Mental illness can be part of the story of how a person ends up homeless — or part of the price of survival on the streets, where sleep and safety are scarce. Homeless people in Multnomah County, which includes Portland, than the average American. These grim realities have ratcheted up the pressure on politicians to do something.

High housing costs and financial adversity are among the root causes of the burgeoning population on the streets.

About 1 in 3 people who are homeless in Portland a mental illness or a substance use disorder, and the combination of homelessness and substance use or untreated mental illness has led to very public tragedies.

People with schizophrenia, for example, on the city’s streets. One resident in a snowstorm to a stillborn infant. Methamphetamine, cheaper and more potent than it used to be, is of overdose and psychosis.

In Oregon, some politicians, including Portland Mayor Ted Wheeler, have so doctors have more leeway in compelling treatment for patients too sick to know they need care. Without such changes, they argue, people with untreated addictions or mental illnesses are stuck cycling between the streets, county jails, and state psychiatric hospitals.

“I think we can do better by people than allowing them to flounder,” said Janelle Bynum, a state legislator who represents suburbs southeast of Portland.

Bynum, a Democrat, signed on to a of , introduced by Republicans this year, that would expand the criteria for involuntary commitment in Oregon.

“My intention was to signal how cruel I think our current system is,” she said.

people live in California, and though only about a quarter to of homeless people are estimated to have a serious mental illness, they are the ones other residents are likely to encounter in California’s cities. Mayors from San Francisco, San Jose, and San Diego have all expressed frustration that the threshold for psychiatric intervention is so high.

‘Why Aren’t You Doing Something?’

“When I’m often asked, ‘Mayor, why aren’t you doing something about this person who is screaming at the top of their lungs on the street corner?’ and I said, ‘Well, they’re not a threat to themselves or to others,’ that rings hollow,” said , mayor of San Diego.

Now, state lawmakers in Sacramento, backed by mayors, have introduced laws and bills that would help bring more people into treatment, even against their will.

Last year, legislators approved a new approach to mental health care — called — that allows judges to issue treatment plans for people with certain diagnoses. That program begins on a pilot basis this fall in seven counties, including San Diego and San Francisco counties, with the rest of the state expected to join next year.

This year, a bill moving through the legislature would expand who qualifies for a conservatorship or involuntary psychiatric hold.

The bill is gathering support and sponsors are optimistic that Democratic Gov. Gavin Newsom will sign it if it passes. But it’s been controversial: Opponents fear a return to bygone policies of locking people up just for being sick.

Half a century ago, California policymakers , denouncing them as inhumane. Involuntary commitment was de-emphasized, and state laws ensured that it was used only as a last resort. The thinking was that the patient should have autonomy and participate in their care.

But politicians across California are now reconsidering involuntary commitments. They argue that not helping people who are seriously ill and living in squalor on the streets is inhumane. Psychiatrists who support the bill say it would constitute a modest update to .

The shift is dividing liberals over the very meaning of compassion and which rights should take precedence: civil rights like freedom of movement and medical consent, or the right to appropriate medical care in a crisis?

“The status quo has forced too many of our loved ones to die with their rights on,” said Teresa Pasquini, an activist with the . Her son has schizophrenia and has spent the past 20 years being “failed, jailed, treated, and streeted” by what she called a broken public health system.

“We are doctors who have to watch these people die,” said psychiatrist Emily Wood, chair of the government affairs committee of the , a sponsor of the conservatorship bill, . “We have to talk to their families who know that they need that care, and we have to say we don’t have any legal basis to bring them into the hospital right now.”

Under current California law, a person can be held in the hospital involuntarily if they are a danger to themselves or others or if they are unable to seek food, clothing, or shelter as a result of mental illness or alcoholism. Doctors want to add other substance use disorders to the criteria, as well as an inability to look out for one’s own safety and medical care. (The state law defines what is known as “mental health conservatorship,” which is separate from the that Britney Spears was under.)

Wood, who practices in Los Angeles, gave two examples of people she and her colleagues have tried, but struggled, to care for under the current rules. One is a man who doesn’t take his diabetes medication because he’s not taking his schizophrenia medication and doesn’t understand the consequences of not managing either condition.

Wood explained that even if he repeatedly ends up in the emergency room with dangerously high blood sugar, no one can compel him to take either medication under current law, because poorly managing one’s health is not a trigger for conservatorship.

Another man Wood described has a developmental disability that went untreated in childhood. He developed an addiction to methamphetamine in his 20s. Wood said the man is now regularly found sleeping in a park and acting inappropriately in public. His family members have begged doctors to treat him, but they can’t, because substance use disorder is not a trigger for conservatorship.

To Wood, treating these people, even when they’re unable to consent, is the compassionate, moral thing to do.

“It’s essential that we respect all the rights of our patients, including the right to receive care from us,” she said.

But other advocates, including some of those working for Californians with mental illnesses, see the issue very differently.

Lawyers from the nonprofit said the proposed expansion of conservatorship and the ongoing rollout of CARE Courts are misguided efforts, focused on depriving people of their liberty and privacy.

Instead, they said, the state should invest in better voluntary mental health services, which help maintain people’s dignity and civil rights. The group in January to try to of CARE Courts.

These advocates are particularly concerned that people of color, specifically Black residents, who are overrepresented in the homeless population and , will now be disproportionately targeted by more forceful measures.

“When people are told that they have to go to court to get what they should be getting voluntarily in the community, and then they get a care plan that subjugates them to services that still do not meet their cultural needs, that is not compassion,” said , an advocate who has schizophrenia and has experienced homelessness.

More Housing: Another Badly Needed Prescription

Under current state law in Oregon, a person can be held for involuntary treatment if they are a danger to themselves or others or are at risk of serious physical harm because they cannot provide for their basic personal needs due to a mental illness.

Oregon, like California, does not include substance use disorders as grounds for commitment.

But its law is slightly broader than California’s, at least in one respect: Legislators in 2015 to give doctors more leeway to step in if a person’s psychosis or other chronic mental illness is putting them at risk of a medical crisis.

Terry Schroeder, a civil commitment coordinator with the Oregon Health Authority, said that, before the change, a person would have to be nearly comatose or within a few days of death to meet the criteria for doctors to forcibly treat them for their own welfare.

The law now allows care providers to intervene earlier in an ongoing medical crisis.

In Oregon and California, the lack of adequate treatment options is frequently invoked in the ongoing debates over forced commitment and conservatorship.

“Expanding conservatorships doesn’t solve for those structural issues around the lack of housing and the lack of funding for treatment services,” said Michelle Doty Cabrera, executive director of the .

Cabrera’s group also questions the premise that forced treatment works, and there is indeed that compulsory treatment for substance use disorder is effective, and some evidence that it could even be harmful.

Critics of involuntary commitment have questioned the California Legislature’s objectives. If the ultimate goal of forced treatment is to reduce homelessness — and ease the moral failing of ill people sleeping on the street or using drugs in the open — then lawmakers are writing the wrong prescription, they said.

“The problem of homelessness is that people don’t have housing,” said primary care physician Margot Kushel, director of the University of California-San Francisco’s .

“If you had all the treatment in the world and you didn’t have the housing, we would still have this problem.”

Supporters of involuntary commitments say both are needed. Many of the California lawmakers backing expanded conservatorship and CARE Courts are also backing efforts to increase the housing supply, including for the construction of small, neighborhood-oriented residences for people with mental illness.

Nationwide, rents have than people’s incomes in the past 20 years, particularly impacting people who rely on a fixed income, such as monthly disability payments.

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But beds and space aren’t the main concern. It’s the workforce. Hospitals are worried staffing levels won’t be able to keep up with demand as doctors, nurses and specialists such as respiratory therapists become exhausted or, worse, infected and sick themselves.

The typical workaround for staffing shortages — hiring clinicians from out of town — isn’t the solution anymore, even though it helped ease the strain early in the pandemic, when the first surge of cases was concentrated in a handful of “hot spot” cities such as New York, Detroit, Seattle and New Orleans.

Recruiting those temporary reinforcements was also easier in the spring because hospitals outside of the initial hot spots were than normal, which led to . That meant many nurses were able — and excited — to catch a flight to another city and  on the front lines.

In many cases, hospitals  for traveling nurses, and the payment rates for temporary nurses spiked. In April, Vanderbilt University Medical Center in Nashville, Tennessee, had to  of some staff nurses, who were making less than newly arrived temporary nurses.

In the spring, nurses who answered the call from beleaguered “hot spot” hospitals weren’t merely able to command higher pay. Some also  about how meaningful and gratifying the work felt, trying to save lives in a historic pandemic, or the importance of  for family members who could not visit loved ones who were sick or dying.

“It was really a hot zone, and we were always in full PPE and everyone who was admitted was COVID-positive,” said Laura Williams of Knoxville, Tennessee, who helped launch the Ryan Larkin Field Hospital in New York City.

“I was working six or seven days a week, but I felt very invigorated.”

After two taxing months, Williams returned in June to her nursing job at the . For a while, the COVID front remained relatively quiet in Knoxville. Then the fall surge hit. There have been in Tennessee nearly every day, increasing in the past month.

Health officials report that backup clinicians are becoming much harder to find.

Tennessee has built its own field hospitals to handle patient overflows — one is inside the old Commercial Appeal newspaper offices in Memphis, and another occupies two unused floors in Nashville General Hospital. But if they were needed right now, the state would have  finding the doctors and nurses to run them because hospitals are already struggling to staff the beds they have.

“Hospital capacity is almost exclusively about staffing,” said Dr. Lisa Piercey, who heads the Tennessee Department of Health. “Physical space, physical beds, not the issue.”

When it comes to staffing, the coronavirus creates a compounding challenge.

As patient caseloads reach new highs, record numbers of hospital employees are themselves out sick with COVID-19 or temporarily forced to stop working because they have to quarantine after a possible exposure.

“But here’s the kicker,” said Dr. Alex Jahangir, who chairs Nashville’s coronavirus task force. “They’re not getting infected in the hospitals. In fact, hospitals for the most part are fairly safe. They’re getting infected in the community.”

Some states, like North Dakota, have already decided to allow COVID-positive nurses to keep working as long as they feel OK, a move that has generated backlash. The nursing shortage is so acute there that some traveling nurse positions posted pay of $8,000 a week. Some retired nurses and doctors were asked to consider returning to the workforce early in the pandemic, and at least 338 who were 65 or older have died of COVID-19.

In Tennessee, Gov. Bill Lee issued an loosening some regulatory restrictions on who can do what within a hospital, giving them more staffing flexibility.

For months, staffing in much of the country had been a concern behind the scenes. But it’s becoming palpable to any patient.

Dr. Jessica Rosen is an emergency physician at St. Thomas Health in Nashville, where having to divert patients to other hospitals has been rare over the past decade. She said it’s a common occurrence now.

“We have been frequently on diversion, meaning we don’t take transfers from other hospitals,” she said. “We try to send ambulances to other hospitals because we have no beds available.”

Even the region’s largest hospitals are filling up. This week, Vanderbilt University Medical Center  in its children’s hospital for non-COVID patients. Its adult hospital has more than 700 beds. And like many other hospitals, it has had the challenge of staffing two intensive care units — one exclusively for COVID patients and another for everyone else.

And patients are coming from as far away as Arkansas and southwestern Virginia.

“The vast majority of our patients now in the intensive care unit are not coming in through our emergency department,” said Dr. Matthew Semler, a pulmonary specialist at VUMC who works with COVID patients.

“They’re being sent hours away to be at our hospital because all of the hospitals between here and where they present to the emergency department are on diversion.”

Semler said his hospital would typically bring in nurses from out of town to help. But there is nowhere to pull them from right now.

National provider groups are still moving personnel around, though increasingly it means leaving somewhere else short-staffed. Dr. James Johnson with the Nashville-based physician services company Envision has deployed reinforcements to Lubbock and El Paso, Texas, this month.

He said the country hasn’t hit it yet, but there’s a limit to hospital capacity.

“I honestly don’t know where that limit is,” he said.

At this point, the limitation won’t be ventilators or protective gear, he said. In most cases, it will be the medical workforce. People power.

Johnson, an Air Force veteran who treated wounded soldiers in Afghanistan, said he’s more focused than ever on trying to boost doctors’ morale and stave off burnout. He’s generally optimistic, especially after serving four weeks in New York City early in the pandemic.

“What we experienced in New York and happened in every episode since is that humanity rises to the occasion,” he said.

But Johnson said the sacrifices shouldn’t come just from the country’s health care workers. Everyone bears a responsibility, he said, to try to keep themselves and others from getting sick in the first place.

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And, at the opposite ends of the spectrum: Texas and Massachusetts. At 25 percent, Texas has the highest rate of uninsured people in the nation. Massachusetts, where a 2006 law made coverage mandatory, has the lowest rate — less than 2 percent of people are uninsured. Here’s a look at two Americans who are living the reality of that difference:

Walking A Health Care ‘Tightrope’

For six million uninsured Texans, having health problems can mean an anxious scramble for care at overcrowded charity clinics or the local emergency room. Melinda Maarouf knows that experience all too well. She’s a teacher’s aide at the Faith Christian Academy, a private school just outside of Houston.

“Unfortunately, we’re a small school and the budget doesn’t allow for insurance for the employees,” she says.

Maarouf is divorced and has a daughter in college. The school where Maarouf works can’t afford to bring her on full time right now, so she makes just over $11,000 a year. That income puts her right around the federal poverty line, and it makes for some hard health choices.

Melinda Maarouf, 55, works part time at a small Texas private school that doesn’t provide her with health insurance (Photo by Carrie Feibel for NPR).

She has high blood pressure, and has skipped pills to make her prescriptions last longer. “I can always tell when the blood pressure’s elevated,” she says. “I feel uncomfortable. I feel edgy and kind of shaky, and my ears ring.”

Maarouf knows that if she doesn’t keep her blood pressure under control, she could have a stroke, heart attack or kidney damage. She recently found help at a charity clinic where she pays only $25 per visit. Even so, Maarouf says the blood pressure is all she can afford to treat right now.

“I haven’t had a Pap smear — goodness, I couldn’t even tell you — probably since my daughter was born, and she’s 26,” she says. “I haven’t had a well-woman exam. And I’m sure it’s time for some routine blood work.”

Maarouf has never had a mammogram and she’s continued to push off some needed dental work — but medical bills scare her. In 2010, she went to the emergency room with chest pain. Doctors didn’t find anything wrong, but she ended up with $3,000 in bills.

Maarouf couldn’t keep up with the payment plan, so she simply shoved the bills into the bottom of a drawer and swallowed her anxiety.

“Oh, my credit’s pretty much shot, as far as that goes. But there’s not much I can do about it,” she says. “You just have to move on, do what you have to do to survive.”

Like millions of other working Texans without minor children, Maarouf can’t get Medicaid. And she’s years away from Medicare.

Hospitals in Texas spend over $4 billion a year treating uninsured patients like Maarouf. Some of the cost gets absorbed by county taxpayers, and some gets shifted onto insured Texans, who pay higher premiums for their own coverage.

Maarouf says she feels stuck and exposed. “It’s like you’re sort of walking a tightrope. I sometimes feel like I’m on the edge of a cliff. As long as everything is status quo and there’s no glitches or bumps in the road, I feel OK,” she says. “But I sometimes feel like I’m one emergency room visit away from a catastrophe.”

In Massachusetts, Relief For The Uninsured

Five years before Massachusetts started offering free and subsidized coverage, Peter Brook couldn’t afford health insurance or the daily insulin and needles he needs to treat his diabetes. Things have changed for Brook since the Massachusetts health care law, the same one that helped shape the federal Affordable Care Act.

“When I didn’t have health insurance, I’d use a needle for 30 days, like 150 shots or something, so it gets a little bit dull,” says Brook, who does odd jobs like landscaping to cover his basic needs.

When he had health complications related to his diabetes, he didn’t have money for care. The worst was a digestion problem that would bring on crippling stomach pain.

“I would tend to hole up in a fetal position at home, and then over the course of week or two, my skinny body would lose 25 to 30 pounds and then I’d end up looking like a death camp survivor,” he says.

Handyman Peter Brook, 51, pulls weeds outside his church in Boston. Before 2006, Brook says he couldn’t afford health care (Photo by Martha Bebinger for NPR).

And then there was the time Brook fractured his pinky and set it by taping the broken section to his ring finger. The pinky is still crooked, but today Brook has free health insurance and a regular doctor at the South Boston Community Health Center. His only expense is a $3.65 co-pay for prescriptions, which adds up to about $14 a month.

“I now have good health care, so that is a weight off of my mind,” he says. “It’s been a year and half since I’ve been in a hospital, and for the first 50 years of my life I never went six months without an inpatient hospital stay for one thing or another.”

Brook’s care is free, but Massachusetts — with help from the federal government — spends roughly $182 million more every year on health coverage for low-income residents than it did before 2006, according to the . And Brook worries about those costs.

“Who’s paying for it? Where’s that money coming from?” he asks. “If society were a human being, then they’re dragging a ball and chain down the street on their ankle.”

Brook has joined the  in lobbying Massachusetts legislators to control health care cost increases so that coverage will be affordable. And as lawmakers finalize bills, there’s a vigorous debate underway about what state government can or should do to about limiting spending.

These stories by Carrie Feibel (Texas) and Martha Bebinger (Massachusetts) are part of a reporting partnership between , , NPR and Kaiser Health News.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—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).