In this empirical study of an evidence-based intervention with aggressive and violent adolescent males, I show how the state repeatedly fails Native American youth, their families and their communities. Using grounded theory methods with a critical realist lens, I demonstrate how the provision of substandard care to the poor—what I call, slumcare—was enabled, justified and allowed to continue. In particular, I reveal how slumcare is the result of the state’s repeated failure to achieve its mandate of balancing quality care with other priorities. In this account of how poor quality care persists, I show how a form of governing I call the fail-state enables slumcare to emerge and linger. In addition, this study demonstrates that practitioners of evidence-based ‘conformist’ interventions can be a surprising resource for discovering ‘transformative’ solutions.