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Paper 01: Safe streets

Signed 1 October 2026.

Plank: Order is the floor. We deliver a clean, safe city; above that floor, the city runs itself.

1. What we want

We want the blocks around every American downtown to be places a parent will walk through with a kid at 6 p.m., which takes three things, no more. Violence is not tolerated, and the sidewalk and the park are not permanently taken over by an encampment or an open drug market. Entry into the country is controlled, and once a city meets those conditions, it can tax itself, school itself, and govern itself however its residents choose. We offer to deliver what almost nobody else can credibly deliver in city government, then get out of the way without asking anyone to change their politics first.

2. The evidence

Two things happened at the same time in American cities, and they are usually discussed as if they were separate problems. On the West Coast, they were connected. Encampment enforcement stopped in large part because the law changed there, and mental illness on the street got worse because psychiatric hospital capacity collapsed and never came back.

On the law: from 2018 to 2024, the Ninth Circuit's ruling in Martin v. Boise held that cities in the circuit could not enforce public camping bans unless they had enough shelter beds for every homeless person in the city, and most West Coast cities responded by scaling back enforcement sharply. That ruling bound only the Ninth Circuit, and it is not the whole national story: unsheltered homelessness had already been rising across the country since 2015, driven mainly by housing costs and, more recently, fentanyl, in states Boise never touched. But inside the circuit, it removed the clearest tool cities had for keeping a sidewalk or a park clear. On June 28, 2024, the Supreme Court decided City of Grants Pass v. Johnson, holding that enforcing a generally applicable camping ordinance is not "cruel and unusual punishment" under the Eighth Amendment, and effectively overruled Boise [3]. Cities can now clear encampments again. The legal obstacle that stopped enforcement across the Ninth Circuit for six years is gone.

On capacity: in 1955, state and county psychiatric hospitals held about 560,000 patients, or roughly 340 beds per 100,000 people. Today the state hospital system holds about 35,000 to 40,000 patients, or about 11 to 12 beds per 100,000 [4][5][6]. A 2008 panel of 15 psychiatric-care experts, using a structured consensus method, put the minimum adequate supply at 50 beds per 100,000, assuming good outpatient care is also available [5][7]. We are operating at roughly a fifth of that floor, and the shortfall is not evenly felt: more than half of the remaining state beds are occupied by patients who came through the criminal justice system, which means the beds available for someone who is gravely disabled and has not been charged with a crime are fewer still [4].

Two carve-outs already let Medicaid pay into facilities larger than 16 beds, and they show the mechanism works without showing it works at scale. States can apply for a Section 1115 waiver to get federal matching funds for short-term substance-use treatment in an IMD; 38 states, including D.C., had one approved as of April 2026 [8]. A separate, much narrower waiver track covers serious mental illness directly: only 13 states adopted one between 2019 and 2024, against 35 states that took the substance-use version in its first six years [9]. States want the mental-illness carve-out much less than the addiction one, likely because the standard 30-day average length-of-stay cap this waiver imposes fits an addiction detox stay far better than it fits stabilizing someone who is gravely disabled from psychosis. A separate 2018 statute lets Medicaid managed-care plans pay for up to 15 days a month of IMD care outside the waiver process entirely [8][11]. None of these routes were built to fund permanent, longer-stay psychiatric capacity, which is the gap this paper is about.

On policing: crime is not spread evenly across a city, and the concentration is consistent enough to plan around. Across the multi-city research literature, roughly half of a city's crime happens on somewhere between 4 and 6 percent of its street segments, a pattern that holds year over year in the same city and across cities as different as Seattle, New York, and Tel Aviv [12]. A systematic review of 78 tests of hot-spot policing found that concentrating police presence on those specific blocks reduces crime and disorder there, with a small but statistically significant effect [1][2]. The strongest objection to this kind of policing is that it just pushes crime to the next block over. The evidence says otherwise: of 40 tests that measured what happened in the surrounding area, the reviewers found a small but statistically significant diffusion of benefit to nearby blocks rather than displacement onto them [1][2]. That finding has held up across two decades of updates to the same review, which is unusual in criminology and worth taking seriously.

The honest caveat on both halves: these results describe what carefully targeted, evaluated programs achieve. They do not describe what any police department or health system does by default. A hot-spot program that becomes generalized aggressive patrol loses the evidence base behind it, and a bed expansion that reopens custodial warehousing without care standards would recreate the conditions that justified closing the old asylums in the first place.

3. Why it happened

The specific rule is the Medicaid Institution for Mental Disease exclusion, part of the original Medicaid statute in 1965. Congress wanted state governments to keep paying for long-term psychiatric institutional care rather than shift that cost onto the new federal program, so it barred Medicaid from paying for care given to adults aged 21 to 64 in any institution "primarily engaged" in treating mental illness that has more than 16 beds [4][10]. The 16-bed line was written into federal regulation and later into the statute itself by the Medicare Catastrophic Coverage Act of 1988 [10]. The rule did not ban state psychiatric hospitals. It made the federal government's largest health insurance program refuse to help pay for a hospital bed the moment a state facility grew past a small size, while that same program paid its normal share for the same patient's care in almost any other kind of hospital. States responded exactly as the incentive predicted: they shrank or closed their large state hospitals rather than run large facilities Medicaid would not help fund, and did not build enough smaller or alternative capacity to replace what closed. Deinstitutionalization is usually told as a story about a change in clinical philosophy in the 1960s and 1970s. The financial incentive behind it was a specific, datable rule, and that rule is still in the statute today.

On the encampment side, the specific ruling is Martin v. Boise (2018), which the Ninth Circuit read the Eighth Amendment to require: no enforcement of a camping ban without a shelter bed for every unsheltered person in the jurisdiction. Most cities in the circuit could not meet that threshold, so camping enforcement stopped in practice across a large share of the West Coast for six years, and Grants Pass (2024) is the ruling that reopened enforcement [3].

4. What to change

Federal: repeal the Medicaid IMD exclusion, and fund psychiatric beds before the enforcement side of this plank scales up. The existing waiver tracks prove the federal government can already pay for IMD-eligible care under emergency and short-stay conditions; the sixteen-bed cap should end outright rather than staying a waiver-by-waiver exception, and new federal dollars should be sequenced to build the beds first. Standing up commitment authority before capacity exists just reproduces the shortage that discredited the old system.

State: adopt civil commitment standards that reach people who are gravely disabled, a broader group than those who are an immediate danger to themselves or others, and enforce public camping law now that Grants Pass allows it. California's 2023 expansion of "gravely disabled" to include people unable to manage their own medical care or basic needs because of a severe mental illness or substance use disorder, effective statewide by January 2026, is the model: a blue state adopted it, which is evidence this is not a partisan non-starter [13].

Local: saturate the specific blocks adjacent to downtown that generate a disproportionate share of a city's calls for service with a sustained police presence, the hot-spot approach the research above evaluates, rather than spreading the same personnel thinly across the whole city.

5. What a bill would do

A model state bill would rewrite the civil commitment statute's "gravely disabled" standard to include a person's inability to obtain food, shelter, medical care, or personal safety because of a mental illness or a severe substance use disorder, following the California language. Without that clause, the standard still requires a showing of imminent danger that people who are chronically and severely impaired but not acutely violent routinely fail to meet. The bill would also direct the state Medicaid agency to build out IMD-eligible bed capacity in a specific, funded phase before any local jurisdiction is authorized to begin sustained camping enforcement under the new standard. Requiring that capacity before enforcement begins would keep the bill from repeating the old failure of tightening the law before there is anywhere to place someone. The bill would authorize and fund a hot-spot policing pilot in the highest-crime census blocks adjacent to each participating city's downtown core, with boundaries set by recent crime data and reviewed annually, rather than left to police discretion. The companion federal ask, repealing the IMD exclusion, is not something a state bill can do; it is included here because state civil commitment reform only works once federal Medicaid dollars can follow the patient into a large facility.

6. What would prove us wrong

If a state adopts the wider gravely-disabled standard and psychiatric bed occupancy does not rise, that means either commitment authority was not the binding constraint or the beds still are not being built, and the sequencing claim in this paper is wrong. If cities that run sustained hot-spot policing near downtown see crime fall on those blocks but rise by a comparable amount on the blocks immediately surrounding them, that is displacement, not diffusion, and it would undercut the central claim in section 2 that this approach does not just move the problem next door. If Congress repeals the IMD exclusion and states do not build additional long-stay psychiatric capacity with the new federal match, that would show the exclusion was not the binding constraint on bed supply after all.

Sources

  1. Braga, A.A., Papachristos, A.V., and Hureau, D.M., "Hot Spots Policing and Crime Reduction: An Update of an Ongoing Systematic Review and Meta-Analysis," Journal of Experimental Criminology, 2019. https://www.ojp.gov/library/publications/hot-spots-policing-and-crime-reduction-update-ongoing-systematic-review-and

  2. Braga, A.A., Papachristos, A.V., and Hureau, D.M., "Hot Spots Policing Effects on Crime," Campbell Systematic Reviews, 2012:8. https://onlinelibrary.wiley.com/doi/10.4073/csr.2012.8

  3. Congressional Research Service, "The Eighth Amendment and Homelessness: Supreme Court Upholds Camping Ordinances in City of Grants Pass v. Johnson," 2024. https://www.congress.gov/crs-product/LSB11203 ; Wikipedia summary of the opinion, https://en.wikipedia.org/wiki/City_of_Grants_Pass_v._Johnson

  4. Manhattan Institute, "Medicaid's IMD Exclusion: The Case for Repeal," 2024 (citing 1955 and current state hospital census figures and the "more than half occupied by justice-involved patients" finding). https://manhattan.institute/article/medicaids-imd-exclusion-the-case-for-repeal

  5. Treatment Advocacy Center, "Bed Shortages," 2023 data cited (12 beds per 100,000 against a recommended 50 per 100,000). https://www.tac.org/bed-shortages/

  6. Psychiatric Times, "A Dearth of Psychiatric Beds," citing state hospital census figures showing a decline from roughly 560,000 (1955) to about 36,000 (2023), or 10.8 beds per 100,000. https://www.psychiatrictimes.com/view/dearth-psychiatric-beds

  7. Treatment Advocacy Center, "Estimating Psychiatric Bed Need in the United States" (2008 Delphi panel of 15 experts recommending 40-60, median 50, beds per 100,000). https://www.tac.org/wp-content/uploads/2024/03/TAC_ORPA_ResearchSummary1.24.pdf

  8. KFF, "A Look at 1115 Waiver Evaluations for Medicaid Payments to Institutions of Mental Disease (IMD) for Substance Use Disorder," April 2026 (38 states, including D.C., approved). https://www.kff.org/medicaid/a-look-at-1115-waiver-evaluations-for-medicaid-payments-to-institutions-of-mental-disease-imd-for-substance-use-disorder/

  9. PMC/NIH, "Medicaid 1115 Waivers for Mental Health: Time for Redesign?" (13 states adopted SMI/SED waivers 2019-2024 versus 35 states for SUD waivers in their first six years). https://pmc.ncbi.nlm.nih.gov/articles/PMC13484728/

  10. MACPAC, "Payment for Services in Institutions for Mental Diseases (IMDs)" (16-bed definition, Medicare Catastrophic Coverage Act of 1988 codification). https://www.macpac.gov/subtopic/payment-for-services-in-institutions-for-mental-diseases-imds/ ; eCFR 42 CFR 435.1010, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-435/subpart-K/subject-group-ECFR87e8ed6bfd3adb9/section-435.1010

  11. NAMI, "Medicaid: IMD Exclusion" (SUPPORT Act 2018 managed-care 15-day-per-month option). https://www.nami.org/advocacy-at-nami/policy-positions/improving-health/medicaid-imd-exclusion/

  12. Weisburd, D., et al., "The Law of Crime Concentration at Places" and its 2017 replication, Journal of Quantitative Criminology, 2017 (roughly 50% of crime on 4-6% of street segments across multiple cities). https://link.springer.com/article/10.1007/s10940-017-9342-0

  13. California SB 43 (2023), effective statewide January 1, 2026, expanding the LPS Act's "gravely disabled" definition to include severe substance use disorder and inability to obtain food, clothing, shelter, medical care, or personal safety. https://www.disabilityrightsca.org/publications/sb-43-and-care-court-community-faq

  14. H.R. 6727, "Repealing the IMD Exclusion Act," 119th Congress, introduced December 2025. https://www.congress.gov/bill/119th-congress/house-bill/6727