Macau is seeing more people than ever seeking help for their gambling disorders
A record number of people self-excluded from casinos in 2025
Macau is experiencing a rise in problem gambling. The increase in the number of people seeking help for their gambling comes after the enclave’s casinos pivoted from the VIP and high roller to the premium mass and general public player.
People wait on a bus that’s enroute to Wynn Macau. Macau’s focus on the mass and general public is leading to higher rates of problem gambling in the Chinese region. (Image: AFP via Getty Images)
Macau is the world’s richest casino market, with the six gaming operators combining to win $30.9 billion from their table games and slot machines in 2025. The $30.9 billion was the highest annual gross gaming revenue (GGR) mark since 2019.
How Macau’s casinos generate GGR, however, has changed drastically since the COVID-19 pandemic. Once a gambling hub largely reserved for Mainland China’s wealthiest elite, Beijing used the global health crisis to alter how Macau ticks.
The People’s Republic and President Xi Jinping shuttered the VIP junket model. The businesses were accused of facilitating the transfer of money from the communist regime to Macau, a Special Administration Region under Chinese control that’s considered a tax haven.
Junkets and Macau’s casinos colluded to bring mainland high rollers to the city. Customers were typically afforded a line of casino credit close to the amount of money they paid the junket for their lavish trip and accommodations. Such high rollers gambled in private rooms on high-stakes games of baccarat, with per-bet hands often upwards of $10,000.
Macau Problem Gambling
In exchange for 10-year casino license extensions, Beijing and Macau forced Sands, Wynn, MGM, Galaxy, Melco, and SJM to invest $16 billion in non-gaming projects. The agreement was designed to alter Macau from a high-stakes gambling paradise to a destination for leisure travel, family-friendly vacations, and business.
The VIP gambling rooms are largely no more. Macau casinos have instead widened their marketing focus, and, so far, their multibillion-dollar bets on non-gaming are helping drive gaming, too. But Macau government officials say it’s also driving gambling problems.
Macau’s Gaming Inspection and Coordination Bureau reports that 828 people removed their access to casinos in 2025. In 2024, only 475 individuals requested self-exclusion.
During the seven years from 2013 through 2019, Macau’s self-exclusion program averaged 341 new enrollees each year. There were 254 self-exclusions in 2020, 359 in 2021, 292 in 2022, and 418 in 2023.
There were another 124 people who were excluded last year through third-party-initiated requests, typically a family member or close friend. The individual must agree to be excluded before a third-party application is executed.
The total number of exclusions includes exclusions requested by casinos. Excluded people are banned from entering casinos in Macau for a term of two years.
Macau Market Maturation
Following the overhaul of the Macau gaming industry, analysts at S&P are predicting a stabilization of gaming revenues after three years of growth.
Macau’s gaming boom is fading. The sector will be moving from a post-pandemic rebound to a more maturity-driven phase, as capacity limits and potentially softer mass demand temper growth,” the S&P note read.
“We think 2026 revenue growth will slow, but steady operations, selective share gains, and deleveraging still support modest upside,” the brokerage predicted.
Jeffrey Hamilton came to live in an empty condominium, as many do, after a painful breakup.
“It was a stressful time even though it was an amicable breakup,” says the 38-year-old anesthesiologist. “I had two weeks to move and was desperate to find something.”
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Hamilton, who is drawn to “gallery-esque white boxes,” ultimately settled in a two-bedroom, two-bathroom Lorcan O’Herlihy Architects-designed condo four blocks away in West Hollywood. With few possessions other than his cats, he proceeded to furnish the unit with secondhand items he found primarily on Facebook Marketplace.
During the process, he says, he found himself.
“It was the first time I had lived on my own in a long time and it was nice to listen to my own instincts,” says Hamilton, sitting in the living room of his elegant condo, which he now shares with his boyfriend David Poli, his cats Romulus and Remus and Poli’s Husky mix, Janeway (named for Kathryn Janeway, the first female captain on the television series “Star Trek: Voyager”). All the pets are rescues.
Not to be upstaged by Romulus the cat, Janeway, a husky mix adopted from Hollywood Huskies, makes a statement in the living room.
Black CB2 shelves Hamilton found on Facebook Marketplace store artfully arranged ceramics, books and his and his boyfriend’s shoes.
“Jeffrey likes to say that everything in his apartment is a rescue, including me,” says Poli jokingly.
When Hamilton adopted his cats six years ago during his medical residency in San Diego, they were kittens; now, as adults, he says, the spotted Bengal cats have not just grown but have influenced his design choices in his new home.
The den features more pet-friendly choices including a Rove Concepts modular sofa that Hamilton bought on clearance. “It’s a little small for two grown men and three pets,” he says.
“My original inspiration was to match the furniture to the kitties so I don’t see their cat hair,” he says. “The cats very much informed the color scheme. I find them so handsome; it felt like having matching furniture was practical.”
In the living room, for instance, Hamilton chose a camel-colored Curvo sofa in velvet by Goop for CB2, which he found on Facebook Marketplace. Similarly, the accompanying swivel chairs from HD Buttercup and the barstool seats in the kitchen are upholstered in Bengal and Husky-durable textiles that camouflage pet hair.
Actor Kit Williamson, a Hollywood friend who has tackled many of his own interior design projects, says Hamilton and Poli’s home is more than just a safe place to land. “I love that Jeffrey’s design for the apartment was inspired by his cats — and that David’s dog not only gets along with the cats, but complements the color palette,” he says. “It’s not just cohesive, it’s kismet.”
A second-hand desk from Facebook Marketplace in the bedroom provides a place for remote work.
No need for lint rollers as Janeway blends in with the furnishings.
Hamilton grew up in the Bay Area but has moved around the country for his education and medical training, including stints in New York City, San Francisco, San Diego and Seattle. So when he moved to Los Angeles for good in 2022, he found shopping for furnishings on Craigslist and Facebook Marketplace to be a great way to get to know the city.
“It was nice originally because I was new to L.A., and it helped me get a better sense of Los Angeles,” he says. “I ventured to Woodland Hills and Calabasas — I got a lot of vintage stuff in Woodland Hills.”
Living alone, Hamilton says, is what allowed him to “find space and time to honor” his own interests a little more.
Hamilton’s condo in West Hollywood, which was designed by Lorcan O’Herlihy Architects, includes an outdoor patio and a rooftop deck with views of the Hollywood Hills.
“I think with medical school, residency and fellowship training, I didn’t have much time and space or resources to self-examine, as so much of my time was occupied working and thinking about the wellness of others,” he says.
For him, part of his process for creating a welcoming home was focusing on “sustainable goods — things that were used, vintage or local,” he says.
That accounts for some of Hamilton’s home decor selections: The CB2 bookshelves from Facebook Marketplace, which store artfully arranged ceramics, books and the couple’s neatly stacked shoes and a travertine dining room table, also from Facebook Marketplace.
Down the hall, in their bedroom, is a second-hand desk from Facebook Marketplace where Poli can work from home several days a week. “It’s a little beat-up, which I like,” Hamilton says. “I like things that are shiny and nice but also beat-up around the edges. Nothing too perfect. “
Romulus reclines on the camel-colored velvet sofa in the living room.
And then there is the art. “It was important to me to have pieces from either local artisans or artists who are L.A.-based,” he says, noting the tall, plaster lamp in the living room by Kate O’Connor and a graphic stoneware bowl by Chad Callaghan atop his marble coffee table.
In the living room, Hamilton hung a large-scale artwork by Texas-based painter Jason Adkins for General Public, a company developed by Portia de Rossi that licenses and 3D-prints artworks. In the den, another Adkins piece for General Public hangs alongside a vintage print by Cy Twombly. “They feel like real paintings,” he says of the Synographs. “You can’t tell the difference. “
Elegant, clutter-free and homey, the condominium is a calm place to come home to after working long shifts, including overnights, at Children’s Hospital. “A sense of calm and serenity was probably a very important implicit priority,” Hamilton says. “My work can be very stressful at times, so having a place of refuge came naturally.”
Luckily, balancing comfort and pets is another thing that came naturally to the couple after they moved in together.
The open-concept kitchen is modern and streamlined.
“We have a nice synergy,” Hamilton says of Poli. “We tend to agree when it comes to interior design.”
“I’m more of a minimalist,” Poli says. “Jeffrey likes pillows too much. It’s getting a little busy in here,” he adds, teasing his partner.
“I do like pillows,” Hamilton says, noting that he recently bought a sewing machine so he can make his own soft furnishings. “I’ve learned that the best outdoor pillows for pets are from Arhaus. They don’t stain, and they are really durable.”
Like many millennials his age, Hamilton often thinks about buying a home but finds real estate prices, combined with the housing shortage in Los Angeles, daunting. “It’s so expensive,” he says. “I keep doing the math, get approved for a mortgage, then see the interest rates and how much you have to put down — and I just can’t do it. My rent is ridiculous, but it’s more economical than any mortgage I’ve seen in West Hollywood.”
For now, Hamilton enjoys living in a 30-unit building in a pedestrian-friendly neighborhood with a rooftop deck overlooking the Sunset Strip. “I don’t need a ton of space,” he says. “Maybe a condo in West Hollywood would be a nice starting point someday.”
After all, he’s learned he’s good at starting over.
Back in the spring, around the end of the COVID-19 public-health emergency, hospitals around the country underwent a change in dress code. The masks that staff had been wearing at work for more than three years vanished, in some places overnight. At UChicago Medicine, where masking policies softened at the end of May, Emily Landon, the executive medical director of infection prevention and control, fielded hate mail from colleagues, some chiding her for waiting too long to lift the requirement, others accusing her of imperiling the immunocompromised. At Vanderbilt University Medical Center, which did away with masking in April, ahead of many institutions, Tom Talbot, the chief hospital epidemiologist, was inundated with thank-yous. “People were ready; they were tired,” he told me. “They’d been asking for several months before that, ‘Can we not stop?’”
But across hospitals and policies, infection-prevention experts shared one sentiment: They felt almost certain that the masks would need to return, likely by the end of the calendar year. The big question was exactly when.
For some hospitals, the answer is now. In recent weeks, as COVID-19 hospitalizations have been rising nationwide, stricter masking requirements have returned to a smattering of hospitals in Massachusetts, California, and New York. But what’s happening around the country is hardly uniform. The coming respiratory-virus season will be the country’s first after the end of the public-health emergency—its first, since the arrival of COVID, without crisis-caliber funding set aside, routine tracking of community spread, and health-care precautions already in place. After years of fighting COVID in concert, hospitals are back to going it alone.
A return to masking has a clear logic in hospitals. Sick patients come into close contact; medical procedures produce aerosols. “It’s a perfect storm for potential transmission of microbes,” Costi David Sifri, the director of hospital epidemiology at UVA Health, told me. Hospitals are on the front lines of disease response: They, more than nearly any other place, must prioritize protecting society’s vulnerable. And with one more deadly respiratory virus now in winter’s repertoire, precautions should logically increase in lockstep. But “there is no clear answer on how to do this right,” says Cameron Wolfe, an infectious-disease physician at Duke. Americans have already staked out their stances on masks, and now hospitals have to operate within those confines.
When hospitals moved away from masking this spring, they each did so at their own pace—and settled on very different baselines. Like many other hospitals in Massachusetts, Brigham and Women’s Hospital dropped its mask mandate on May 12, the day the public-health emergency expired; “it was a noticeable difference, just walking around the hospital” that day, Meghan Baker, a hospital epidemiologist for both Brigham and Women’s Hospital and Dana-Farber Cancer Institute, told me. UVA Health, meanwhile, weaned staff off of universal masking over the course of about 10 weeks.
Most masks at the Brigham are now donned on only a case-by-case basis: when a patient has active respiratory symptoms, say, or when a health-care worker has been recently sick or exposed to the coronavirus. Staff also still mask around the same subset of vulnerable patients that received extra protection before the pandemic, including bone-marrow-transplant patients and others who are highly immunocompromised, says Chanu Rhee, an associate hospital epidemiologist at Brigham and Women’s Hospital. UVA Health, meanwhile, is requiring masks for everyone in the hospital’s highest-risk areas—among them, certain intensive-care units, as well as cancer, transplant, and infusion wards. And although Brigham patients can always request that their providers mask, at UVA, all patients are asked upon admission whether they’d like hospital staff to mask.
Nearly every expert I spoke with told me they expected that masks would at some point come back. But unlike the early days of the pandemic, “there is basically no guidance from the top now,” Saskia Popescu, an epidemiologist and infection-prevention expert at the University of Maryland School of Medicine, said. The CDC still has a webpage with advice on when to mask. Those recommendations are tailored to the general public, though—and don’t advise covering up until COVID hospital admissions go “way high, when the horse has well and truly left the barn,” Landon, at UChicago, told me. “In health care, we need to do something before that”—tamping down transmission prior to wards filling up.
More specific advice could still emerge from the CDC, or individual state health departments. But going forward, the assumption is that “each hospital is supposed to have its own general plan,” Rhee told me. (I reached out to the CDC repeatedly about whether it might update its infection-prevention-guidance webpage for COVID—last retooled in May—but didn’t receive a response.)
Which leaves hospitals with one of two possible paths. They could schedule a start to masking season, based on when they estimate cases might rise—or they could react to data as they come in, tying masking policies to transmission bumps. With SARS-CoV-2 still so unpredictable, many hospitals are opting for the latter. That also means defining a true case rise—“what I think everybody is struggling with right now,” Rhee said. There is no universal definition, still, for what constitutes a surge. And with more immunity layered over the population, fewer infections are resulting in severe disease and death—even, to a limited extent, long COVID—making numbers that might have triggered mitigations just a year or two ago now less urgent catalysts.
Further clouding the forecast is the fact that much of the data that experts once relied on to monitor COVID in the community have faded away. In most parts of the country, COVID cases are no longer regularly tallied; people are either not testing, or testing only at home. Wastewater surveillance and systems that track all influenza-like illnesses could provide some support. But that’s not a whole lot to go on, especially in parts of the country such as Tennessee, where sewage isn’t as closely tracked, Tom Talbot, of Vanderbilt, told me.
Some hospitals have turned instead to in-house stats. At Duke—which has adopted a mitigation policy that’s very similar to UVA’s—Wolfe has mulled pulling the more-masking lever when respiratory viruses account for 2 to 4 percent of emergency and urgent-care visits; at UVA, Sifri has considered taking action once 1 or 2 percent of employees call out sick, with the aim of staunching sickness and preserving staff. “It really doesn’t take much to have an impact on our ability to maintain operations,” Sifri told me. But “I don’t know if those are the right numbers.” Plus, internal metrics are now tricky for the same reasons they’ve gotten shaky elsewhere, says Xiaoyan Song, the chief infection-control officer at Children’s National Hospital, in Washington, D.C. Screening is no longer routine for patients, skewing positivity stats; even sniffly health-care workers, several experts told me, are now less eager to test and report.
For hospitals that have maintained a more masky baseline, scenarios in which universal masking returns are a little easier to envision and enact. At UChicago Medicine, Landon and her colleagues have developed a color-coded system that begins at teal—masking for high-risk patients, patients who request masked care, and anyone with symptoms, plus masking in high-risk areas—and goes through everyone-mask-up-everywhere red; their team plans to meet weekly to assess the situation, based on a variety of community and internal metrics, and march their masking up or down. Wolfe, of Duke, told me that his hospital “wanted to reserve a little bit of extra masking quite intentionally,” so that any shift back toward stricter standards would feel like less of a shock: Habits are hard to break and then reform.
Other hospitals that have been living mostly maskless for months, though, have a longer road back to universal masking, and staff members who might not be game for the trek. Should masks need to return at the Brigham or Dana-Farber, for instance, “I suspect the reaction will be mixed,” Baker told me. “So we really are trying to be judicious.” The hospital might try to preserve some maskless zones in offices and waiting rooms, for instance, or lower-risk rooms. And at Children’s National, which has also largely done away with masks, Song plans to follow the local health department’s lead. “Once D.C. Health requires hospitals to reimplement the universal-masking policy,” she told me, “we will be implementing it too.”
Other mitigations are on the table. Several hospital epidemiologists told me they expected to reimplement some degree of asymptomatic screening for various viruses around the same time they reinstate masks. But measures such as visiting restrictions are a tougher call. Wolfe is reluctant to pull that lever before he absolutely has to: Going through a hospital stay alone is one of the “harder things for patients to endure.”
A bespoke approach to hospital masking isn’t impractical. COVID waves won’t happen synchronously across communities, and so perhaps neither should policies. But hospitals that lack the resources to keep tabs on viral spread will likely be at a disadvantage, and Popescu told me she worries that “we’re going to see significant transmission” in the very institutions least equipped to handle such influx. Even the best-resourced places may hit stumbling blocks: Many are still reeling from three-plus years of crisis and are dealing with nursing shortages and worker burnout.
Coordination hasn’t entirely gone away. In North Carolina, Duke is working with the University of North Carolina at Chapel Hill and North Carolina State University to shift policies in tandem; in Washington State, several regional health-care organizations have pledged to align their masking policies. And the Veterans Health Administration—where masking remains required in high-risk units—has developed a playbook for augmenting mitigations across its many facilities, which together make up the country’s largest integrated health-care system, says Shereef Elnahal, the undersecretary of Veterans Affairs for health. Still, institutions can struggle to move in sync: Attitudes on masking aren’t exactly universal across health-care providers, even within a hospital.
The country’s experience with COVID has made hospitals that much more attuned to the impacts of infectious disease. Before the pandemic began, Talbot said, masking was a rarity in his hospital, even around high-risk patients; many employees would go on shifts sick. “We were pretty complacent about influenza,” he told me. “People could come to work and spread it.” Now hospital workers hold themselves to a stricter standard. At the same time, they have become intimately attuned to the drawbacks of constant masking: Some have complained that masks interfere with communication, especially for patients who are young or hard of hearing, or who have a language barrier. “I do think you lose a little bit of that personal bonding,” Talbot said. And prior to the lifting of universal masking at Vanderbilt, he said, some staff were telling him that one out of 10 times they’d ask a patient or family to mask, the exchange would “get antagonistic.”
When lifting mandates, many of the hospital epidemiologists I spoke with were careful to message to colleagues that the situation was fluid: “We’re suspending universal masking temporarily,” as Landon put it to her colleagues. Still, she admits that she felt uncomfortable returning to a low-mask norm at all. (When she informally polled nearly two dozen other hospital epidemiologists around the country in the spring, most of them told her that they felt the same.) Health-care settings aren’t meant to look like the rest of the world; they are places where precautions are expected to go above and beyond. COVID’s arrival had cemented masks’ ability to stop respiratory spread in close quarters; removing them felt to Landon like pushing those data aside, and putting the onus on patients—particularly those already less likely to advocate for themselves—to account for their own protection.
She can still imagine a United States in which a pandemic-era response solidified, as it has in several other countries, into a peacetime norm: where wearing masks would have remained as routine as donning gloves while drawing blood, a tangible symbol of pandemic lessons learned. Instead, many American hospitals will be entering their fourth COVID winter looking a lot like they did in early 2020—when the virus surprised us, when our defenses were down.
When someone becomes homeless, the instinct is to ask what tragedy befell them. What bad choices did they make with drugs or alcohol? What prevented them from getting a higher-paying job? Why did they have more children than they could afford? Why didn’t they make rent? Identifying personal failures or specific tragedies helps those of us who have homes feel less precarious—if homelessness is about personal failure, it’s easier to dismiss as something that couldn’t happen to us, and harsh treatment is easier to rationalize toward those who experience it.
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But when you zoom out, determining individualized explanations for America’s homelessness crisis gets murky. Sure, individual choices play a role, but why are there so many more homeless people in California than Texas? Why are rates of homelessness so much higher in New York than West Virginia? To explain the interplay between structural and individual causes of homelessness, some who study this issue use the analogy of children playing musical chairs. As the game begins, the first kid to become chairless has a sprained ankle. The next few kids are too anxious to play the game effectively. The next few are smaller than the big kids. At the end, a fast, large, confident child sits grinning in the last available seat.
You can say that disability or lack of physical strength caused the individual kids to end up chairless. But in this scenario, chairlessness itself is an inevitability: The only reason anyone is without a chair is because there aren’t enough of them.
Now let’s apply the analogy to homelessness. Yes, examining who specifically becomes homeless can tell important stories of individual vulnerability created by disability or poverty, domestic violence or divorce. Yet when we have a dire shortage of affordable housing, it’s all but guaranteed that a certain number of people will become homeless. In musical chairs, enforced scarcity is self-evident. In real life, housing scarcity is more difficult to observe—but it’s the underlying cause of homelessness.
In their book, Homelessness Is a Housing Problem, the University of Washington professor Gregg Colburn and the data scientist Clayton Page Aldern demonstrate that “the homelessness crisis in coastal cities cannot be explained by disproportionate levels of drug use, mental illness, or poverty.” Rather, the most relevant factors in the homelessness crisis are rent prices and vacancy rates.
Colburn and Aldern note that some urban areas with very high rates of poverty (Detroit, Miami-Dade County, Philadelphia) have among the lowest homelessness rates in the country, and some places with relatively low poverty rates (Santa Clara County, San Francisco, Boston) have relatively high rates of homelessness. The same pattern holds for unemployment rates: “Homelessness is abundant,” the authors write, “only in areas with robust labor markets and low rates of unemployment—booming coastal cities.”
Why is this so? Because these “superstar cities,” as economists call them, draw an abundance of knowledge workers. These highly paid workers require various services, which in turn create demand for an array of additional workers, including taxi drivers, lawyers and paralegals, doctors and nurses, and day-care staffers. These workers fuel an economic-growth machine—and they all need homes to live in. In a well-functioning market, rising demand for something just means that suppliers will make more of it. But housing markets have been broken by a policy agenda that seeks to reap the gains of a thriving regional economy while failing to build the infrastructure—housing—necessary to support the people who make that economy go. The results of these policies are rising housing prices and rents, and skyrocketing homelessness.
It’s not surprising that people wrongly believe the fundamental causes of the homelessness crisis are mental-health problems and drug addiction. Our most memorable encounters with homeless people tend to be with those for whom mental-health issues or drug abuse are evident; you may not notice the family crashing in a motel, but you will remember someone experiencing a mental-health crisis on the subway.
I want to be precise here. It is true that many people who become homeless are mentally ill. It is also true that becoming homeless exposes people to a range of traumatic experiences, which can create new problems that housing alone may not be able to solve. But the claim that drug abuse and mental illness are the fundamental causes of homelessness falls apart upon investigation. If mental-health issues or drug abuse were major drivers of homelessness, then places with higher rates of these problems would see higher rates of homelessness. They don’t. Utah, Alabama, Colorado, Kentucky, West Virginia, Vermont, Delaware, and Wisconsin have some of the highest rates of mental illness in the country, but relatively modest homelessness levels. What prevents at-risk people in these states from falling into homelessness at high rates is simple: They have more affordable-housing options.
With similar reasoning, we can reject the idea that climate explains varying rates of homelessness. If warm weather attracted homeless people in large numbers, Seattle; Portland, Oregon; New York City; and Boston would not have such high rates of homelessness and cities in southern states like Florida, Georgia, Alabama, and Mississippi such low ones. (There is a connection between unsheltered homelessness and temperature, but it’s not clear which way the causal arrow goes: The East Coast and the Midwest have a lot more shelter capacity than the West Coast, which keeps homeless people more out of view.)
America has had populations of mentally ill, drug-addicted, poor, and unemployed people for the whole of its history, and Los Angeles has always been warmer than Duluth—and yet the homelessness crisis we see in American cities today dates only to the 1980s. What changed that caused homelessness to explode then? Again, it’s simple: lack of housing. The places people needed to move for good jobs stopped building the housing necessary to accommodate economic growth.
Homelessness is best understood as a “flow” problem, not a “stock” problem. Not that many Americans are chronically homeless—the problem, rather, is the millions of people who are precariously situated on the cliff of financial stability, people for whom a divorce, a lost job, a fight with a roommate, or a medical event can result in homelessness. According to the Los Angeles Homeless Services Authority, roughly 207 people get rehoused daily across the county—but 227 get pushed into homelessness. The crisis is driven by a constant flow of people losing their housing.
The homelessness crisis is most acute in places with very low vacancy rates, and where even “low income” housing is still very expensive. A study led by an economist at Zillow shows that when a growing number of people are forced to spend 30 percent or more of their income on rent, homelessness spikes.
Academics who study homelessness know this. So do policy wonks and advocacy groups. So do many elected officials. And polling shows that the general public recognizes that housing affordability plays a role in homelessness. Yet politicians and policy makers have generally failed to address the root cause of the crisis.
Few Republican-dominated states have had to deal with severe homelessness crises, mainly because superstar cities are concentrated in Democratic states. Some blame profligate welfare programs for blue-city homelessness, claiming that people are moving from other states to take advantage of coastal largesse. But the available evidence points in the opposite direction—in 2022, just 17 percent of homeless people reported that they’d lived in San Francisco for less than one year, according to city officials. Gregg Colburn and Clayton Aldern found essentially no relationship between places with more generous welfare programs and rates of homelessness. And abundantotherresearch indicates that social-welfare programs reduce homelessness. Consider, too, that some people move to superstar cities in search of gainful employment and then find themselves unable to keep up with the cost of living—not a phenomenon that can be blamed on welfare policies.
But liberalism is largely to blame for the homelessness crisis: A contradiction at the core of liberal ideology has precluded Democratic politicians, who run most of the cities where homelessness is most acute, from addressing the issue. Liberals have stated preferences that housing should be affordable, particularly for marginalized groups that have historically been shunted to the peripheries of the housing market. But local politicians seeking to protect the interests of incumbent homeowners spawned a web of regulations, laws, and norms that has made blocking the development of new housing pitifully simple.
This contradiction drives the ever more visible crisis. As the historian Jacob Anbinder has explained, in the ’70s and ’80s conservationists, architectural preservationists, homeowner groups, and left-wing organizations formed a loose coalition in opposition to development. Throughout this period, Anbinder writes, “the implementation of height limits, density restrictions, design review boards, mandatory community input, and other veto points in the development process” made it much harder to build housing. This coalition—whose central purpose is opposition to neighborhood change and the protection of home values—now dominates politics in high-growth areas across the country, and has made it easy for even small groups of objectors to prevent housing from being built. The result? The U.S. is now millions of homes short of what its population needs.
Los Angeles perfectly demonstrates the competing impulses within the left. In 2016, voters approved a $1.2 billion bond measure to subsidize the development of housing for homeless and at-risk residents over a span of 10 years. But during the first five years, roughly 10 percent of the housing units the program was meant to create were actually produced. In addition to financing problems, the biggest roadblock was small groups of objectors who didn’t want affordable housing in their communities.
Los Angeles isn’t alone. The Bay Area is notorious in this regard. In the spring of 2020, the billionaire venture capitalist Marc Andreessen published an essay, “It’s Time to Build,” that excoriated policy makers’ deference to “the old, the entrenched.” Yet it turned out that Andreessen and his wife had vigorously opposed the building of a small number of multifamily units in the wealthy Bay Area town of Atherton, where they live.
The small-c conservative belief that people who already live in a community should have veto power over changes to it has wormed its way into liberal ideology. This pervasive localism is the key to understanding why officials who seem genuinely shaken by the homelessness crisis too rarely take serious action to address it.
The worst harms of the homelessness crisis fall on the people who find themselves without housing. But it’s not their suffering that risks becoming a major political problem for liberal politicians in blue areas: If you trawl through Facebook comments, Nextdoor posts, and tweets, or just talk with people who live in cities with large unsheltered populations, you see that homelessness tends to be viewed as a problem of disorder, of public safety, of quality of life. And voters are losing patience with their Democratic elected officials over it.
In a 2021 poll conducted in Los Angeles County, 94 percent of respondents said homelessness was a serious or very serious problem. (To put that near unanimity into perspective, just 75 percent said the same about traffic congestion—in Los Angeles!) When asked to rate, on a scale of 1 to 10, how unsafe “having homeless individuals in your neighborhood makes you feel,” 37 percent of people responded with a rating of 8 or higher, and another 19 percent gave a rating of 6 or 7. In Seattle, 71 percent of respondents to a recent poll said they wouldn’t feel safe visiting downtown Seattle at night, and 91 percent said that downtown won’t recover until homelessness and public safety are addressed. There are a lot of polls like this.
As the situation has deteriorated, particularly in areas where homelessness overruns public parks or public transit, policy makers’ failure to respond to the crisis has transformed what could have been an opportunity for reducing homelessness into yet another cycle of support for criminalizing it. In Austin, Texas, 57 percent of voters backed reinstating criminal penalties for homeless encampments; in the District of Columbia, 75 percent of respondents to a Washington Post poll said they supported shutting down “homeless tent encampments” even without firm assurances that those displaced would have somewhere to go. Poll data from Portland, Seattle, and Los Angeles, among other places, reveal similarly punitive sentiments.
This voter exasperation spells trouble for politicians who take reducing homelessness seriously. Voters will tolerate disorder for only so long before they become amenable to reactionary candidates and measures, even in very progressive areas. In places with large unsheltered populations, numerous candidates have materialized to run against mainstream Democrats on platforms of solving the homelessness crisis and restoring public order.
By and large, the candidates challenging the failed Democratic governance of high-homelessness regions are not proposing policies that would substantially increase the production of affordable housing or provide rental assistance to those at the bottom end of the market. Instead, these candidates—both Republicans and law-and-order-focused Democrats—are concentrating on draconian treatment of people experiencing homelessness. Even in Oakland, California, a famously progressive city, one of the 2022 candidates for mayor premised his campaign entirely on eradicating homeless encampments and returning order to the streets—and managed to finish third in a large field.
During the 2022 Los Angeles mayoral race, neither the traditional Democratic candidate, Karen Bass, who won, nor her opponent, Rick Caruso, were willing to challenge the antidemocratic processes that have allowed small groups of people to block desperately needed housing. Caruso campaigned in part on empowering homeowners and honoring “their preferences more fully,” as Ezra Klein put it in The New York Times—which, if I can translate, means allowing residents to block new housing more easily. (After her victory, Bass nodded at the need to house more people in wealthier neighborhoods—a tepid commitment that reveals NIMBYism’s continuing hold on liberal politicians.)
“We’ve been digging ourselves into this situation for 40 years, and it’s likely going to take us 40 years to get out,” Eric Tars, the legal director at the National Homelessness Law Center, told me.
Building the amount of affordable housing necessary to stanch the daily flow of new people becoming homeless is not the project of a single election cycle, or even several. What can be done in the meantime is a hard question, and one that will require investment in temporary housing. Better models for homeless shelters arose out of necessity during the pandemic. Using hotel space as shelter allowed the unhoused to have their own rooms; this meant families could usually stay together (many shelters are gender-segregated, ban pets, and lack privacy). Houston’s success in combatting homelessness—down 62 percent since 2011—suggests that a focus on moving people into permanent supportive housing provides a road map to success. (Houston is less encumbered by the sorts of regulations that make building housing so difficult elsewhere.)
The political dangers to Democrats in those cities where the homelessness crisis is metastasizing into public disorder are clear. But Democratic inaction risks sparking a broader political revolt—especially as housing prices leave even many middle- and upper-middle-class renters outside the hallowed gates of homeownership. We should harbor no illusions that such a revolt will lead to humane policy change.
Simply making homelessness less visible has come to be what constitutes “success.” New York City consistently has the nation’s highest homelessness rate, but it’s not as much of an Election Day issue as it is on the West Coast. That’s because its displaced population is largely hidden in shelters. Yet since 2012, the number of households in shelters has grown by more than 30 percent—despite the city spending roughly $3 billion a year (as of 2021) trying to combat the problem. This is what policy failure looks like. At some point, someone’s going to have to own it.
This article appears in the January/February 2023 print edition with the headline “The Looming Revolt Over Homelessness.” When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.
Way back in the early, whirlwind days of the pandemic, surfaces were the thing to worry about. The prevailing scientific wisdom was that the coronavirus spread mainly via large droplets, which fell onto surfaces, which we then touched with our hands, with which we then touched our faces. (Masks, back then, were said by public health authorities to be unnecessary for the general public.) So we washed our hands until they were raw. We contorted ourselves to avoid touching doorknobs. We went through industrial quantities of hand sanitizer, and pressed elevator buttons with keys and pens, and disinfected our groceries and takeout orders and mail.
And then we learned we’d had it all backwards. The virus didn’t spread much via surfaces; it spread through the air. We came to understand the danger of indoor spaces, the importance of ventilation, and the difference between a cloth mask and an N95. Meanwhile, we mostly stopped talking about hand-washing. The days when you could hear people humming “Happy Birthday” in public restrooms quickly disappeared. And wiping down packages and ostentatious workplace-disinfection protocols became a matter of lingering hygiene theater.
This whole episode was among the stranger and more disorienting shifts of the pandemic. Sanitization, that great bastion of public health, saved lives; actually, no, it didn’t matter that much for COVID. On one level, this about-face should be seen as a marker of good scientific progress, but it also raises a question about the sorts of acts we briefly thought were our best available defense against the virus. If hand-washing isn’t as important as we thought it was in March 2020, how important is it?
Any public-health expert will be quick to tell you that, please, yes, you should still wash your hands. Emanuel Goldman, a microbiologist at Rutgers New Jersey Medical School, considers it “commonsense hygiene” for protecting us against a range of viruses spread through close contact and touch, such as gastrointestinal viruses. Also, let’s be honest: It’s gross to use the bathroom and then refuse to wash, whether or not you’re going to give someone COVID.
Even so, the pandemic has piled on evidence that the transmission of the coronavirus via fomites—that is, inanimate contaminated objects or surfaces—plays a much smaller role, and airborne transmission a much larger one, than we once thought. And the same likely goes for other respiratory pathogens, such as influenza and the coronaviruses that cause the common cold, Linsey Marr, an environmental engineer and aerosols expert at Virginia Tech, told me.
This realization is not an entirely new one: A 1987 study by researchers at the University of Wisconsin found that a group of men playing poker with “soggy,” rhinovirus-contaminated cards were not infected, while a group playing with other sick players were. Now Goldman intends to push this point even further. At a conference in December, he is going to present a paper arguing that, with rare exceptions, such as RSV, all respiratory pathogens are transmitted predominantly through the air. The reason we’ve long thought otherwise, he told me, is that our understanding has been founded on faulty assumptions. Generally speaking, the studies pointing toward fomite-centric theories of transmission were virus-survival studies, which measure how long a virus can survive on a surface. Many of them either used unrealistically large amounts of virus or measured only the presence of the virus’s genetic material, not whether it remained infectious. “The design” of these experiments, he said, “was not appropriate for being able to extrapolate to real-life conditions.”
The upshot, for Goldman, is that surface transmission of respiratory pathogens is “negligible,” probably accounting for less than .01 percent of all infections. If correct, this would mean that your chance of catching the flu or a cold by touching something in the course of daily life is virtually nonexistent. Goldman acknowledged that there’s a “spectrum of opinion” on the matter. Marr, for one, would not go quite so far: She’s confident that more than half of respiratory-pathogen transmission is airborne, though she said she wouldn’t be surprised if the proportion is much, much higher—the only number she would rule out is 100 percent.
For now, it’s important to avoid binary thinking on the matter, Saskia Popescu, an epidemiologist at George Mason University, told me. Fomites, airborne droplets, smaller aerosol particles—all modes of transmission are possible. And the proportional breakdown will not be the same in every setting, Seema Lakdawa, a flu-transmission expert at Emory University, told me. Fomite transmission might be negligible at a grocery store, but that doesn’t mean it’s negligible at a day care, where kids are constantly touching things and sneezing on things and sticking things in their mouths. The corollary to this idea is that certain infection-prevention strategies prove highly effective in one context but not in another: Frequently disinfecting a table in a preschool classroom might make a lot of sense; frequently disinfecting the desk in your own private cubicle, less so.
Much of the conspicuous cleaning we did early in the pandemic was excessive, Popescu said, but she worries that we may have slightly overcorrected, lumping some useful behaviors—targeted disinfection, even hand-washing in some cases—into the category of hygiene theater. Whatever the setting, the experts I spoke with all agreed that these behaviors remain important for contending with non-respiratory pathogens. Recently, when several members of Marr’s family came down with norovirus, an extremely unpleasant stomach bug that causes vomiting, diarrhea, and stomach cramping, she disinfected a number of high-touch surfaces around the house. Picture that: one of the country’s foremost experts on airborne transmission wiping down doorknobs and light switches.
Marr isn’t convinced we’ve overcorrected. Hand sanitizer still abounds, businesses still tout their surface-cleaning protocols, and air quality still gets comparatively little attention. Recently, she watched a person use their shirt to open the door of a visitor center without touching the handle … then proceed inside unmasked. There’s nothing wrong with taking certain precautions to prevent fomite transmission, she said—these should not all be dismissed en masse as hygiene theater—as long as they don’t come at the expense of efforts to block airborne transmission. “If you’re doing extra hand washing … then you should also be wearing a good mask in crowded indoor environments,” Marr said. “If you’re bothering to clean the surfaces, then you should be bothering to clean the air.”
On Friday, with respiratory-virus season looming, CDC Director Rochelle Walensky tweeted out three pieces of advice for staying healthy: “Get an updated COVID-19 vaccine & get your annual flu vaccine,” “Stay home if you are sick,” and—not to be forgotten—“Practice good hand hygiene.” She made no mention of masks or ventilation.
