WASHINGTON — Democrats and Republicans forged agreement early Wednesday on a spending package that will fund the government for the next eight months, as well as provide billions in emergency funding for COVID-19 and the war in Ukraine. 

The announcement means Congress should be able to avert a government shutdown when a spending patch expires at midnight on Friday, though an additional patch until next week will have to be passed as well.

The $1.5 trillion government funding section of the bill includes the first round of earmarks in more than a decade, allowing members from both political parties to secure federal dollars for home-state projects. 

The overhauled program, now referred to as congressionally directed spending or community project funding, was brought back less than a year ago with members of both political parties requesting millions for projects ranging from addiction treatment programs to bridge repairs to agriculture programs. 

The new earmarks include more guardrails and oversight mechanisms than lawmakers had in place before House Republicans and Senate Democrats banned the former practice in 2011 following years of scandal. 

For example, funding cannot go to for-profit entities and the Government Accountability Office will audit the process annually. The total amount of spending on earmarks is now capped at 1%. 

In addition to funding for the whole of the federal government, the measure includes $13.6 billion for military and humanitarian assistance in Ukraine amid the Russian war and $15 billion in pandemic assistance for testing, therapeutics and vaccines. 

The $1.5 trillion government funding section of the package provides $782 billion, or a 6% increase, for defense and $730 billion, or a 6.7% increase, for domestic and foreign aid programs for the fiscal year that began on Oct. 1. 

The U.S. House is expected to vote on the  2,741-page measure Wednesday to send it to the Senate. President Joe Biden is expected to sign the measure into law once it reaches his desk.

But lawmakers will also vote on a stopgap spending bill to keep the government running through March 15 to give the Senate enough time to hold votes on the package. 

Senate Minority Leader Mitch McConnell said in a statement that he would be encouraging his colleagues to vote for the bill.

“The bipartisan product contains major wins for our national defense, for our friends in Ukraine, for the conscience rights of the American people, and for many other key priorities, and it keeps new left-wing poison pills out,” the Kentucky Republican said in a statement.

Acting White House Budget Director Shalanda Young said: “The bipartisan funding bill is proof that both parties can come together to deliver for the American people and advance critical national priorities.”

Hyde amendment

GOP lawmakers were able to keep the nearly 50-year-old Hyde amendment in the spending package after Democrats removed it from the original batch of House and Senate appropriations bills. 

The provision, as well as several others like it, bars the federal government from spending money on abortion with limited exceptions. 

Progressive Democrats have long sought to remove the funding prohibitions from the annual government funding measures, but this was the first fiscal year Democratic party leaders did so. 

Republicans said they wouldn’t agree to any funding measure that didn’t include the spending restriction, leading to it being added back into the final version of the bills Congress is set to pass in the coming days. 

House Appropriations Chair Rosa DeLauro, a Connecticut Democrat, said in a statement that the spending measure “delivers transformative federal investments to help lower the cost of living for working families, create American jobs, and provide a lifeline for the vulnerable.” 

The federal spending section of the bill has been in the works for months, though both political parties reached agreement on a “framework” for the deal just last month. 

Aid for Ukraine

Negotiations over assistance for Ukraine and the pandemic began a little over a week ago when the Biden administration told Congress that Ukraine needed about $6.4 billion in assistance. As Russia continued to bomb the country, killing civilians and sending more than 2 million people fleeing to Europe as refugees, the White House increased the request to $10 billion. Biden also asked Congress to include $22.5 billion in COVID-19 aid. 

White House wants $10 billion for Ukraine aid, $22.5 billion for more COVID help

The government spending bill wraps up the dozen annual government spending bills that fund federal departments and agencies. The package is supposed to pass before the start of the fiscal year on Oct. 1, but Congress rarely reaches agreement by the deadline. 

This year, lawmakers used three stopgap spending bills to keep money flowing at levels last agreed to during the Trump administration before coming to agreement this week. 

The White House said in a Statement of Administration Policy that it supported the package, in part, because it “would end a damaging series of short-term continuing resolutions that for months have undermined the Government’s ability to meet pressing challenges and would provide critical resources to invest in American workers and families and advance American leadership abroad.”

The funding packages, which generally get broad bipartisan support, also carry several additional bills with them. 

This year that includes a reauthorization of the Violence Against Women Act, which hasn’t been authorized since lawmakers allowed it to expire in December 2018. 

“The expiration of VAWA three years ago put many lives in jeopardy,” Senate Majority Leader Chuck Schumer said in a statement. “It is such good news that it is finally being reauthorized.” 

A version of this commentary originally appeared in the Daily Montanan.

Recently, I was talking to an educator whose job it is to run training programs for students and adults in higher education. She told me that around a dozen different companies and groups were sponsoring training courses for things like nursing assistants, medical workers, electricians and truck driving.

All of the courses were being underwritten by businesses and organizations in hopes of finding workers for jobs that are – and have been open – for some time. Classrooms were available. Instructors were ready. But only one class had enough students to hold the class.

Of all the things COVID-19 has taken from us – freedom to travel, a feeling of safety when going to the store – one of the most profound has been the change in workforce.

I asked, “So where are all those students and workers?”

“You’re the journalist. You tell me,” she replied.

The workers and students that seemed more plentiful before 2020 have disappeared. We could speculate that they’ve wandered off to other states, other areas, but we know other towns and states are struggling with the same workforce shortage. And the demand for housing has rarely been greater.

While the statistics look good on paper — including Montana’s historically low unemployment rate — the hidden truth behind those numbers is that those surveys include people who are actively looking for jobs or are in the workforce presently. What it doesn’t quite capture is the one statistic we need most: How many of the people have dropped out?

There are certainly a lot of practical questions that “non-participating” workers raise: How are they living? Where are they living? And what would make them come back?

Those aren’t the topic of this column, instead they are at the front of what journalists are trying to solve, discover and report.

Instead, I wonder if we’re overthinking the issue a bit.

The workforce shortage issue is being framed as an economic problem — employers can’t find enough workers and wages don’t seem to entice them.

Yet, maybe there are drivers of this wave of joblessness that we all know, but don’t really want to tackle. Maybe we just don’t like what the workforce shortage is telling us, and so we search for other more complex, nuanced interpretations.

As an observer and reporter, I think maybe the answer to the workforce shortage is a combination of time and fatigue.

American productivity, an actual calculation maintained by the government, shows that Americans have consistently been working harder and putting in more hours while wages have remained stagnant. In some cases, workers have been above 100% capacity, meaning they’re putting in more work and longer hours above what is expected in an effort to simply keep pace. In an effort to cling to good jobs, workers have been pushing themselves hard. In short, the economy was, to borrow a phrase, punching above its weight.

Meanwhile, inflation and housing prices have continued to escalate faster than wages, meaning those already overworked workers are doing more, falling farther behind. And no one wants to work harder to find themselves deeper in a hole.

And that leads me to time: While it seems like COVID has been one long episode of “Groundhog Day,” it’s now been more than two years since the disease has impacted the American economy and the country. While not an expansive amount of time, it’s enough for workers to change their habits, expectations and start over.

Maybe — just maybe — workers have downsized, found a new path, or readjusted to what they can or should expect. They’ve had plenty of time to think about working 40 to 80 hours per week and still not being able to afford housing or food. They may have decided: It’s just not worth it. Whether that means living with family or friends, living in a much smaller place, or finding a new career, people are fatigued and not going to back to how it was.

This also seems to be a crisis of mental health, hidden by the extreme consequences of COVID itself. We keep tabs on the hospitalizations and deaths, but calculating mental health problems is more nebulous. I suspect part of the key to the where-are-the-workers mystery could likely be told by mental health professionals. I would wager they’re seeing depression, burnout and anxiety from folks that might have otherwise never seen a counselor. One of the hidden costs of the virus has been the toll the disease has taken on the already frazzled worker.

Maybe we’re just making this whole situation too complex — as if there’s some undiscovered enclave of workers playing hide-and-seek. That would be an easy sort of problem to wrap your mind around.

Instead, after several years of reporting what is happening, a different narrative may be emerging, and it’s even more scary than the prospect of COVID itself. It’s what happens when the notion of the American Dream — a home, a career, a retirement — starts to evaporate.

When the American Dream ceases to become a vision that can be realized, people simply quit dreaming.

And if there’s nothing to work for, nothing to build toward, it would certainly stand to reason that there’d be a lot of empty classroom seats and a lot more “Help Wanted” signs.

Angela Hart

LAS VEGAS — Case manager Bryon Johnson flashed a light into a dark tunnel beneath the glitz of the Las Vegas Strip on a recent fall afternoon. He stepped into an opening in a concrete ditch littered with trash and discarded clothing to search an underground world for his homeless clients.

Beneath the Caesars Palace hotel and casino, Johnson found one of them stretched out on a plywood bed. Jay Flanders, 49, had sores across his back, up his arms, and into his fingers. The homeless man acknowledged occasional meth use and mental health concerns. He couldn’t recall exactly how long he’d lived underground, but it had been several years.

“Why don’t you come inside,” asked Johnson, trying to persuade Flanders to leave the tunnels. “Come get treatment.”

It’s Johnson’s job to coax homeless people out of drainage tunnels that stretch beneath Las Vegas, a perilous grid where people hide from law enforcement and shelter from extreme weather but risk being swept away by floodwaters. Drugs and alcohol are prevalent. Johnson tells clients they have a better shot at recovery above ground, where they can get medical care to treat chronic illnesses, such as diabetes, depression, and heart disease, and start drug and alcohol treatment programs.

Street medicine providers and homeless outreach workers who travel into the tunnels said they have noticed an uptick in the number of people living underground as housing costs have skyrocketed and local officials have adopted a zero-tolerance approach to homelessness. Caseworkers are also confronting a level of drug addiction that’s making it harder to get people, many suffering from mental illness and health conditions, to come aboveground for care.

“It’s meth. It’s fentanyl. It’s opioids. We’re seeing it more and more,” said Rob Banghart, vice president of community integration for the nonprofit homeless outreach organization Shine a Light, who lived in the tunnels for 2½ of the five years he was homeless, often using drugs.

Now sober for more than six years, Banghart recalled the tunnels providing a respite. “In that state of mind, I said to myself, ‘It’s got a roof; it’s out of the sun.’ It’s a little twisted, but it was a community.”

Outreach workers say more people are retreating underground. Though dark and damp, the tunnels provide cover from the harsh desert sun, warmth when temperatures drop, and privacy from society’s judgment above ground.

Constructed in the 1990s and measuring some 600 miles, the tunnels provide flood control for the city and outlying communities. Homeless outreach workers said 1,200 to 1,500 people live in them. Many have constructed elaborate shelters, often out of plywood and scraps of metal or brick below the casinos that define the Strip.

Tunnel living is not limited to Nevada. Across California’s Central Valley and its southern deserts, people unable to afford housing are retreating into caves and earthen tunnels, often dug into flood control berms, riverbanks, or along drainage canals, where people can escape the heat and law enforcement. In San Antonio, homeless people have constructed tunnel encampments, and in New York, homeless people have long retreated into subterranean existence in tunnels and defunct train corridors.

In Las Vegas, some tunnel dwellers said they hide to avoid constant encampment sweeps, which have increased nationally since the U.S. Supreme Court this year ruled that local authorities have a right to enforce sleeping or camping bans in public spaces, even when no shelter or housing is available.

Others said they go down to escape the unbearable weather. Triple digits are common in the summer; this year, Las Vegas climbed as high as 120 degrees. And the tunnels provide protection when temperatures drop into the 30s in the winter. It even snows there.

Street medicine providers are also trying to persuade homeless people to leave the tunnels to receive care. In addition to more drug and alcohol use, they have seen new problems with wounds and skin disorders associated with the street drug known as “tranq,” slang for the animal tranquilizer xylazine, which is often mixed with fentanyl or meth.

Tranq causes deep skin infections that, left untreated, can lead to bone infections and require amputation.

Flanders, the homeless man in the tunnels, had several of these skin sores, which he referred to as spider bites — a euphemism for the deep skin wounds caused by tranq. He estimated he has been to the emergency room at least 10 times this year, several times requiring hospitalization.

“One time I was there for six days; I almost lost a finger,” Flanders said, holding up the index finger that had been warped from a deep infection, as he started to tear up. Despite the risks, Flanders said, he still felt safer living in the tunnels than aboveground.

Las Vegas’ population boom has contributed to rising housing costs. The market rent for southern Nevada rose 20% from 2022 to 2023, according to a Clark County homelessness report — higher than the national average.

As more people get displaced, more retreat underground. And often, outreach workers say, it’s not just locals who can’t afford the rising cost of living who wind up homeless, but also out-of-towners. Some come to make it in the city’s booming entertainment industry, while others become homeless after losing it all at the casinos.

“People come here on vacation to gamble or try and make it, and they lose everything,” said Johnson, who works for Shine a Light, one of two organizations in Las Vegas that provide substantial outreach, housing referrals, and drug treatment services for homeless people in the tunnels.

“The housing market is insane; rents keep going up. A lot of people wind up down here,” said Johnson, who lived in the tunnels until he got sober with help from Shine a Light. “People just get stuck.”

Still, Nevada’s scorching heat and rains and monsoons pose a major threat to those living in the tunnels, though it’s unclear exactly how deadly life in them can be.

But Louis Lacey, homeless response director for the nonprofit Help of Southern Nevada, said homeless people living belowground put their lives at risk, often in the monsoon season when the tunnels flood. His organization coordinates with the city of Las Vegas and Clark County to get as many people as possible into shelters before the start of the rainy season, which typically runs from June to September.

“We go into the tunnels to make sure people who want to get out are out, but not everyone leaves, often because they don’t want to leave their belongings,” he said. “People die every year.”

KFF 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 KFF.

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LAS VEGAS — Maurice Clark huddled in his tent along dusty railroad tracks as two homeless-outreach workers began asking him questions to determine whether he would qualify for free or subsidized housing.

Did he use drugs? Had he ever been in jail? How many times had he been to an emergency room? Had he been attacked on the streets? Tried to harm himself? Engaged in sex for money?

Clark didn’t feel comfortable being honest with the two surveyors he’d never met before, who were flanked by police officers as they recorded his responses from a questionnaire on a tablet.

“I’ve done some crazy things to survive, but I’m, like, I’m going to say no because there’s these officers right there,” he said, recalling the encounter on a fall afternoon outside his tent.

“I’m a Black man in America, so asking this stuff hits a little bit different.”

National homelessness experts and local leaders say such personal questions exacerbate racial disparities in the ranks of the nation’s unhoused, particularly as more people experiencing homelessness compete for scarce taxpayer-subsidized housing amid a deepening affordability crisis.

Clark was given a questionnaire by two homeless-outreach workers flanked by police officers.(Angela Hart/KFF Health News)

Vulnerability questionnaires were created to determine how likely a person is to get sick and die while homeless, and the system has been adopted widely around the country over the past decade to help prioritize who gets housing. The more a homeless person is perceived to be vulnerable, the more points they score on the questionnaire and the higher they move in the housing queue. The surveys are being singled out for worsening racial disparities by systematically placing homeless white people at the front of the line, ahead of their Black peers — partly because the scoring awards more points for using health care, and relies on trust in the system, both of which favor white people.

Black people make up 13.7% of the overall U.S. population yet account for 32.2% of the nation’s homeless population. White people, including some people of Hispanic descent, make up 75% of the country and represent 55% of America’s homeless.

“It’s racist in a systemic way,” said Marc Dones, a California-based policy director at the University of California-San Francisco and a lead researcher for one of the nation’s largest studies analyzing the Black homeless population. “If you’re a white person, the more likely you are to rank higher than if you’re a Black person, so you’re more likely to get selected for housing.”

Vulnerability surveys took off after President Barack Obama in 2009 signed into law sweeping rules requiring the country’s local homelessness agencies, known as Continuums of Care and currently numbering 381, to adopt a method to assess the vulnerability of homeless people to receive federal housing and homelessness funding. Cities and counties predominantly adopted a survey called VI-SPDAT, which is still used by an estimated two-thirds of homeless agencies, even as it has been found to favor white people and rank Black people lower.

Some experts argue it’s time to toss the vulnerability assessment altogether and look not only at health and social needs but also systemic racism, poverty, involvement in the criminal justice system, barriers to housing, and other economic drivers that influence, and in some cases cause, homelessness. Several U.S. communities are revamping their vulnerability assessment systems to reduce racial disparities and help more Black people get housing.

In Los Angeles, officials are launching an effort to use artificial intelligence to better assess whether someone should be prioritized for placement, in part by looking at overpolicing of Black people and discrimination in health care. In Las Vegas, officials are revamping their vulnerability assessment to give higher scores for systemic problems including incarceration. In Austin, Texas, officials are testing a system to account for people displaced by gentrification.

“We need to own the racism that is embedded in our systems,” said Quiana Fisher, vice president of homelessness response systems for the lead agency in Travis County, Texas, which includes Austin. “It’s not just about the tool — it’s about funding, and it’s about program outcomes. Even if it’s unintentional, we have created a homeless response system that is rooted in racism.”

The assessment tool was first tested in Boston, where members of the homeless population were more likely to be white, male, and have a severe mental illness or substance use disorder. Black people, meanwhile, are more likely to be homeless because of economic reasons, such as poverty or joblessness, and are less likely to have a record of medical care due to higher uninsurance and less use of health care.

“This whole system was piloted on this older white population in Boston, so it does a poor job of capturing the needs of Black folks, who don’t tend to be as sick as white folks — they’re more broke,” Dones said. “The initial thought was to prioritize these people because they’re going to die sooner. It was trying to tackle mortality, but it wound up in racism.”

Outreach workers Bryon Johnson (center) and Nick Freddes (left) talk to Clark in October.(Angela Hart/KFF Health News)

As a result, white people are more likely to gain housing because they tend to score more points on vulnerability assessments that rank sickness higher, including histories of chronic disease, addiction, mental illness, and emergency room visits and hospitalizations, according to national surveys. Black people, meanwhile, are less likely to have health insurance or medical diagnoses and to reveal their ailments, and are more mistrustful due to biases in the health care system. “Black folks are less likely to seek care, even with coverage, due to medical racism,” Dones said.

Local leaders say part of the problem is becoming homeless in the first place and economic disadvantages that drive more Black people into homelessness, including placement in foster care and higher rates of eviction and joblessness. But once homeless, helping Black people get into stable housing becomes more elusive.

In Los Angeles County, home to more homeless people than any other county in the country, 31% of homeless people are Black, though the overall Black population accounts for 9%. In Austin, Black people account for nearly 32% of the homeless population, compared with 7.6% overall. And in Clark County, which includes Las Vegas, Black people represent 42% of the homeless population but just 12% of the overall population.

“We’ve failed to capture the complex vulnerabilities of our marginalized groups. We’re asking all these questions, but we created a waiting list to nowhere,” said Brenda Barnes, who leads the Southern Nevada Homelessness Continuum of Care.

Streets of Las Vegas

Grasping his toothbrush after cleaning up in his tent on a recent morning, Clark, 45, recalled taking his housing questionnaire this year. He ticked off responses to outreach workers that should rank him high in the queue — he lacked stable housing, has been homeless for nearly four years, and has no job or reliable income.

He’d frequented emergency rooms and had been to jail, pleading guilty to a felony theft crime he said he didn’t commit, and several times for possession of drugs and paraphernalia, he told them. He used methamphetamine, mostly to be alert at night when it became dangerous. Was he ever assaulted? Yes, especially in adulthood since becoming homeless in 2020.

In reality, he hustled sometimes for a dime, and he worried he’d be targeted for taking recyclables or engaging in prostitution. “I’ve done it to get a room for a night. It’s like a last resort,” he said.

And Clark wasn’t forthcoming with outreach workers about the details of his drug use or involvement with law enforcement, that he’d sold his body for sex, that he’d experienced abuse. He couldn’t recall all the details of his medical history either. Continually fleeing law enforcement sweeps with his tent, hauling it along busy train tracks, he’s high at times, and often in a state of chaos and fear that can scramble his memory or make him fearful of arrest. He didn’t share with them his occasional thoughts of suicide or his health concerns, including possibly having diabetes.

“They asked me about drugs, I was like, um, I don’t know,” Clark said. “Like I’m supposed to tell them I got addicted to meth or sold my body for a meal and hotel room? I had no idea where this information was going or what it was being used for.” After he took the survey, no housing came.

John Harris, who is homeless, has taken a housing assessment a couple of times but says he didn’t score high enough to qualify.(Angela Hart/KFF Health News)

Even those who do answer honestly find themselves competing for a limited supply of affordable housing. John Harris was sleeping under a bridge on a recent October afternoon. He said he has taken the questionnaire twice. It led nowhere.

“They asked me, have I been incarcerated? And I said yes. I’ve been to prison too many times. And I have mental health struggles,” said Harris, 59, who has been in and out of sober living shelters but still uses methamphetamine. He has been a repeat visitor to emergency rooms, and on an October afternoon recorded a high blood pressure reading that put him at risk for a heart attack — factors that should score points for vulnerability.

“I called and asked what happened with my housing. They said I didn’t score high enough,” he said. After getting his blood pressure checked by a street medicine nurse, he shrugged, saying he may just wind up back in the emergency room, as he retreated under the bridge.

“No matter what society says today, things ain’t never going to change,” he said.

‘I Don’t Know What the Solution Is’

How communities assign points to homeless people and rank them for housing is the biggest problem.

The most common questionnaire deployed by communities around the country, the VI-SPDAT, assigns points meant to gauge the vulnerability of a person living on the streets. Experts say this model was never tested as a housing assessment tool, nor meant to determine whether someone gets into housing.

“This is not a reliable instrument, and Black men consistently score the lowest for vulnerability, so they are deprioritized for housing — to get housing, you really need to score high,” said Courtney Cronley, a University of Tennessee researcher who analyzed the vulnerability assessment. Her findings were published in 2020 in the Journal of Social Distress and Homelessness.

Cronley pointed to a range of questions that exacerbate racial bias and have little to do with qualifying for housing:

How many times have you received health care in an emergency room? Have you been attacked or beaten up? Have you threatened to harm yourself or anyone else in the last year?

Does anyone force you or trick you to do things that you do not want to do? Do you exchange sex for money? Run drugs?

Experts who study the vulnerability questionnaire also point out that the racial or ethnic background of surveyors often doesn’t reflect that of the people being questioned, which can lead to inaccurate results if a respondent doesn’t feel safe or understand the survey’s purpose.

Some cities and counties are creating surveys that local homeless agencies hope will narrow racial disparities.

Clark County deployed a new vulnerability assessment in June after a 2023 secret-shopper project found the system was not connecting homeless people with housing or services, especially people of color.

“We failed in every category,” Barnes said. Formerly homeless people fanned out on the streets and in the tunnels to test whether the housing questionnaire resulted in providing housing for the most vulnerable. “All we were doing is counting people.”

Harris gets his blood pressure checked on an October afternoon.(Angela Hart/KFF Health News)

Clark County’s new weighted questionnaire now considers how likely a person is to exit homelessness on their own — instead of how likely they are to die on the streets or in the tunnels.

The new system assigns homeless people points in four categories to get higher in the queue for housing: whether someone is pregnant or a parent; whether they have a substance use disorder, chronic health condition, or mental health diagnosis; whether they’re 55 or older; and whether they have committed a felony or violent crime.

“Because you’re not going to get approved for a job or housing if they run a background check and there’s a criminal record,” she said, “so we want to address that in our housing system.”

Still, Barnes isn’t sure Clark County will get it right this time. As of mid-November, more homeless Black people were waiting for housing than white people. According to local data obtained through public records requests, nearly 1,500 Black people are in the county’s housing queue, compared with roughly 1,000 white people.

“I don’t know what the solution is,” Barnes said. “To be honest, the numbers may spike again.”

Los Angeles County, where an estimated 75,000 people experience homelessness, is creating a weighted tool to assign more points for factors that disproportionately affect people of color.

If someone has been incarcerated or detained by law enforcement, instead of getting one point, a homeless person would score five, moving them up on the housing list, said Eric Rice, a social scientist and professor at the University of Southern California.

“We are assigning more points to structural inequities,” said Rice, who is helping develop the new questionnaire.

Los Angeles County also plans to assign more points for drug use and for having HIV, which affects Black men more than any other group. New HIV diagnoses for Black adults were eight times those of white people, according to research by KFF, a health information nonprofit that includes KFF Health News.

Homelessness coordinators have also revamped their vulnerability assessment in Travis County, Texas, where a Black resident is six times as likely to fall into homelessness as a white person.

The county’s homelessness agency, according to Fisher, looked at historically Black neighborhoods in Austin that had been gentrified and scored homeless people higher if they’d lived in those areas but were now homeless.

“If you lived in a place that was previously redlined or now gentrified, you got a point for that,” Fisher said. The survey also gave points for involvement in the criminal justice system, because Black people are more likely to get arrested or jailed, she said.

Some experts say the idea of using a tool to rank people should disappear altogether.

Instead, communities should have flexibility to tailor their housing resources based on the local needs and demographic makeup of their homeless populations, said Mary Frances Kenion, vice president of training and technical assistance at the National Alliance to End Homelessness.

She said communities can cultivate trust between homeless people and outreach workers through a one-on-one approach that can be more responsive to individual needs and local housing conditions, which can better determine whether someone should be moved to the top of the housing list.

Kenion also encouraged federal, state, and local governments to reimagine their approach to prioritizing people for housing based not on vulnerability but economic factors like income, history of eviction, or having a felony record. She argued communities should devote more resources to stem the flow of Black people into homelessness.

“If we don’t manage to stop that,” she said, “this is just going to keep getting exponentially worse.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Angela Hart:
ahart@kff.org,
@ahartreports

Bill Hall, 71, has been fighting for his life for 38 years. These days, he’s feeling worn out.

Hall contracted HIV, the virus that can cause AIDS, in 1986. Since then, he’s battled depression, heart disease, diabetes, non-Hodgkin lymphoma, kidney cancer, and prostate cancer. This past year, Hall has been hospitalized five times with dangerous infections and life-threatening internal bleeding.

But that’s only part of what Hall, a gay man, has dealt with. Hall was born into the Tlingit tribe in a small fishing village in Alaska. He was separated from his family at age 9 and sent to a government boarding school. There, he told me, he endured years of bullying and sexual abuse that “killed my spirit.”

Bill Hall, who lives alone in Seattle, contracted HIV in 1986. Since then, he has battled depression, heart disease, diabetes, non-Hodgkin lymphoma, kidney cancer, and prostate cancer. This past year, he’s been hospitalized five times with potentially life-threatening medical crises. (Ernestine Grimm)

Because of the trauma, Hall said, he’s never been able to form an intimate relationship. He contracted HIV from anonymous sex at bath houses he used to visit. He lives alone in Seattle and has been on his own throughout his adult life.

“It’s really difficult to maintain a positive attitude when you’re going through so much,” said Hall, who works with Native American community organizations. “You become mentally exhausted.”

It’s a sentiment shared by many older LGBTQ+ adults — most of whom, like Hall, are trying to manage on their own.

Of the 3 million Americans over age 50 who identify as gay, bisexual, or transgender, about twice as many are single and living alone when compared with their heterosexual counterparts, according to the National Resource Center on LGBTQ+ Aging.

This slice of the older population is expanding rapidly. By 2030, the number of LGBTQ+ seniors is expected to double. Many won’t have partners and most won’t have children or grandchildren to help care for them, AARP research indicates.

They face a daunting array of problems, including higher-than-usual rates of anxiety and depression, chronic stress, disability, and chronic illnesses such as heart disease, according to numerous research studies. High rates of smoking, alcohol use, and drug use — all ways people try to cope with stress — contribute to poor health.

Keep in mind, this generation grew up at a time when every state outlawed same-sex relations and when the American Psychiatric Association identified homosexuality as a psychiatric disorder. Many were rejected by their families and their churches when they came out. Then, they endured the horrifying impact of the AIDS crisis.

“Dozens of people were dying every day,” Hall said. “Your life becomes going to support groups, going to visit friends in the hospital, going to funerals.”

It’s no wonder that LGBTQ+ seniors often withdraw socially and experience isolation more commonly than other older adults. “There was too much grief, too much anger, too much trauma — too many people were dying,” said Vincent Crisostomo, director of aging services for the San Francisco AIDS Foundation. “It was just too much to bear.”

In an AARP survey of 2,200 LGBTQ+ adults 45 or older this year, 48% said they felt isolated from others and 45% reported lacking companionship. Almost 80% reported being concerned about having adequate social support as they grow older.

Embracing aging isn’t easy for anyone, but it can be especially difficult for LGBTQ+ seniors who are long-term HIV survivors like Hall.

Of 1.2 million people living with HIV in the United States, about half are over age 50. By 2030, that’s estimated to rise to 70%.

Christopher Christensen, 72, of Palm Springs, California, has been HIV-positive since May 1981 and is deeply involved with local organizations serving HIV survivors. “A lot of people living with HIV never thought they’d grow old — or planned for it — because they thought they would die quickly,” Christensen said.

Jeff Berry is executive director of the Reunion Project, an alliance of long-term HIV survivors. “Here people are who survived the AIDS epidemic, and all these years later their health issues are getting worse and they’re losing their peers again,” Berry said. “And it’s triggering this post-traumatic stress that’s been underlying for many, many years. Yes, it’s part of getting older. But it’s very, very hard.”

Being on their own, without people who understand how the past is informing current challenges, can magnify those difficulties.

“Not having access to supports and services that are both LGBTQ-friendly and age-friendly is a real hardship for many,” said Christina DaCosta, chief experience officer at SAGE, the nation’s largest and oldest organization for older LGBTQ+ adults.

Diedra Nottingham, a 74-year-old gay woman, lives alone in a one-bedroom apartment in Stonewall House, an LGBTQ+-friendly elder housing complex in New York City. “I just don’t trust people,“ she said. “And I don’t want to get hurt, either, by the way people attack gay people.”

When I first spoke to Nottingham in 2022, she described a post-traumatic-stress-type reaction to so many people dying of covid-19 and the fear of becoming infected. This was a common reaction among older people who are gay, bisexual, or transgender and who bear psychological scars from the AIDS epidemic.

Nottingham was kicked out of her house by her mother at age 14 and spent the next four years on the streets. The only sibling she talks with regularly lives across the country in Seattle. Four partners whom she’d remained close with died in short order in 1999 and 2000, and her last partner passed away in 2003.

When I talked to her in September, Nottingham said she was benefiting from weekly therapy sessions and time spent with a volunteer “friendly visitor” arranged by SAGE. Yet she acknowledged: “I don’t like being by myself all the time the way I am. I’m lonely.”

Donald Bell, a 74-year-old gay Black man who is co-chair of the Illinois Commission on LGBTQ Aging, lives alone in a studio apartment in subsidized LGBTQ+-friendly senior housing in Chicago. He spent 30 years caring for two elderly parents who had serious health issues, while he was also a single father, raising two sons he adopted from a niece.

Bell has very little money, he said, because he left work as a higher-education administrator to care for his parents. “The cost of health care bankrupted us,” he said. (According to SAGE, one-third of older LGBTQ+ adults live at or below 200% of the federal poverty level.) He has hypertension, diabetes, heart disease, and nerve damage in his feet. These days, he walks with a cane.

To his great regret, Bell told me, he’s never had a long-term relationship. But he has several good friends in his building and in the city.

“Of course I experience loneliness,” Bell said when we spoke in June. “But the fact that I am a Black man who has lived to 74, that I have not been destroyed, that I have the sanctity of my own life and my own person is a victory and something for which I am grateful.”

Now he wants to be a model to younger gay men and accept aging rather than feeling stuck in the past. “My past is over,” Bell said, “and I must move on.”

Judith Graham:
khn.navigatingaging@gmail.com,
@judith_graham

MIAMI — When leaders of Florida’s most populous county met in September to pick a site for what could become the nation’s largest trash incinerator, so many people went to the government center to protest that overflow seating spilled into the building’s atrium.

“MIRAMAR SAYS NO TO INCINERATOR! NOT IN OUR BACKYARD,” read green T-shirts donned by some attendees who wanted to stop the new industrial waste facility — capable of burning up to 4,000 tons of garbage a day — from being built near their homes.

Residents feared the site would not only sink their property values and threaten the environment, but also potentially harm people’s health.

Even more, the locations appeared to have been selected in a way that worried civil rights and environmental advocacy groups. All four sites considered that day were in, or near, some of the region’s most diverse communities, and the state is arguing in federal court that race should not be a consideration in permitting industries that pollute the environment.

“Historically, communities of color have suffered the impacts of toxic plants near our cities, affecting our health and well-being,” Elisha Moultrie, a 30-year Miramar resident and committee leader with the Miami-Dade NAACP, told the county commissioners.

It’s “environmental injustice and racial injustice,” she said.

Miami-Dade leaders see a different challenge: the need to effectively manage trash. The county produces nearly double the national average per person of garbage, in part due to one of the region’s major industries: tourism.

Yet, throughout 2024, Miami-Dade’s elected officials delayed a decision on where to build the planned $1.5 billion incinerator, as the county mayor and commissioners wrestled with politics. County leaders are scheduled to vote on a new site in February.

“There is no perfect place,” Miami-Dade Mayor Daniella Levine Cava said in a recent memo to county leaders.

The conundrum unfolding in South Florida is indicative of what some see as a broader trend in the national fight for environmental justice, which calls for a clean and healthy environment for all, including low-wealth and minority communities. Too often land inhabited by Black and Hispanic people is unfairly overburdened with air pollution and other emissions from trash incinerators, chemical plants, and oil refineries that harm their health, said Mike Ewall, director of Energy Justice Network, a nonprofit that advocates for clean energy and maps municipal solid waste incinerators.

“All the places that they would consider putting something no one wants are in communities of color,” he said.

More than 60 municipal solid waste incinerators operate nationwide, according to data from Energy Justice. Even though more than 60% of incinerators are in majority-white communities, those in communities of color have more people living nearby, burn more trash, and emit more pollutants, Ewall said.

And in Florida, six of the nine existing incinerators are in places where the percentages of people of color are higher than the statewide average of 46%, according to data from the Environmental Protection Agency’s EJScreen, an online tool for measuring environmental and socioeconomic information for specific areas.

Before Miami-Dade County’s old trash incinerator burned down in February 2023, the county sent nearly half of its waste to the facility. Now, the county is burying much of its trash in a local landfill or trucking it to a central Florida facility — an unsustainable solution.

Joe Kilsheimer, executive director of the Florida Waste-to-Energy Coalition, a nonprofit that advocates for owners and operators of trash incinerators, acknowledges that choosing a location is hard. Companies decide based on industry-accepted parameters, he said, and local governments must identify strategies to manage waste in ways that are both safe and efficient.

“We have an industrial-scale economy that produces waste on an industrial scale,” Kilsheimer said, “and we have to manage it on an industrial scale.”

Al Salvi (left), 63, of Pembroke Pines, Florida, attends a hearing of the Miami-Dade Board of County Commissioners in Miami on Sept. 17 to speak against the county mayor’s plan to build the nation’s largest trash incinerator about 3 miles from his home. He was among dozens of people who live near the proposed site and oppose the plan. “I don’t want the byproducts of ash and dioxins affecting our health,” says Salvi, a retiree. “We don’t want that stuff in our air and water. People can move, but not when you’re a senior.”(Daniel Chang/KFF Health News)

‘Those People Don’t Matter’

Florida burns more trash than any other state, and at least three counties besides Miami-Dade are considering plans to build new facilities. Managing the politics of where to place the incinerator has especially been a challenge for Miami-Dade’s elected officials.

In late November, commissioners in South Florida considered rebuilding the incinerator where it had been for nearly 40 years — in Doral, a predominantly Hispanic community that also is home to Trump National Doral, a golf resort owned by the president-elect less than 3 miles from the old site. But facing new opposition from the Trump family, the county mayor requested delaying a vote that had been scheduled for Dec. 3.

President Joe Biden created a national council to address inequities about where toxic facilities are built and issued executive orders mandating that the Environmental Protection Agency and Department of Justice address these issues.

Asked if Trump would carry on Biden’s executive orders, Karoline Leavitt, the incoming White House press secretary, said in an email that Trump “advanced conservation and environmental stewardship” while reducing carbon emissions in his first term.

“In his second term, President Trump will once again deliver clean air and water for American families while Making America Wealthy Again,” Leavitt said.

However, during his presidency, Trump proposed drastic reductions to the EPA’s budget and staff, and rolled back rules on clean air and water, including the reversal of regulations on air pollution and emissions from power plants, cars, and trucks.

That’s a big concern for minority neighborhoods, especially in states such as Florida, said Dominique Burkhardt, an attorney with the nonprofit legal aid group Earthjustice, which filed a complaint against Florida’s Department of Environmental Protection in March 2022.

The complaint, on behalf of Florida Rising, a nonprofit voting rights group, alleges that Florida’s environmental regulator violated the Civil Rights Act of 1964 by failing to translate into Spanish documents and public notices related to the permitting of incinerators in Miami and Tampa, and by refusing to consider the impact of the facilities on nearby minority communities.

“They’re not in any way taking into account who’s actually impacted by air pollution,” Burkhardt said of the state agency. The EPA is now investigating the complaintinvestigating the complaint.

Conservative lawmakers and state regulators have been hostile to laws and regulations that center on the rights of people of color, Burkhardt said. Florida Gov. Ron DeSantis, a Republican, has signed into law bills limiting race education in public schools and banning public colleges and universities from spending money on diversity, equity, and inclusion programs.

“They want to be race-neutral,” Burkhardt said. But that ignores “the very real history in our country of racism and entrenched systemic discrimination.”

Residents and city officials from Miramar, Florida, gather in Miami on Sept. 17 to voice their opposition to Miami-Dade County’s plan to build a trash incinerator capable of burning up to 4,000 tons of garbage a day near their community, which predominantly is made up of Black and Hispanic residents. In Florida, as in the rest of the nation, municipal trash incinerators disproportionately affect people of color.(Daniel Chang/KFF Health News)

Historical racism like segregation and redlining, combined with poor access to health care and exposure to pollution, has a lasting impact on health, said Keisha Ray, a bioethicist with the University of Texas Health Science Center at Houston.

Studies have found that neighborhoods with more low-income and minority residents tend to have higher exposure to cancer-causing pollutants. Communities with large numbers of industrial facilities also have stark racial disparities in health outcomes.

Incinerators emit pollutants such as carbon monoxide, nitrogen oxides, and fine particulate matter, which have been associated with heart disease, respiratory problems, and cancer. People living near them often don’t have the political power to push the industries out, Ray said.

Ignoring the disparate impact sends a clear message to residents who live there, she said.

“What you’re saying is, ‘Those people don’t matter.’”

Covered in Ash

Florida is one of 23 states that have petitioned the courts to nullify key protections under the Civil Rights Act. The protections prohibit racial discrimination by organizations receiving federal funding and prevent polluting industries from overburdening communities of color.

Those rules ask the states “to engage in racial engineering,” argued Florida Attorney General Ashley Moody in an April 2024 letter to the EPA, co-signed by attorneys general for 22 other states. A federal court in Louisiana, which sued the EPA in May 2023, has since stopped the agency from enforcing the rules against companies doing business in that state.

Miami-Dade’s incinerator, built west of the airport in 1982, was receiving nearly half the county’s garbage when it burned down in February 2023. Though the facility had pollution control devices, those measures did not always protect nearby residents from the odor, smoke, and ash that the incinerator emitted, said Cheryl Holder, an internal medicine physician who moved into the neighborhood in 1989.

Holder said every morning her car would be covered in ash. Residents persuaded the county, which owned the facility, to install “scrubbers” that trapped the ash in the smokestack. But the odor persisted, she said, describing it as “a strange chemical — faint bleach/vinegar mixed with garbage dump smell” — that often occurred in the late evening and early morning.

Holder still started a family in the community, but by 2000 they moved, out of concern that pollution from the incinerator was affecting their health.

“My son ended up with asthma … and nobody in my family has asthma,” said Holder, who in 2018 helped found Florida Clinicians for Climate Action, a group focused on the health harms of climate change. Though she cannot prove that incinerator pollution caused her son’s illness — the freeways, airport, and landfill nearby also emit toxic substances — she remains convinced it was at least a contributing factor.

An industrial trash incinerator in Miami-Dade County, Florida, burned down in February 2023, leaving elected officials with the challenge of effectively managing nearly 5 million tons of trash produced each year. County leaders have proposed a new $1.5 billion incinerator while wrestling with the politics of where to build it. The conundrum unfolding in South Florida reflects what some see as a broader trend in the national fight for environmental justice, which calls for a clean and healthy environment, especially for low-wealth and minority communities. (Miami-Dade Fire Rescue)

Many South Florida residents are concerned about the health effects of burning trash, despite assurances from Miami-Dade Mayor Cava and the county’s environmental consultants that modern incinerators are safe.

Cava’s office did not respond to KFF Health News’ inquiries about the incinerator. She has said in public meetings and a September memo to county commissioners that the health and ecological danger from the new incinerator would be minimal. She cited an environmental consultant’s assessment that the health risk is “below the risk posed by simply walking down the street and breathing air that includes car exhaust.”

But some environmental health experts say it’s not only a facility’s day-to-day operations that are cause for concern. Unplanned events, such as the fire that destroyed Miami-Dade’s incinerator, can cause environmental catastrophes.

“It might not be part of their regular operations,” said Amy Stuart, a professor of environmental and occupational health at the University of South Florida’s College of Public Health. “But it happens every once in a while. And it hasn’t been that well regulated.”

No Easy Solutions

In addition to Miami-Dade’s planned incinerator, three other facilities have been proposed elsewhere in the state, according to Energy Justice Network and news reports.

State lawmakers adopted a law in 2022 that awards grants for expansions of existing trash incinerators and financial help for waste management companies losing revenue on the sale of the electricity their facilities generate.

A bill filed in the Florida Legislature by Democrats this year would have required an assessment of a facility’s impact on minority communities before the state provided financial incentives. The legislation died in committee.

As local governments in Florida and elsewhere turn to incineration to manage waste, the industry has argued that burning trash is better than burying it in a landfill.

Kilsheimer, whose group represents the incinerator industry, said Miami-Dade has no room to build another landfill, though the toxic ash left behind from burning trash must be disposed of in a landfill somewhere.

“This is the best solution we have for the conditions that we have to operate in,” he said.

But University of South Florida’s Stuart said that burning trash isn’t the only option and that the government should not ignore historical and environmental racism. The antidote cannot be to put more incinerators and other polluting facilities in majority-white neighborhoods, she said.

The focus of public money instead should be on reducing waste altogether to eliminate the need for incinerators and landfills, Stuart said, by reducing communities’ consumption and increasing recycling, repurposing, and composting of refuse.

South Florida residents have organized against Miami-Dade County’s plan to build the nation’s largest trash incinerator near their communities. At a September meeting of the county’s board of commissioners, many protesters dressed in green T-shirts with a simple message printed in white, “MIRAMAR SAYS NO TO INCNERATOR.” They filled the commission’s chambers and overflowed into the atrium, where they watched the meeting on a television screen. (Daniel Chang/KFF Health News)

Daniel Chang:
dchang@kff.org,
@dchangmiami