several other states — including Arizona, Arkansas, Florida, New York, and North Carolina — are now using the mechanism in a similar fashion.

Early results suggest such support saves on health care spending. When Jamboree, in Northern California, in the Central Valley, and other permanent supportive housing providers employ a holistic approach that includes social services, they have reported higher rates of formerly homeless people remaining in housing, less frequent use of costly emergency health services, and more residents landing jobs that help them pay rent and stay housed.

At the nonprofit MidPen Housing, which serves 12 counties in and around the San Francisco Bay Area, roughly 40% of the units in the program’s pipeline are earmarked for “extremely low-income” people, a group that includes the homeless, said Danielle McCluskey, senior director of resident services.

CalAIM reimbursements help fund the part of MidPen that focuses on supportive services across a wide range of experiences, from chronic homelessness to mental health issues to those leaving the foster care system. McCluskey described it as one leg of a three-legged stool, the others being real estate development and property management.

“If any of those legs are not getting what they need, if they’re not funded or not staffed or resourced, then that stool is kind of wobbly — off-kilter,” the director said.

A recent found that people who used at least one of the housing support services — including navigation into new housing, health care assistance, and a deposit to secure an apartment — saw a 13% reduction in emergency department visits and a 24% reduction in inpatient admissions in the six months that followed.

Documenting those outcomes is critical because the department needs to show federal officials that the services lessen the need for other, often costlier Medicaid-covered care — the essence of the classification.

Advocates for the inclusion of supportive services argue that the American system ultimately saves money on those investments. As California’s homeless population to more than 187,000 on a given night — nearly a quarter of the U.S. total — Jamboree has been allocating more of its resources to permanent supportive housing.

Founded in 1990 in Orange County, Jamboree builds various types of affordable housing using federal, state, and private funding. Reider said about a fifth of the organization’s portfolio is dedicated to permanent supportive housing.

“They’re not going back out to the streets. They’re not going to jail. They’re not going to the hospitals,” Reider said. “Keeping people housed is the No. 1 outcome, and it is the cost-saver, right? We’re using Medicaid dollars, but we’re saving the system money in the long run.”

Guevara, who wound up on the streets after a falling-out with family in 2015, spent years living out of her truck before a shelter worker connected her with Jamboree. There, she was paired with a specialist to help her figure out how to get and see a doctor, and to keep up with scheduling the battery of medical tests she needed after years spent living in temporary shelters.

“I also got a job developer, who helped me get this job with the county so I can pay my rent,” Guevara said of her position as a part-time in-home caregiver. “Now I take care of people kind of the same way people have been taking care of me.”

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Pero por dentro, el lugar es un oasis acogedor. Luces colgantes decoran los estantes de ropa donada. Hay repisas y contenedores llenos de libros infantiles, medicamentos para la alergia y artículos de higiene personal. Separado por cortinas, hay un salón con un escenario para músicos y un letrero de neón con patines, para las noches gratuitas de patinaje que se organizan cada semana.

El espacio es en parte tienda gratuita de segunda mano, en parte farmacia de medicamentos de venta libre, sede de conciertos punk y en su totalidad “un centro comunitario radical”, explicó Dan Bingler, quien lo administra.

Bingler es mesero y bartender en la ciudad, y fundó una organización de ayuda mutua llamada . Contó que los dueños del edificio le permiten usar el espacio siempre y cuando él pague el agua, la luz y la recolección de basura.

Los lunes por la tarde, se presentan voluntarios de otras organizaciones comunitarias —algunos de ellos solían instalarse en el estacionamiento antes de que Bingler abriera el local—. Ofrecen pruebas gratuitas de infecciones de transmisión sexual, atención médica básica, comidas calientes, jeringas estériles y otros suministros para personas que utilizan drogas.

El propósito del lugar es simple, dijo Bingler: “Vamos a asegurarnos de brindar apoyo a la comunidad”.

Aunque lleva varios años en funcionamiento, el espacio se ha vuelto aún más crucial en los últimos meses, con la administración Trump recortando fondos a muchas organizaciones de servicios sociales y adoptando una postura agresiva frente a las personas sin hogar y el consumo de drogas.

En Washington D.C., su administración ha de tiendas para obligar a quienes viven en la calle a . A nivel nacional, ha pedido que se que consumen drogas a iniciar un tratamiento. Ha rechazado la —estrategias que, según expertos en salud pública, protegen a las personas que usan drogas y salvan vidas, pero que sus críticos dicen fomentan el consumo de sustancias ilegales—.

El espacio comunitario en Nueva Orleans —llamado Fred Hampton Free Store, en honor al , conocido por unir a grupos diversos para luchar por reformas sociales— busca ser un refugio frente a todos estos cambios.

Bingler dijo que no recibe fondos federales, ni subvenciones estatales o locales, ni dinero de fundaciones. Simplemente son vecinos ayudando a vecinos, dijo con la voz entrecortada, y agregó: “Es algo realmente hermoso poder compartir este espacio”.

Todos los artículos del lugar provienen de personas u organizaciones de la comunidad. En una ocasión, contó Bingler, un hotel local que estaba en remodelación donó 50 televisores de pantalla plana.

En las noches que el local está abierto, suelen llegar más de 100 personas, agregó.

Una noche de otoño, decenas de personas buscaban ropa gratuita y medicamentos de venta libre. Otros estaban sentados sobre el césped, conversando mientras vigilaban sus bicicletas o carritos de supermercado llenos de pertenencias.

James Beshears pasó por el grupo de reducción de daños en el estacionamiento para recibir suministros estériles que usa para inyectarse heroína y fentanilo. Dijo que estuvo en tratamiento durante años, pero recayó cuando su doctor se mudó y lo derivaron a una clínica que cobraba $250 por día. Las drogas callejeras eran más baratas que el tratamiento, comentó.

Quiere dejar de consumir. Pero hasta que encuentre atención médica accesible, lugares como esta tienda gratuita lo ayudan a seguir adelante. Sin ella, dijo, ya tendría “un pie en la tumba”.

Otro hombre en el estacionamiento esperaba la llegada de Aquil Bey, un paramédico y ex miembro de las fuerzas especiales del ejército, conocido por ayudar a personas a superar obstáculos para acceder a atención médica. Apenas vio la camioneta negra de Bey, corrió a encontrarlo.

“Tengo enfermedad renal en etapa 4”, le dijo, y añadió que tenía citas programadas en el hospital, pero que le costaba llegar.

“Hazme un favor”, le respondió Bey mientras bajaba mesas plegables y equipo médico de su auto. “Cuando llegue nuestro equipo, ven a vernos. Tal vez podamos conseguirte transporte”.

Bey es fundador de , una organización dirigida por voluntarios que ofrece atención médica básica gratuita y derivaciones a personas sin hogar, que usan drogas o pertenecen a otras comunidades vulnerables. El grupo tiene presencia constante en la tienda gratuita.

Ese día, Bey y su equipo conectaron al hombre que necesitaba tratamiento para su enfermedad renal con programas de transporte de bajo costo. También hicieron controles de presión arterial y azúcar en sangre, trataron heridas infectadas y llamaron a clínicas para pedir citas para pacientes que no tienen teléfono.

Un hombre con una lesión en la pierna mencionó que dormía en el piso de concreto de una base naval abandonada. Bey notó que en la sección de muebles del local había un colchón. Junto con otro voluntario, lo cargó, lo amarró al techo de un auto y lo llevó hasta donde dormía el hombre.

“Estamos tratando de identificar todas estas barreras” que enfrenta la gente y “buscar formas de resolverlas”, dijo Bey.

La clínica en la tienda gratuita ayudó a Stephen Wiltz a conectarse con tratamiento para su adicción. Nació y creció en el Lower 9th Ward, y había estado consumiendo drogas desde los 10 años.

Cansado de la discriminación por parte de doctores que lo culpaban por su adicción, Wiltz dijo que evitaba ir a cualquier centro de tratamiento. Pero después de años de conocer a los voluntarios de la tienda gratuita, confió en ellos para que lo orientaran.

A sus 56, estaba en recuperación sostenida por primera vez en su vida, dijo en una entrevista telefónica en otoño.

Esos voluntarios “cuidaron de personas que no tenían a nadie que los cuidara”, afirmó.

Cuando cayó el sol esa noche en la tienda, una banda punk empezó a preparar su presentación al otro lado del salón, donde estaba la clínica médica. Las luces se atenuaron y la música comenzó a sonar a todo volumen, un recordatorio de que no se trata de una clínica ni de un centro comunitario convencional.

Bey seguía atendiendo a un paciente con gota.

“Ya me acostumbré al sonido”, dijo sobre los golpes rápidos de la batería y los acordes potentes. “A veces hasta me gusta”.

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But inside, the store is a welcoming oasis. Twinkly string lights adorn racks of donated clothing. Shelves and bins overflow with children’s books, allergy medications, and toiletries. Curtains cordon off one side of the room, where there’s a stage for musicians and a neon sign depicting roller skates for weekly free skate nights.

The space is part free thrift store, part over-the-counter pharmacy, part punk show venue — and wholly “a radical community center,” said Dan Bingler, who runs the place.

Bingler is a waiter and bartender in the city who founded a mutual-aid organization called the . He said the building owners allow him to use the space as long as he pays the water, electricity, and trash bills.

On Monday evenings, volunteers from other community organizations show up — some used to set up in the parking lot before Bingler opened the store. They offer free testing for sexually transmitted infections, basic medical care, hot meals, and sterile syringes and other supplies for people who use drugs.

The purpose of the space is simple, Bingler said: “We’re going to make sure we provide for the community.”

Although it’s been open for a few years now, the space has become even more crucial to this community in recent months, with the Trump administration slashing funding for many social service organizations and taking an aggressive approach to homelessness and drug use. In Washington, D.C., the administration has to push people living on the street to . Nationally, it has called for people who use drugs to be . It has — practices that public health experts say keep people who use drugs safe and alive but that critics say promote illegal drug use.

The community space in New Orleans — named the Fred Hampton Free Store after the known for bringing together diverse groups to fight for social reforms — aims to be a haven among this sea of changes.

It doesn’t receive federal funding, state or local grants, or money from foundations, Bingler said. It’s simply neighbors helping neighbors, he said, tearing up and adding, “It’s a really beautiful thing to be able to share all this space.”

All items inside are provided by people or organizations in the community. Bingler said one time a local hotel undergoing renovations donated 50 flat-screen TVs.

On nights the store is open, often more than 100 people visit, Bingler said.

One fall evening, dozens of people browsed for free clothing and over-the-counter medications. Others sat on the grass outside, chatting while keeping an eye on their bicycles or grocery carts full of possessions.

James Beshears stopped by the harm reduction group in the parking lot to get sterile supplies he uses to inject heroin and fentanyl. He said he’d been in treatment for years but relapsed after his doctor moved away and he was referred to a clinic that charged $250 a day. Street drugs were cheaper than treatment, he said.

He wants to stop. But until he can find affordable care, places like the free store keep him going. Without it, he said, he’d have “one foot in the grave.”

Another man in the parking lot was waiting for the arrival of Aquil Bey, a paramedic and former Green Beret well known for helping people overcome obstacles to getting health care. As soon as the man spotted Bey’s black Jeep, he ran up.

“I’ve got stage 4 kidney disease,” the man said, adding that he was scheduled for treatments at a hospital but was struggling to get there.

“Do me a favor,” Bey said as he unloaded folding tables and medical equipment from his car. “When our team gets here, come and see us. Maybe we can get you transportation.”

Bey is the founder of , a volunteer-run organization that provides free basic medical care and referrals for people who are homeless, using drugs, or part of other vulnerable communities. The group has a steady presence at the free store.

That day, Bey and his team connected the man needing kidney disease treatment to reduced-cost transit programs. They also did blood pressure and blood sugar checks for anyone who wanted them, cleaned infected wounds, and called clinics to make appointments for patients without phones.

A man with a leg injury mentioned he was sleeping on the concrete floor of an abandoned naval base. Bey noticed the free store’s furniture section had a mattress. He and another volunteer hauled it out, strapped it to the top of a car, and delivered it to where the man was sleeping.

“We’re just trying to find all these barriers” that people face and “find ways to fix them,” Bey said.

The clinic at the free store helped Stephen Wiltz connect with addiction care. He grew up in the Lower 9th Ward and had been using drugs since he was 10.

Fed up with discrimination from doctors who blamed him for his addiction, Wiltz said, he was reluctant to go to any treatment facility. But after years of knowing the volunteers at the free store, he trusted them to point him in the right direction.

At 56, Wiltz was in sustained recovery for the first time in his life, he said during a phone interview in the fall.

Those volunteers “cared for people who didn’t have nobody to care for them,” he said.

As the sun went down that fall evening at the store, a punk band started setting up for a show across the room from the medical clinic. Lights dimmed and music blared — a reminder that this was not your everyday clinic or community center.

Bey continued consulting with a patient who had gout.

“I get used to the sound,” Bey said of the rapid drums and loud power chords. “I like it sometimes.”

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Residents share rooms designed to be accessible to those with mobility issues. There are also private bathrooms, which are a big deal for seniors struggling with incontinence.

Unlike the MVP, most homeless shelters aren’t equipped to help seniors, especially those 65 and older. They are the fastest-growing homeless population nationwide, according to , a researcher at the University of Pennsylvania. Not only are people who struggle with chronic homelessness aging, but many seniors are becoming homeless for the first time in their lives.

Getting in and out of bunks, managing medications, and making it to a shared bathroom in time are among the major challenges of shelter life for older adults. Staff at traditional shelters sometimes ask seniors to leave if they’re unable to care for themselves.

The MVP is unusual among shelters because it provides on-site medical care to better serve its residents as they age.

Last spring, Jamie Mangum, who is in her 50s and has lung cancer, tripped and fell in her room. To visit with an emergency medical technician, she needed only to make it downstairs. Her swollen wrist was quickly wrapped, and she returned to her room. She said that wouldn’t have been possible at other shelters she’s stayed in.

“There, I’d have to wait hours as opposed to come in here, be seen,” Mangum said.

Mangum said that in other shelters she’d likely have had to find her own way to an urgent care office or get an ambulance ride. Specialized case managers at the MVP have helped her get treatment for lung cancer as well.

“We have clients that need memory care. Maybe they were living independently before, but they were unable to maintain that and got evicted due to dementia or different things like that,” said Baleigh Dellos, who manages the MVP shelter for , a local nonprofit.

Specialized medical case managers work at the shelter. Primary care doctors and therapists visit weekly. Residents can even receive physical therapy in private spaces on-site.

A Path to Stability

The MVP partnered with the to offer medical care.

The first thing most new residents need help with is medication, said Matt Haroldsen with the Fourth Street Clinic, which provides health services at the shelter.

For people living on the streets, just keeping hold of regular medications is a challenge. “Their medications get jacked when they’re in their camps,” he said.

Diabetes patients without homes often bury their insulin to keep it cold. Haroldsen said they might forget where they buried it, or the vials might get too warm and spoil.

Helping residents at the shelter get those medications can stabilize their conditions, allowing them to focus on other priorities, such as getting an ID and other documents they need to apply for disability, Social Security, and various programs that can help them secure housing.

Nonprofits and local governments have opened similar shelters in Florida, California, and Arizona to meet the needs of older unhoused adults.

Having access to specialized shelters can be the difference between life and death, said , assistant director of the National Health Care for the Homeless Council.

In cold-weather states, denying seniors a bed because of mobility and other health issues can be especially risky. In 2022, a Bozeman, Montana, after he was asked to leave a shelter because of incontinence.

Complex medical needs can pose a danger to other residents that most shelters aren’t prepared to manage.

“A typical shelter doesn’t allow somebody on oxygen to come in because that’s such a fire hazard and risk,” she said.

Synovec said giving seniors better access to health care inside shelters is the best way to help them succeed once they get housing. Health issues are a common reason seniors can’t afford or maintain housing, she said.

A Growing Model

The MVP model is showing promise, both in Utah and elsewhere.

“Over 80% of the people who’ve stayed in our program this past year have moved into stable or permanent housing,” said , vice president of programs for the TaskForce for Ending Homelessness in Fort Lauderdale, Florida. The nonprofit runs a shelter called .

The MVP shelter near Salt Lake City is also marking success. It was able to permanently house 36 seniors as of late last year.

Still, there are more seniors in need of shelter than it can accommodate. Dellos, the shelter’s manager, said the MVP’s waitlist hovers around 200 people. She said the shelter prioritizes people based on medical need, not time spent on the waitlist.

For residents who do get a room, it’s life-changing.

Last spring, 62-year-old Jeff Gregg was playing fetch with his dog, Ruffy, just beyond the lawn in front of the MVP.

An old back injury forced Gregg to hunch over as he threw the ball. It also fueled a decades-long addiction to opioids. That cycle was hard to escape, he said.

“Fighting that, having a job, insurance, then losing the job, not having insurance, going out to the streets and being back in that crap, and I’d be back in the same position,” he said.

Gregg said sobriety took a back seat to more immediate needs like finding food and a bed in a shelter. He said the MVP was the first place where he could relax and focus on recovery.

“I was able to get clean. It took me a couple months, but I just kept plucking away,” he said.

He said the experience paved the way for him to get back surgery. He hopes that with less back pain, he can eventually get a job to help him afford an apartment.

This article is part of a partnership with and .

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“That’s what I’m trying to avoid,” said Ferguson, who still calls Quincy Jackson III her baby. She remembers a boy who dressed himself in three-piece suits, donated his allowance, and graduated high school at 16 with an academic scholarship and plans to join the military or start a business.

Instead, Ferguson watched as her once bright-eyed, handsome son sank into disheveled psychosis, bouncing between family members’ homes, homeless shelters, jails, clinics, emergency rooms, and Ohio’s regional psychiatric hospitals.

Over the past year, The Marshall Project – Cleveland and Ñî¹óåú´«Ã½Ò•îl Health News interviewed Jackson, other patients and families, current and former state hospital employees, advocates, lawyers, judges, jail administrators, and national behavioral health experts. All echoed Ferguson, who said the mental health system makes it “easier to criminalize somebody than to get them help.”

State psychiatric hospitals nationwide have largely lost the ability to treat patients before their mental health deteriorates and they are charged with crimes. Driving the problem is a meteoric rise in the share of patients with criminal cases who stay significantly longer, generally by court order.

Patients Wait or Are Turned Away

Across the nation, psychiatric hospitals are short-staffed and consistently turn away patients or leave them waiting with few or no treatment options. Those who do receive beds are often sent there by court order after serious criminal offenses.

In Ohio, the share of state hospital patients with criminal charges jumped from about half in 2002 to .

The surge has coincided with a steep decline in total state psychiatric hospital patients served, down 50% in Ohio in the past decade, from 6,809 to 3,421, according to the . During that time, total patients served nationwide dropped about 17%, from 139,434 to 116,320, with state approaches varying widely, from adding community services and building more beds to closing hospitals.

Ohio Department of Behavioral Health officials declined multiple interview requests for this article.

The decline in capacity at state facilities unfurled as a spate of local hospitals across the country shuttered their psychiatric units, which disproportionately serve patients with Medicaid or who are uninsured. And the financial stability of is likely to deteriorate further after Congress passed President Donald Trump’s One Big Beautiful Bill Act, which slashes nearly $1 trillion from the federal Medicaid budget over the next decade.

The constricted flow of new patients through state hospitals is “absolutely” a crisis and “a huge deal in Ohio and everywhere,” said retired Ohio Supreme Court Justice Evelyn Lundberg Stratton. As co-chair of the state attorney general’s , Lundberg Stratton has spent decades searching for solutions.

“It hurts everybody who has someone who needs to get a hospital bed that’s not in the criminal justice system,” she said.

‘It’s Heartbreaking’

Quincy Jackson III’s white socks stuck out of the end of a hospital bed as police officers stood watch.

At 5 feet, 7 inches tall, Jackson has a stocky build and robotic stare. Staff at Blanchard Valley Hospital in Findlay, Ohio, had called for help, alleging Jackson had assaulted a security guard.

“I’m sick; I take medication,” Jackson said to the officers, according to law enforcement body camera footage. His hands were cuffed behind his back as he lay on the bed, a loose hospital gown covering him.

Ferguson called it one of his “episodes” and said her son experienced severe psychosis frequently. In one incident, she said, Jackson “went for a knife” at her home.

From December 2023 through this July, Jackson was arrested or cited in police reports on at least 17 occasions. He was jailed at least five times and treated more than 10 times at hospitals, including three state-run psychiatric facilities. A recent psychiatric evaluation noted that Jackson has been in and out of community and state facilities since 2015.

Jackson is among a glut of people nationwide with severe mental illness who overwhelm community hospitals, courtrooms, and jails, eventually leading to backlogs at state hospitals.

High-Profile Incidents

That dearth of care is often cited by families, law enforcement authorities, and mental health advocates after people struggling with severe mental illness harm others. In the past six months, at least four incidents made national headlines.

In August, a homeless reportedly diagnosed with schizophrenia fatally stabbed a woman on a train. Also in August, police said a with a history of mental health issues killed three people, including a child, at a Target store. In July, a homeless who family members said had needed treatment for decades attacked 11 people at a Walmart store with a knife. In June, police shot and killed a reportedly diagnosed with schizophrenia after authorities said he attacked law enforcement.

Mark Mihok, a longtime municipal judge near Cleveland, told a spring that he had never seen so many people with serious mental illnesses living on the streets and “now punted into the criminal justice system.”

37-Day Wait for a Bed

At Blanchard Valley Hospital, sheriff’s deputies had taken Jackson from jail for a mental health check. But Jackson’s actions raised concerns.

In the body camera video, a nurse said Jackson was “going to be here all weekend. And we’re going to be calling you guys every 10 minutes.”

The officer responded: “Yeah, well, if he keeps acting like that, he’s going to go right back” to the county jail.

Within minutes, Jackson was taken back to jail, yelling at the officers: “Kill me, motherf—–. Yeah, shoot them, shoot them. Pop!”

Statewide, Ohio has about 1,100 beds in its six regional psychiatric hospitals. In May, the median wait time to get a state bed was 37 days.

That’s “a long time to be waiting in jail for a bed without meaningful access to mental health treatment,” said Shanti Silver, a senior research adviser at the national nonprofit Treatment Advocacy Center.

Long waits, often leaving people who need care lingering in jails, have drawn lawsuits in several states, including , , and , where a large 2014 class action case forced systemic changes such as expansion of crisis intervention training and residential treatment beds.

Ohio officials noticed bed shortages as early as 2018. State leaders assembled task forces and . They launched community programs, crisis units, and a statewide emergency hotline.

Yet backlogs at the Ohio hospitals mounted.

Ohio Department of Behavioral Health Director LeeAnne Cornyn, who left the agency in October, wrote in a May emailed statement that the agency “works diligently to ensure a therapeutic environment for our patients, while also protecting patient, staff, and public safety.”

Eric Wandersleben, director of media relations and outreach for the department, declined to respond to detailed questions submitted before publication and, instead, noted that responses could be publicly found in a governor’s working group report .

Elizabeth Tady, a hospital liaison who also spoke to judges and lawyers at the May gathering, said 45 patients were waiting for beds at Northcoast Behavioral Healthcare, the state psychiatric hospital serving the Cleveland region.

“It’s heartbreaking for me and for all of us to know that there are things that need to be done to help the criminal justice system, to help our communities, but we’re stuck,” she said.

Ohio officials added 30 state psychiatric beds by in Columbus and are planning in southwestern Ohio.

Still, Ohio Director of Forensic Services Lisa Gordish told the gathering in Cleveland that adding capacity alone won’t work.

“If you build beds — and what we’ve seen in other states is that’s what they’ve done — those beds get filled up, and we continue to have a waitlist,” she said.

This year, Jackson waited 100 days in the and Montgomery County jail for a bed at a state hospital, according to jail records.

Ferguson said she was afraid to leave him there but could not bail him out, in part, she said, because her son cannot survive on his own.

“There’s no place for my son to experience symptoms in the state of Ohio safely,” Ferguson said.

Sick System

Patrick Heltzel got the extended treatment Ferguson has long sought for her son, but he stabbed a 71-year-old man to death before getting it.

The 32-year-old is one of more than receiving treatment in Ohio’s psychiatric hospitals.

“People need long-term care,” Heltzel said in October, calling from inside Heartland Behavioral Healthcare, near Canton, where he has lived for more than a decade after being found not guilty by reason of insanity of aggravated murder. Inpatient care, he said, helps patients figure out what medication regimen will work and deliver the therapy needed “to develop insight.”

As he spoke, the sound of an open room and patients chatting filled the background.

“You have to know, ‘OK, I have this chronic condition, and this is what I have to do to treat it,’” Heltzel said.

As the ranks of criminally charged patients in Ohio’s hospitals have increased over the past decade, the shift has had an impact on patient care: The hospitals have endangered patients, have become more restrictive, and are understaffed, according to interviews with Heltzel, other patients, and former staff members, as well as documents obtained through public records requests.

Escapes and a Lockdown

Katie Jenkins, executive director of the National Alliance on Mental Illness Greater Cleveland, said the shift from mostly civil patients, who haven’t been charged with a crime, to criminally charged patients has changed the hospitals.

“It’s hard in our state hospitals right now,” she said. Unfortunately, she said, patients who have been in jail bring that culture to the hospitals.

In the first 10 months of 2024, at least nine patients escaped from Ohio’s regional psychiatric hospitals — compared with three total in the previous four years, according to .

, two female patients at Summit Behavioral Healthcare near Cincinnati escaped after one lunged at a staff member. In another, a man broke a window and climbed out.

Most of the escapes, though, were not violent. Days after a patient at Northcoast during a trip to the dentist in a Cleveland suburb, state officials stopped allowing patients to leave any of the six regional hospitals.

to leaders at the hospitals said officials had seen “similarities across multiple facilities,” raising significant concern about “ensuring patient and public safety.”

For Heltzel, the inability to go on outings or to his mother’s house on the weekends was a setback for his treatment. In 2024, when the lockdown began, he had more freedom than most patients at the psychiatric hospitals, regularly leaving to go to the local gym and attend off-site group therapy.

His mother signed him out each Friday to go home for the weekend, where he drove a car and played with his 2-year-old German shepherd, Violet. On Sundays, Heltzel was part of the “dream team” at church, volunteering to operate the audio and slides.

Federal records reveal that, at Ohio’s larger state-run psychiatric hospitals, including Summit and Northcoast, patients and staff have faced imminent danger.

In 2019 and 2020, federal investigators responded to patient deaths, including two suicides in six months at Northcoast. One hospital employee told federal inspectors, “The facility has been understaffed for a while and it’s getting worse,” according to . “It is very dangerous out here.”

Disability Rights Ohio, which has a federal mandate to monitor the facilities, in October against the department. The advocacy group, alleging abuse and neglect, asked for records of staff’s response to a Northcoast patient who suffocated from a plastic bag over their head. At the end of October, the court docket showed the parties had settled the case.

Retired sheriff’s deputy Louella Reynolds worked as a police officer at Northcoast for about five years before leaving in 2022. She said the increase in criminally charged patients meant the hospitals “absolutely” became less safe. Her hip still hurts from a patient who threw her against a cement wall.

Reynolds said officers should be able to carry weapons, which they don’t, and that more staff are needed to handle the patients. Mandatory overtime was common, she said, and often staff would report to work and not “know when we would get off.”

A Disaster That Wasn’t Averted

Back at Heartland, Heltzel requested conditional release. The judge denied the release request.

Heltzel said it was devastating. He grew up Catholic and said, “I was kind of looking for absolution.”

Now, Heltzel said he is practicing acceptance. “Acceptance is all the more important to practice when you don’t agree with something,” Heltzel said, adding, “I’m a ward of the state.”

He still hopes to be released: “I just do what I can to move forward.”

Heltzel, like Jackson, had been hospitalized before and released.

In early 2013, Heltzel said, he asked his dad to kill him. “And he refused and I did smack him,” he said. Heltzel was sent to Heartland for a short stay — about 10 days, according to his mother, Jan Dyer. She recalled “begging” the hospital staff to keep him.

Heltzel said he remembers not being ready to leave: “I was still sick, and I was still delusional.” Back at home, he said, he had a “sense of existential dread, like that all this horrible stuff was going to happen.” He stopped taking his medication.

Within weeks, Heltzel killed 71-year-old Milton A. Grumbling III at his home, placing him in a chokehold and stabbing him repeatedly, according to . He beat him with a remote control and then left, taking a Bible from the home, as well as a ring. Delusional with schizophrenia, Heltzel believed that Grumbling had sexually abused him in another life, according to the records.

A family member of the man he killed told the judge in 2023 that Heltzel should “stay in prison,” according to .

In denying his conditional release, judges cited Heltzel’s failure to take medication before killing Grumbling.

Jenkins, who said she worked at a state hospital for nine years before becoming the lead advocate for NAMI Greater Cleveland, said psychiatric medications can take as long as six weeks to become fully effective.

“So clients aren’t even getting stabilized when they’re being hospitalized,” Jenkins said.

‘He’s Not a Throwaway Child’

In a July interview, Jackson said inconsistent care or unmedicated time in jail “worsens my symptoms.” Jackson was on the phone during a stay at a state psychiatric hospital.

Without medicine, “my head hurts, to be honest,” Jackson said, before asking to get off the phone because he was hungry. It was lunchtime. “Can you get the information from my mom?” Jackson said. “She has the records.”

After Jackson hung up the phone, Ferguson explained that “he says the food is excellent, so he does not want to miss it.” And, she added, the hospital staff had not yet seen the explosive side of her son.

In early September, after 45 days at Summit — his longest stay yet at a state psychiatric hospital — Jackson returned to the Montgomery County jail facing misdemeanor charges because of with staff at a Dayton behavioral health hospital. In court, Ferguson said, her son struggled to explain to the judge why he was there. On a video call from the jail days later, she saw him playing with his hair and ears.

“That tells me he’s not OK,” Ferguson said.

Before Jackson’s diagnosis more than a decade ago, Ferguson said, her son wasn’t a troublemaker. He had goals and dreams. And he’s still “loved and liked by a lot of people.”

“He’s not a throwaway child,” she said.

 is a nonprofit news team covering Ohio’s criminal justice systems.

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Cuando cae la noche y bajan las temperaturas, arma una tienda de campaña y enciende una fogata bajo un grupo de pinos, abetos y cedros.

Evita a las autoridades rotando el uso de tres tiendas de distintos colores en tres campamentos diferentes. Al amanecer, desmonta su refugio, enrolla sus pertenencias y las esconde para la noche siguiente. “No te ven si estás en el bosque”, dijo este hombre de 32 años. “Pero asegúrate de tener todo desmontado por la mañana o te van a encontrar”.

Durante el día, deambula, haciendo paradas en una biblioteca pública para calentarse o en un comedor comunitario para comer. Lo importante es no llamar la atención por no tener hogar.

“La policía quiere que no estorbemos”, dijo, vestido con una chaqueta gris y sin cargar ninguna de sus pertenencias. “Fuera de la vista, fuera de sus mentes”.

Ibrahim ha buscado intencionalmente pasar desapercibido desde agosto, cuando el presidente Donald Trump puso a la policía del distrito y ordenó que soldados de la Guardia Nacional patrullaran las calles. También ordenó el de las personas sin hogar. “No habrá ningún señor amable”, .

La administración Trump argumenta que los operativos para desmantelar campamentos han reducido la visibilidad del problema de personas sin hogar, mejorando así la ciudad. “Es innegable que Washington, D.C., es una ciudad más segura, limpia y hermosa gracias a las acciones históricas del presidente Trump para restaurar la capital del país”, dijo la vocera de la Casa Blanca, Taylor Rogers.

Aunque puede parecer que hay menos personas sin hogar en la capital del país, no han desaparecido.

En entrevistas, personas sin hogar dijeron que cambian de lugar constantemente, escondiéndose a plena vista.

Durante el día, se mantienen en movimiento, comen en comedores comunitarios y descansan de vez en cuando en bibliotecas públicas, bancos de parques o paradas de autobús. Por la noche, muchos duermen en entradas de negocios, aceras de parques y escalinatas de iglesias. Algunos pasan la noche en el autobús, otras se refugian en salas de emergencia, y algunas buscan cobijo en áreas boscosas o se van a suburbios en Virginia o Maryland.

Hay aproximadamente 5.100 personas sin hogar en Washington, D.C., incluyendo aquellas en albergues temporales, según realizado a inicios de 2025. Después de que Trump ordenara la ofensiva contra la falta de vivienda en espacios públicos, las personas que vivían en comunidades improvisadas se dispersaron y ahora viven en las sombras. En agosto, funcionarios de la ciudad estimaron que cerca de 700 personas vivían al aire libre sin tiendas ni ningún tipo de refugio.

Con la llegada del invierno, estas personas están expuestas al clima extremo y se enferman más, ya que afecciones crónicas como la diabetes o enfermedades cardíacas no se tratan. Proveedores de atención médica en la calle afirman que, desde el despliegue de la Guardia Nacional, ha sido sumamente difícil localizar a sus pacientes.

Muchos afectados por los operativos han perdido medicamentos esenciales y son más propensos a faltar a citas médicas porque viven en constante desplazamiento.

Los equipos médicos no logran entregar medicamentos ni transportar a pacientes a sus consultas. Este caos permanente también puede hundir aún más a quienes padecen enfermedades mentales o adicciones, aumentando el riesgo de sobredosis.

Trabajadores sociales reportan las mismas dificultades: cuando pierden el rastro de sus clientes, se rompe la conexión esencial para conseguir documentos clave como identificaciones oficiales o tarjetas del Seguro Social.

Funcionarios del distrito y proveedores de salud advierten que esta cadena de efectos puede empeorar la situación de las personas sin hogar, poner en riesgo la salud pública y la seguridad, y generar costos enormes para el sistema de salud.

“Ya era difícil encontrar a las personas, pero la presencia federal lo empeoró”, dijo la doctora Tobie Smith, médica de atención en la calle y directora ejecutiva de Street Health D.C.

El ir y venir de los sin techo

Chris Jones nació y creció en Washington, D.C., pero ahora vive en la calle, luego de ser desplazado de su tienda de campaña cerca de la Casa Blanca en los primeros días de la ofensiva federal.

Dijo que durante los operativos le confiscaron dos tiendas. Ahora duerme en una acera frente a una iglesia y ya no intenta conseguir otra. “¿Para qué? ¿Cuál es el punto? Igual la van a tirar a la basura”.

Jones, de 57 años, tiene una lesión grave en la rodilla que a veces le impide caminar y tiene programada una cirugía de reemplazo de rodilla en diciembre. Dice que necesita quedarse en esa zona porque depende de una farmacia cercana para surtir sus medicamentos para el trastorno bipolar, la diabetes y la presión alta. Cuando tiene hambre, va al comedor comunitario o trata de conseguir una hamburguesa con refresco en un local de comida rápida enfrente de donde está.

También se mantiene en ese lugar para que su trabajadora social lo pueda encontrar si se libera una plaza de vivienda permanente. Si hace demasiado frío, cruza la calle y duerme en la entrada de un negocio, que le da un poco más de protección. Quiere estar bajo techo, pero por ahora espera.

Desde que tomó el control de la policía del distrito, la administración Trump sobre ciudades y condados en todo el país para desmantelar campamentos de personas sin hogar, bajo amenaza de arresto, citaciones o detenciones. Ha ordenado o amenazado con desplegar la Guardia Nacional en ciudades con grandes poblaciones sin hogar como Los Ángeles y .

Rogers, la vocera de la Casa Blanca, dijo que el presidente mantiene la presencia de la Guardia Nacional y fuerzas federales del orden en la capital para “garantizar el éxito a largo plazo de la operación federal”.

Desde marzo, funcionarios federales y del distrito han eliminado más de 130 campamentos, según dijo. Sin embargo, algunos expertos en temas de personas sin hogar creen que esa cifra está inflada.

La Corte Suprema facilitó el año pasado que funcionarios y agentes del orden impusieran multas o arrestaran a personas sin hogar por vivir en la calle. Luego, en julio de este año, el presidente emitió una orden ejecutiva que exige una ofensiva nacional contra los campamentos urbanos, incluyendo el desalojo masivo de personas que viven al aire libre y tratamientos forzados para la salud mental o adicciones.

Trump también lidera una reforma de la política federal de vivienda, con planes de para vivienda permanente y servicios para personas sin hogar.

Esta medida limitaría el uso de una política federal conocida como “Primero la Vivienda” (Housing First), que ofrece vivienda sin exigir tratamiento para salud mental o adicciones.

La Alianza Nacional para Terminar con la Falta de Vivienda (National Alliance to End Homelessness) advierte que este cambio podría dejar sin hogar a por lo menos actualmente en viviendas de apoyo permanente. El Departamento de Vivienda y Desarrollo Urbano (HUD, por sus siglas en inglés) suspendió el plan el 8 de diciembre para hacer revisiones, que “piensan” implementar.

Funcionarios del distrito dicen que están cumpliendo con la exigente campaña federal contra las personas sin hogar en espacios públicos. Bajo presión de la Casa Blanca, reconocen haber intensificado la disolución de campamentos. Defensores de personas sin hogar señalan que algunos operativos se han realizado de noche o sin previo aviso.

Líderes locales creen que se podrían hacer de manera más compasiva, ofreciendo servicios y refugio.

“Hemos pasado de permitir campamentos si no afectaban la salud o la seguridad pública, a decir: ‘No los queremos en la calle’”, dijo Wayne Turnage, vicealcalde para Salud y Servicios Humanos del distrito, quien supervisa el desmantelamiento de campamentos. “Es inseguro, insalubre y peligroso”. Sin embargo, reconoce que los operativos pueden desperdiciar recursos públicos, ya que los trabajadores sociales y equipos médicos deben volver a buscar a sus pacientes y clientes.

Defensores afirman que la administración Trump está generando miedo y desconfianza entre personas sin hogar y quienes tratan de ayudarlas, a la vez que malgasta fondos públicos que podrían utilizarse para brindar atención o ubicar a estas personas en viviendas. Eso sí, ahora hay muchas menos tiendas de campaña y campamentos visibles para turistas y residentes.

“Las personas encontraban seguridad en esas comunidades, y los proveedores de servicios podían localizarlas. Ahora hay gente armada y luces que destellan sacando a la fuerza a personas sin hogar sin previo aviso y tirando sus cosas”, dijo Jesse Rabinowitz, director de campaña y comunicaciones del Centro Nacional de Leyes sobre Personas sin Hogar (National Homelessness Law Center).

Funcionarios del distrito dicen que algunas personas han aceptado ir a refugios de emergencia. Pero incluso mientras la ciudad trata de ampliar la capacidad de albergues y conectar a la gente con servicios, reconoce que no hay suficientes camas ni viviendas permanentes para todos.

Y habrá menos lugares disponibles para quienes viven en la calle.

El presupuesto del distrito para el año fiscal 2026 concentró los fondos para personas sin hogar en las familias, con 336 nuevos vales para viviendas de apoyo permanente.

Sin embargo, se recortó el financiamiento para albergues temporales tanto para familias como para personas solas, y no se asignaron nuevos vales de vivienda permanente para individuos.

Eso significa menos espacios disponibles para adultos solos, que representan la mayoría de quienes deambulan por las calles. No obstante, las autoridades locales señalaron que han incluido 260 nuevas unidades de vivienda permanente para personas sin hogar, ya sean familias o individuos, en sus planes de construcción.

Empeorando la atención médica

La situación ha saturado los comedores comunitarios, como Miriam’s Kitchen en Foggy Bottom. Esta institución local ofrece comidas calientes, asistencia para vivienda y cobijas a personas en situación de necesidad.

Trabajadores sociales dicen que cada vez es más difícil ayudar a los clientes a obtener identificaciones y otros documentos necesarios para servicios sociales y de vivienda.

“Estoy buscando por todos lados, pero no puedo encontrarlos”, dijo Cyria Knight, trabajadora social de Miriam’s Kitchen. “La mayoría de mis clientes se fue a Virginia”.

No está claro cuántas personas se han trasladado a comunidades vecinas en Virginia o Maryland. En enero, antes de la ofensiva de Trump, se estimaba que había unas en la región. Cuatro de los seis condados que rodean Washington vieron un aumento en la falta de vivienda desde 2024, mientras que en el distrito .

“No veo a mis pacientes por un mes o más, y cuando los encuentro, sus enfermedades crónicas están fuera de control. Han entrado y salido de la sala de emergencia, y tienen más probabilidades de ser hospitalizados”, dijo Anna Graham, enfermera especializada en medicina callejera de , una red de clínicas en Washington. “Esto nos hace retroceder”.

El equipo de Graham estaciona su unidad médica móvil afuera de Miriam’s Kitchen durante la hora de la cena para tener más probabilidades de encontrar pacientes.

Willie Taylor, de 63 años, buscaba dónde dormir esa noche tras recibir la cena. Vio a Graham para recibir medicamentos para una enfermedad pulmonar avanzada, convulsiones, dolor crónico y otros padecimientos.

Le cuesta caminar y necesita una silla de ruedas, lo cual es complicado porque no tiene una dirección fija. Sus proveedores médicos dicen que le han robado sillas de ruedas antes mientras dormía en la calle.

Taylor usa un carrito de compras para mantenerse en pie durante el día, caminando sin rumbo hasta que cae la noche.

En una fría noche de noviembre, Graham lo ayudó a organizar sus medicamentos y revisó sus signos vitales. El equipo le dio un abrigo y calentadores de manos antes de que volviera a irse.

Después de caminar unos 45 minutos, encontró un rincón de pavimento en un parque donde pudo armar su cama con lonas y sacos de dormir.

“Mi cuerpo ya no aguanta esto”, dijo Taylor mientras se preparaba para dormir. “Hay hielo en el concreto. Me duele muchísimo más cuando hace frío”.

Las personas sin hogar  y les cuesta más al sistema de salud que quienes tienen vivienda, en gran parte porque no reciben tratamiento en la calle y, cuando buscan atención, suelen ir a la sala de emergencia.

Se estima que, entre las personas inscritas en Medicaid, quienes no tienen hogar generan un gasto anual de $18.764, frente a $7.561 de otros beneficiarios.

Más temprano ese día, en el comedor comunitario So Others Might Eat, Tyree Kelley terminaba su desayuno: un sándwich de salchicha y huevos duros. Estaba considerando ir a un refugio. Dijo que las calles se estaban volviendo demasiado peligrosas, en referencia a la presencia policial y de la Guardia Nacional. Extrañaba la comunidad de su antiguo campamento, que lo ayudaba a mantenerse seguro.

Este año ha ido al hospital al menos siete veces por una fractura en el tobillo tras caer de un scooter eléctrico. El accidente le hizo perder su trabajo y su seguro médico como recolector de basura, contó. Dijo que su situación lo ha hundido en una depresión que comenzó hace tres años, cuando murió su madre.

Después, este año murieron su padre y su hermana. Para adormecer el dolor, comenzó a beber.

“Uno se deprime mucho estando aquí”, dijo Kelley, de 42 años. “Se vuelve adictivo. Empiezas a no preocuparte ni por cambiarte de ropa”.

Esa depresión lo llevó a buscar marihuana. Luego fumó un cigarro mezclado con fentanilo. La sobredosis lo mantuvo en el hospital durante varios días.

“En realidad morí y volví”, dijo, agradeciendo a otras personas sin hogar que le administraron naloxona y le salvaron la vida. “Necesito salir de esto, pero me siento atrapado”.

A unas cuadras al oeste de la Casa Blanca hay un terreno baldío en donde hasta hace poco había más de una docena de tiendas de campaña. Quienes trabajan en la zona perciben lo que ya no se ve.

“Estuve aquí cuando limpiaron todo. Llegó una topadora y tiraron todo a un camión de basura”, dijo Ray Szemborski, quien trabaja frente a ese lote. “Las personas siguen sin hogar. Las sigo viendo debajo del puente. A veces están en las paradas de bus, otras solo caminando. Las tiendas ya no están, pero ellos siguen aquí”.

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As night falls and temperatures drop, he erects a tent and builds a fire beneath a canopy of pine, hemlock, and cedar trees.

He evades authorities by rotating use of three tents of different colors at three campsites. As day breaks, he dismantles his shelter, rolls up his belongings, and hides them for the next night. “They don’t see you if you’re in the woods,” the 32-year-old said. “But make sure it’s broken down by morning or they’ll find you.”

During the day, he wanders, stopping at a public library to warm up or a soup kitchen to eat. What’s important is to not draw attention to himself for being homeless.

Ibrahim has been deliberate about blending in since August, when President Donald Trump placed the district’s police under and ordered National Guard soldiers to patrol its streets. The president homeless people to leave immediately. “There will be no ‘MR. NICE GUY,’” .

The Trump administration says encampment sweeps have reduced the visibility of homelessness, thereby enhancing the city. “There is no disputing that Washington, DC is a safer, cleaner, and more beautiful city thanks to President Trump’s historic actions to restore the nation’s capital,” White House spokesperson Taylor Rogers said.

While there may appear to be fewer homeless people in the nation’s capital now, they have not disappeared.

In interviews, homeless people said they are in a constant shuffle, hiding in plain sight. During the day, they stay on the move, grabbing meals at soup kitchens and resting on occasion in public libraries, on park benches, or at bus stops. At night, many unsheltered people bed down in business doorways, on park sidewalks, and on church stoops. Some ride the bus all night, while a few shelter in emergency rooms. Others find respite in the woods or flee to suburbs in Virginia or Maryland.

There are about 5,100 homeless people in Washington, D.C., including in temporary shelters, according to an . After Trump ordered the crackdown on public homelessness, people living in makeshift communities scattered and are now living in the shadows. City officials estimated in August that nearly 700 homeless people were living outdoors without tents or other shelter.

As winter draws near, they are exposed to the elements and grow sicker as chronic ailments such as diabetes and heart disease go untreated. Street medicine providers say that, since the National Guard was deployed, they have faced enormous difficulty finding patients. Many caught up in sweeps have had their lifesaving medications thrown away, and they are more likely to miss medical appointments because they are constantly on the move. Street medicine providers say they can’t find their patients to deliver medication or transport them to medical appointments. The constant chaos can suck patients with mental illness and substance use deeper into drug and alcohol addiction, raising the risk of overdose.

Caseworkers report similar disruptions, saying as clients get lost, they break connections essential for obtaining housing documents, particularly IDs and Social Security cards.

District officials and health providers say this cascade will make homelessness worse, threatening public health and public safety and racking up enormous costs for the health care system.

“It was already hard locating people, but the federal presence just made it worse,” said Tobie Smith, a street medicine doctor and the executive director of Street Health D.C.

The Homeless Shuffle

Chris Jones was born and raised in Washington, D.C., but now is homeless, having been pushed out of his tent near the White House in the initial days of the federal homelessness crackdown. He said two of his tents were taken during sweeps. Now, sleeping on a sidewalk outside a church, he doesn’t bother trying to get another one. “Why? What’s the point? It’ll just get thrown away again.”

Jones, 57, has a severe knee injury that prevents him from walking some days and said he was scheduled for a knee replacement in December. He said it’s important to stay where he is — he relies on a nearby drugstore to refill his medications for bipolar disorder, diabetes, and high blood pressure. When he’s hungry, he goes to a soup kitchen for a meal or tries to get a cheeseburger and a soda from a fast-food joint across the street.

It’s important for him to stay outside the church, he said, so his case manager can find him when a permanent housing slot opens up. If it gets too cold, he said, he will cross the street and sleep in the doorway of a business, which can provide a bit more shelter. He wants to get indoors, but for now, he waits.

Since taking control of Washington’s police force, the Trump administration has on cities and counties across the nation to clear homeless encampments under threat of arrest, citation, or detention. It has ordered or threatened similar National Guard deployments in Los Angeles; ; and other cities with large homeless populations.

Rogers, the White House spokesperson, said the president is maintaining National Guard and federal law enforcement presence in the nation’s capital “to ensure the long-term success of the federal operation.” Since March, city and federal officials have removed more than 130 homeless encampments, she said, though some local homelessness experts say that number could be inflated.

The Supreme Court last year made it easier for elected officials and law enforcement to fine or arrest homeless people for living outside. Then, in July of this year, the president issued an executive order calling for a nationwide crackdown on urban camping, including a massive removal of people living outdoors and forced mental health or substance use treatment.

Trump is also spearheading an overhaul of homelessness policy, moving to and services for homeless people. The move would limit the use of a long-standing federal policy known as “Housing First” that offers housing without mandating mental health or addiction treatment. The National Alliance to End Homelessness warns the move risks displacing in permanent supportive housing. The Department of Housing and Urban Development paused the plan on Dec. 8 to make revisions, which it “intends” to do, .

City officials say they are complying with the Trump administration’s forceful campaign against homeless people sheltering outside. Pressured by the White House, local officials said they’ve gotten more aggressive in breaking up camps. Advocates for homeless people say some of the sweeps have been conducted at night and others with little or no notice to move. City leaders believe they could be done more compassionately by offering services and shelter.

“We’ve pivoted from the notion of allowing encampments if they didn’t violate public health or safety to a position of, ‘We don’t want you in the streets,’” said Wayne Turnage, deputy mayor for District of Columbia Health and Human Services, who oversees encampment cleanups. “It’s unsafe, it’s unhealthy, and it’s dangerous.” Yet he acknowledges the encampment sweeps can waste city resources as caseworkers and street medicine providers scramble to find their clients and patients.

Advocates say the Trump administration is inciting fear and mistrust between homeless people and those working to help them while wasting taxpayer dollars used to provide care and place people into housing. There are, however, far fewer tents and large-scale encampments visible to tourists and residents.

“People found safety in those communities and service providers could find them. Now there are people with guns and flashing lights dislocating folks experiencing homelessness without notice and just throwing stuff away,” said Jesse Rabinowitz, campaign and communications director for the National Homelessness Law Center.

District officials say some people have accepted emergency shelter. But even as the city works to connect people with services and expand shelter capacity, officials acknowledge there isn’t enough permanent housing or temporary beds for everyone.

And there will be fewer places for people living outside to go.

The city, in its fiscal year 2026 budget, concentrated its homelessness funding on families, funding 336 new permanent supportive housing vouchers. Yet it cut funding for temporary housing for both families and individuals and provided no new permanent supportive housing vouchers for individuals. That means fewer housing slots for single adults, who make up most of those wandering the streets. City officials said, however, that they have slotted 260 more permanent housing units for homeless individuals or families into their construction pipeline.

Worsening Health Care

The fallout is inundating local soup kitchens with demand, including Miriam’s Kitchen in Foggy Bottom. The local institution provides hot meals, housing assistance, and warm blankets to people in need.

Caseworkers say it’s becoming increasingly difficult to help clients secure IDs and other documents needed for housing and other social services.

“I’m looking everywhere, but I can’t find people,” said Cyria Knight, a caseworker at Miriam’s Kitchen. “Most of my clients went to Virginia.”

It’s unclear how much of the district’s homeless population has fanned out to neighboring Virginia and Maryland communities. There were an estimated in the region in January, months before Trump’s crackdown. Four of six counties around Washington saw homelessness rise from 2024, while it .

“I’m not seeing my patients for a month or more, and then when I do, their chronic conditions are uncontrolled. They’ve been in and out of the ER, and they’re more likely to be hospitalized,” said Anna Graham, a street medicine nurse practitioner for , a network of clinics in Washington. “It’s just setting us back.”

Graham’s team stations its mobile medical van outside Miriam’s Kitchen at dinnertime to better find patients.

Willie Taylor, 63, was figuring out where to sleep for the night after grabbing dinner from Miriam’s. He saw Graham to receive his medications for advanced lung disease, seizures, chronic pain, and other health disorders.

He has difficulty walking and needs a wheelchair, which is complicated because he doesn’t have a permanent address. Taylor and his medical providers say his previous wheelchairs have been stolen while he slept outdoors at night. He uses a shopping cart to keep him steady, walking around all day, until nightfall.

On a cold November night, Graham helped Taylor figure out his daily medications and checked his vitals. The team handed him a warm coat and hand warmers before sending him back outside.

After walking for about 45 minutes, he found a piece of park pavement where he could build a bed out of tarps and sleeping bags.

“My body can’t take this,” Taylor said, preparing to sleep. “There’s ice on the concrete. I’m in so much pain; it hurts so much worse when it’s cold.”

Homeless people and cost the health care system more than housed people, largely because conditions go untreated on the streets, and when they do seek care, many go to the ER. Among Medicaid enrollees, homeless people have been estimated to incur $18,764 a year in spending, compared with $7,561 for other enrollees.

Over at the So Others Might Eat soup kitchen earlier that day, Tyree Kelley was finishing his breakfast of a sausage sandwich and hard-boiled eggs. He was considering going into a shelter. The streets were becoming too dangerous for someone like him, he said, referring to the police and National Guard presence. He was feeling the loss of an encampment community that would watch his back.

He’s been to the ER at least seven times this year to get care for a broken ankle he sustained falling off an electric scooter. The accident caused him to lose his job and health insurance as a garbageman, he said. His situation has caused him to sink deeper into a depression that began three years ago after his mother died, he said.

Then his father and sister died this year. He began to numb his pain with beer.

“You get so depressed, being out here,” said Kelley, 42. “It gets addictive. You start to not care about even changing your clothes.”

His depression also led him to seek out marijuana. Then he smoked a joint laced with fentanyl. The overdose sent him to the hospital for days.

“I actually died and came back,” he said, crediting other homeless people with administering naloxone and saving his life. “I need to get out of this, but I feel so stuck.”

A few blocks west of the White House sits a vacant plot of land that earlier this year held more than a dozen tents. Workers in the area sense what they don’t always see.

“I was here when this was all cleared. A bulldozer came in, and all their stuff was thrown in a garbage truck,” said Ray Szemborski, who works across the street from the now-empty lot. “People are still homeless. I still see them around underneath the bridge. Sometimes they’re at bus stops, sometimes just walking around. Their tents are gone but they’re still here.”

is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).