Another Health Industry Initiative to House the Homeless

It is mind-boggling how backwards American policies are. As we chronicled, some hospitals and insurer are waking up to the fact that giving housing to the chronically ill homeless is cheaper than having them make heavy use of emergency rooms, who if they take Federal funds, are require to accept all comers.

Mind you, this is hardly a new observation. Malcolm Gladwell outlined the problem in a 2006 New Yorker article, Million Dollar Murray:

[Reno bicycle cop Patrick] O’Bryan and [his partner Steve] Johns called someone they knew at an ambulance service and then contacted the local hospitals. “We came up with three names that were some of our chronic inebriates in the downtown area, that got arrested the most often,” O’Bryan said. “We tracked those three individuals through justone of our two hospitals. One of the guys had been in jail previously, so he’d only been on the streets for six months. In those six months, he had accumulated a bill of a hundred thousand dollars—and that’s at the smaller of the two hospitals near downtown Reno. It’s pretty reasonable to assume that the other hospital had an even larger bill. Another individual came from Portland and had been in Reno for three months. In those three months, he had accumulated a bill for sixty-five thousand dollars. The third individual actually had some periods of being sober, and had accumulated a bill of fifty thousand.” The first of those people was Murray Barr, and Johns and O’Bryan realized that if you totted up all his hospital bills for the ten years that he had been on the streets—as well as substance-abuse-treatment costs, doctors’ fees, and other expenses—Murray Barr probably ran up a medical bill as large as anyone in the state of Nevada.

“It cost us one million dollars not to do something about Murray,” O’Bryan said….

In the nineteen-eighties, when homelessness first surfaced as a national issue, the assumption was that the problem fit a normal distribution: that the vast majority of the homeless were in the same state of semi-permanent distress. It was an assumption that bred despair: if there were so many homeless, with so many problems, what could be done to help them? Then, fifteen years ago, a young Boston College graduate student named Dennis Culhane lived in a shelter in Philadelphia for seven weeks as part of the research for his dissertation. A few months later he went back, and was surprised to discover that he couldn’t find any of the people he had recently spent so much time with. “It made me realize that most of these people were getting on with their own lives,” he said. Culhane then put together a database—the first of its kind—to track who was coming in and out of the shelter system. What he discovered profoundly changed the way homelessness is understood. Homelessness doesn’t have a normal distribution, it turned out. It has a power-law distribution. “We found that eighty per cent of the homeless were in and out really quickly,” he said. “In Philadelphia, the most common length of time that someone is homeless is one day. And the second most common length is two days. And they never come back. Anyone who ever has to stay in a shelter involuntarily knows that all you think about is how to make sure you never come back.”

The next ten per cent were what Culhane calls episodic users. They would come for three weeks at a time, and return periodically, particularly in the winter. They were quite young, and they were often heavy drug users. It was the last ten per cent—the group at the farthest edge of the curve—that interested Culhane the most. They were the chronically homeless, who lived in the shelters, sometimes for years at a time. They were older. Many were mentally ill or physically disabled, and when we think about homelessness as a social problem—the people sleeping on the sidewalk, aggressively panhandling, lying drunk in doorways, huddled on subway grates and under bridges—it’s this group that we have in mind. In the early nineteen-nineties, Culhane’s database suggested that New York City had a quarter of a million people who were homeless at some point in the previous half decade —which was a surprisingly high number. But only about twenty-five hundred were chronically homeless.

It turns out, furthermore, that this group costs the health-care and social-services systems far more thananyone had ever anticipated. Culhane estimates that in New York at least sixty-two milliondollars was being spent annually to shelter just those twenty-five hundred hard-core homeless. “It costs twenty-four thousand dollars a year for one of these shelter beds,” Culhane said. “We’re talking about a cot eighteen inches away from the next cot.”

Gladwell then proceeds to describe programs underway in places like Denver, to get the chronically homeless off the street, to stabilize them. Even with giving them housing and caseworkers, the cost was one-third of having them on the street. Some might be able to work, which would further lower program costs.

My impression is these municipality-based programs never got very far, despite the obvious economic benefits, and Gladwell anticipated why:

That is what is so perplexing about power-law homeless policy. From an economic perspective the approach makes perfect sense. But from a moral perspective it doesn’t seem fair. Thousands of peoplein the Denver area no doubt live day to day, work two or three jobs, and are eminently deserving of ahelping hand—and no one offers them the key to a new apartment. Yet that’s just what the guy screaming obscenities and swigging Dr. Tich gets. When the welfare mom’s time on public assistance runs out, we cut her off. Yet when the homeless man trashes his apartment we give him another. Social benefits are supposed to have some kind of moral justification. We give them to widows and disabled veterans and poor mothers with small children. Giving the homeless guy passed out on the sidewalk an apartment has a different rationale. It’s simply about efficiency.

And there’s an additional layer of arbitrariness: who gets helped. There are far more people eligible for programs like these than the Denvers of the world were prepared to support.

So fast forward to the latest incarnation of housing the homeless to reduce medical costs. Instead of being driven by cities, health providers are launching some programs. For the most part, they are far more explicit that the goal is to save money and they accordingly expect the time they will house someone to be shorter. For instance, we reposted a Kaiser Health News story on how Denver Health was building “transition housing” for patients it could not legally discharge because “they have no safe place to go.” Denver Health is building a small number of units for them. Here’s the math:

It costs Denver Health $2,700 a night to keep someone in the hospital. Patients who are prime candidates for the transitional units stay on average 73 days, for a total cost to the hospital of nearly $200,000. The hospital estimates it would cost a fraction of that, about $10,000, to house a patient for a year instead.

Bloomberg tonight has an in-depth treatment of insurer UnitedHealth’s housing experiments. UnitedHealth gets nearly 20% of its revenue from acting as an outsourced Medicaid provided, at rates of $500 to $1000 per head, covering 6 million participants. But the most expensive ones, like Murray, are the ones on the street.

UnitedHealth wooed Jeffrey Brenner, a doctor who has spent most of his career working with the poor, and a recent recipient of a MacArthur fellowship for his efforts. From Bloomberg:

[In Phoenix] Brenner is using UnitedHealth’s money to pay for housing and support services for roughly 60 formerly homeless recipients of Medicaid, the safety-net insurance program for low-income people….

Brenner shows me data on a patient named Steve, a 54-year-old with multiple sclerosis, cerebral palsy, heart disease, and diabetes. He was homeless before UnitedHealth got him into an apartment. In the 12 months prior to moving in, Steve went to the ER 81 times, spent 17 days hospitalized, and had medical costs, on average, of $12,945 per month. In the nine months since he got a roof over his head and health coaching from Brenner’s team, Steve’s average monthly medical expenses have dropped more than 80%, to $2,073.

After testing the idea in Phoenix, Milwaukee, and Las Vegas, UnitedHealth is expanding Brenner’s housing program, called MyConnections, to 30 markets by early 2020…

Brenner aims to reduce expenses not by denying care, but by spending more on social interventions, starting with housing. How to do it is still largely uncharted. “I don’t think we’ve figured any of this out,” he says. “We’re at a hopeful moment of recognizing how deep the problem is.” A trip to any big-city ER reveals the magnitude of the challenge.

I strongly urge you to read this article in full. It contains a lot of insightful detail about how emergency rooms deal with the homeless and chronically ill, and how the housing/social service programs operate. And it keeps returning to the grim point that it pays in economic terms only to help the most messed up:

On average about 60 members are enrolled in the Phoenix sites at any given time. Once a week, Brenner and his team get on the phone to evaluate potential candidates—anywhere from 2 to 14 people whose names have surfaced in UnitedHealth’s data. They want patients who are homeless and whose medical spending exceeds $50,000 annually, with most of that coming from ER visits and inpatient stays. People living on the streets with less extreme medical costs may need a home just as much, but it doesn’t pay for UnitedHealth to give them one.

This is yet another indicator of social breakdown, that the intermediate formal and informal social safety nets have broken down to such a degree that the many people who need less help and are better candidates for getting their lives back on track won’t also get the assistance they need.

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  1. diptherio

    So, if you’re homeless and you live in Phoenix, the thing to do is to start spending as much time as possible in the ER, so as to get your medical bills above $50K per annum…

  2. Brooklin Bridge

    A very interesting article. The recidivism rate and size of different groups of homeless, not to mention the cost differential of emergency care vs. shelter provision for the smallest but most persistent group is surprising and I imagine if properly measured (using more than cost efficiency as a metric), it would apply to those who need less help as well. And that touches the heart of the article, our broken social ethos.

    The last paragraph deserved being expanded upon. It’s so close to that nub of what this site has been revealing again and again about the Almighty Market and the poisonous metastasis of neo-liberalism and how our worser selves (as seen in our political representatives – such as Regan) kept nudging us ever on to a broken devil take the hindmost society. Partly similar to an evolutionary process in which we seem to stumble upon fictions that brilliantly get swallowed as truisms and that are remarkably effective – if haphazard- in fostering an ideological framework for generations of hatred and loathing and partly the frighteningly effective work of very focused organized people such as Powell and his Powell Memo.

    Anyway, with apologies for being monsieur critic, the last paragraph seemed a bit rushed.

  3. Wukchumni

    One of the financial slide effects of Fentanyl for cities/counties is somebody else supplying the rope for indigents et al to hang themselves with, cutting them off at the past.

    I’m noticing mounting umbrage in regards to the homeless in Visalia (pop 136k) as it seems more akin to a whack a mole game, in counter measures by retailers who have clearly had enough.

    Like most cities confronting the issue, they have no answers, heck they can’t even get a task force together, ha!

    At its May 7 meeting, the City Council debated the idea of forming its own task force on homelessness to augment the work being done at the county level. The council stopped short of forming its own task force but did agree to have a study session on homelessness in July. Councilmember Greg Collins asked that the issue be placed on a future agenda item, sooner rather than later.

      1. kareninca

        If that church hadn’t stepped up, some of those people would have frozen.

        What a depressing situation.

        “One of those things was providing money for a warming center over the winter months. Earlier at the May 7 meeting, Rev. Suzy Ward gave the council a recap of the winter warming center that she coordinated at St. Paul’s Episcopal Church, located at 120 N. Hall St. in Visalia.

        The warming center opened the day after Christmas and ran every night through the end of February. Ward said Feb. 11 was the busiest night with more than 125 people crowding into the temporary shelter. She said one of the reasons that people preferred the warming center over other overnight shelters in town was because they did not split up couples, children and parents, or pets from pet owners. One man came in with a pet rabbit he carried in a small cage.

        “Rarely did we have animal barking in the night,” Ward said. “We had more noise from snoring than anything else.”

        “You saw a need in our community and you stepped up to fill that need,” said City Councilmember Brian Poochigian. “This was needed in our city.”

        Sharon Seltzer, who lives near St. Paul’s on Main Street, asked if having security guards made a huge difference. Ward responded that most disputes were handled by her staff and only three people in 65 nights had to be thrown out of the shelter.”

  4. divadab

    This is irksome, and it really gets my inner Republican going. Why should responsible people, who maintain themselves and their health, as well as their health insurance, pay for massively expensive healthcare for shiftless irresponsible addicts? Not only that, all the costs of dealing with these people are offloaded onto the taxpaying middle class.

    I don’t have a solution – maybe some kind of housing facility but the problem is that people have agency and you cannot force them into housing or force them to quit drugs/alcohol unless you put them in jail for a crime. And jail is pretty much the most expensive form of housing for the homeless you can imagine. Unless you start to enforce laws against vagrancy and public drunkenness, and put drunk vagrants into supervised housing through force of law, this really stupid waste of public funds will continue.

    Admittedly my view is not exactly compassionate but I’m really fed up with the sketchy homeless people floating through my town, making a mess wherever they go and basically unable to observe any kind of social hygiene. This hospital thing makes the situation worse and more expensive and calls for stronger measures. Isn’t it more compassionate to take homeless addicted vagrants off the street into a facility than to let them continue to sicken and die on the street? Not to mention abuse the local emergency room service?

        1. Other JL

          The thing is, we’re already paying for it via vastly over-inflated hospital and medical insurance bills. Programs like this simply cost less.

          People really are just crabs in a bucket. What if, instead of focusing on why we’re only giving housing to some “undeserving”, we ask “why not make sure everyone can be housed?”

        2. Anarcissie

          Obviously, if you have a competitive social order, to wit, liberal capitalism, then you’re going to have losers, that is, the poor. This has been recognized before. ‘The poor you will have always with you.’ ‘From them that have not shall be taken away even that which they have.’ So if you want to change the situation, you will have to step out of liberal capitalism — a difficult proposition in this time and place.

    1. dcblogger

      because the humanitarian solutions cost less than the punitive ones. There is a vacant housing unit for every homeless person in the United States, our economic system is dysfunctional.

      single payer healthcare would end medical bankruptcy and the homeless that often comes with it. A job guarantee would cut down on homelessness, although since 44% of the homeless have jobs, clearly they don’t need a job guarantee. Raising the minimum wage to $20 would cut down on homelessness. Canceling student debt would end the homelessness of people who are homeless because they spent their $ on their loan repayment instead of housing.

      We don’t have to live this way and victim blaming will not make things better.

      1. divadab

        “victim blaming” – thanks for the signaling your virtue at my expense. I’m looking for practical solutions so I don;t have to worry about someone leaving used needles in the park in my neighborhood where kids from the local preschool play. The larger issues you mention are beyond my influence but patroling the park is somewhere I can make a direct difference in social hygiene. Sure maybe you are right and the poor homeless drug addict shitting in my park is a victim but he;s not a victim of me I’m rather a victim of his anti-social behavior. And I will move him on one way or another but mostly by “lending” him $10 and telling him I’m in the park every day so he can pay me next time he comes to the park. Works like a charm.

    2. jrs

      It’s basically being spent in healthcare premiums anyway, this is probably heavily tax dollars (if it’s Medicaid, ACA subsidized etc. probably mostly Medicaid not so much ACA) but regardless it’s spent in premiums. Believe me this is a real phenomena. I have no idea if it’s because these people are chronically sick or they are just using hospitals as *shelter*, maybe a bit of both. Nor how much of this cost is passed on to healthcare consumers other than the government.

      I do think the whole turning over the entire city to the homeless thing can go too far. When all public parks become unusable because of homeless .. Note some cities crack down on the homeless in parks, and you can still find non-homeless people enjoying public parks, others have turned them over near entirely to the homeless. At a certain point: are OUR public amenities for ALL OF US, or only makeshift areas for the destitute homeless population? But yes housing is needed of course!

    3. JEHR

      divadab, a little kindness and empathy go a long way to making life more livable. You obviously don’t have a solution. What if everyone acted and thought like you do: living would be unbearable. Just try a little kindness the next time you see someone who is not as well off as you are. It will be reward enough without worrying about sharing your pitiful taxpayers’ dollars with others.

      1. divadab

        Another virtue signaller at my expense. Why should I have compassion for the drug addict leaving used needles in the park and shitting behind the bushes?

        FYI I am presently providing housing for a homeless person on my property so you can sniffy away down your nose at someone else’s expense – what do you do for unfortunates? I’ll bet not much.

    4. Krystyn Walentka

      Maybe I can help you quash your inner Republican (and Democrat)…

      I am on medicare for a permanent disability. I do not do any drugs and barely drink alcohol. For the last three years I have been functionally homeless, and was recently forced to live in a van because I could not afford housing. My situation forced me to move away from friends I had for 20 years. All this happened to me yet I receive TWICE as much benefits as the average medicare recipient because I was lucky enough to make over 100k a year before I became disabled.

      It is only because I was lucky to have some spiritual training (and OCD) that I have not succumb to drug addiction in the process. The stress of being homeless comes at you from every direction; economically, socially, spiritually…and experiencing that stress in the only way you can truly have compassion for people who fall into the trap of looking for solace through self-medication. I do not look at the “sketchy, shiftless, irresponsible drug users” as enemies, but rather, fallen brothers and sisters.

      It was not about self responsibility that I have made it this far, it was luck, pure luck.

      But all you see is the drug use, the end result of being ground to pieces under the shifting Overton window. But I get it, being “shifty and irresponsible” is simple, much easier to comprehend, and lets you off the hook at the same time.

      And your assumption that these people do not care about themselves is lacking in data because all you see is their drug addiction. When you get to know these people you will find they care deeply about themselves. Which is why, even when pock marked with sores from shooting up, no teeth, and homeless, most still do not once have the urge to throw themselves off of a bridge. Street drugs are the only thing keeping many of these people alive.

      You do not want the “middle class” to pay more in taxes to help these people? Well, sorry, but it is the same middle-class taxpayer who profits from the system that causes the economic and social suffering that creates homelessness and drug addiction, so why shouldn’t they pay? The middle-class, just like the rich, want to externalize the true costs of their lifestyle. Maybe the benefits you have are smaller than the 1%, but to not see that you gain from a segment of the population being homeless is spiritually ignorant. (Some of my friends who “did not have money” to keep me out of homelessness owned houses worth over 600k.)

      And why should a homeless drug addict respect your thoughts and ideals when you call them “sketchy” without a shred of an attempt at understanding? Why should they care about how they smell or how clean your neighborhood is? Being “sketchy” is probably the only power and agency they have left in a system that takes it all away from them.

      But I think for most people, and probably yourself as well, caring for the homeless and suffering would be a self admission that they are more like you than you think. And that creates the fear there is a chance that you or a loved one could end up being a homeless, sketchy, drug abuser as well. To make them “the other” is to distance yourself from this truth.

      1. smoker

        Thank you so much Krystyn.

        And the stunningly ugly irony is that one repeatedly reads of respect and admiration for those elite and political class who beat their full blown addictions, which weren’t even caused by living on the cement, yet somehow – unlike the ‘nobody’ class who have no access to showers and toilets via wealthy friends and family, and can never escape that deplorable branding once it’s branded on them – miraculously! on their own! through profound willpower and hard work! via a network of incredibly powerful and ‘fabulously wealthy’ elite family and associates, surmount all odds and usually attain fabulous wealth!

        I am totally outraged and horrified by the fact that, increasingly, those apparently not worried about unwarranted homelessness happening to them – are stunningly cruel with their words. Many of those persons, would not even be able to get the profession, or roof over their head they have now, in the current environment – outside of: very well placed family and other connections; and agreeing to look the other way and never whistle blow on the daily inhumanity and corruption they daily witness in their professions.

        The age old wisdom and morality of the once commonly proclaimed walk a mile in another person’s shoes, has been deliberately erased with the advent of a full blown Artificial Intelligence Technocracy.

      2. divadab

        @Krystyn – I have put up several people who were either temporarily or permanently homeless. And stop using me as a straw man to project your opinions on – where did I say I did not want the middle class to pay more in taxes to help these people? In your fantasy of what a bad person I am.

        WHat sane person wants their neighborhood to be more sketchy, anyway? And wanting a safe neighborhood is somehow a bad thing, a judgement on the poor homeless in your mind? I don;t care if a homeless person respects my thoughts or ideals I just don;t want him to shit in the park. And that makes me a bad person to you? What planet do you live on?

        Your situation is tough – I’ve been homeless and I don;t want to be homeless ever again. Yes we need to provide housing for the homeless and sometimes that will mean the bad actors need to be put there involuntarily, IMHO. Dang you speak up honestly and everyone projects their “you’re a bad person and I’m a good person in contrast” rap on you – what have you-all ever done to help a homeless person? I’ve done plenty as if you care.

        1. Krystyn Walentka

          I never said you were a bad person and I do not think you are. My opinion is that your view is myopic and you express the conflict you are having with your larger intuition when you say things like (emphasis mine):

          Why should responsible people, who maintain themselves and their health, as well as their health insurance, pay for massively expensive healthcare for shiftless irresponsible addicts? Not only that, all the costs of dealing with these people are offloaded onto the taxpaying middle class.

          followed by

          Admittedly my view is not exactly compassionate

          If a homeless person shits in a park it does not make him or you a bad person. It just means they do not have easy access to a bathroom. You seem to want to over complicate it with all the morality.

          I am not focusing on fixing the problem in the current framework, which is what you are doing by providing housing on your private property to someone who is homeless. (i mean don’t you see right there that if you did not own that section of yard that person would not be homeless?) I am not saying offering housing is bad, only that we need to think more deeply about the problem to dismantle the Overton window instead of just shifting it back to the left a little. So I am saying your thoughts are superficial and they will not lead to fixing anything, only shifting the problem. Having compassion within a capitalist structure will always mean you lose, that is the source of your conflict, not the homeless person.

          As long as you continue to call people addicted to drugs “bad actors” or express that you are “a victim of his anti-social behavior” I do not know what else to say. I have never heard of an addict getting better by calling them a bad person. And I have rarely met a victim who treated their attacker with kindness.

          1. divadab

            Sorry if a homeless person shits in the park when just around the corner there is a public restroom it means what to you? That it’s somehow my fault for owning private property? You seem to assign no responsibility for anything to the homeless drug addict – it’s always someone else’s fault that they are unable to observe the most basic social hygiene.

            1. Krystyn Walentka

              “Sorry if a homeless person shits in the park when just around the corner there is a public restroom it means what to you?”

              I do not make assumptions, I would need to ask them, homeless or not, why they could not make it to the restroom.

              But it is not your fault or theirs. Why the need to find fault? It is just a problem, so get together and fix it. Part of the problem is caused by you owning property, and part is caused by them not owning any. The separation you see between you and the homeless person is an illusion to protect yourself. The same is true for the homeless persons but i would argue they have less choice in the matter.

              There are many disabled people that cannot manage their own hygiene so I do not see how that is relevant. Do you think these people say “You know what? I want to become addicted to opioids and shit in the park.”

              I am not asking you to put up with the problem and do nothing, I am only maybe trying to open a perspective that helps you fix the problem in a more fundamental way so you do not just push it into another community.

      3. Yves Smith Post author

        Thanks for saying this, and I am sorry you have had such a difficult time. I think most people have no idea what happens when you run out of money and assets, or have a stipend that simply won’t cover housing + food + minimal transportation.

        It’s much more around us than we want to admit. Look at Katie Porter going through the budget math for a JPM employee who has cheap rent by CA standards. This is a full time worker who can’t make ends meet. How are people who can’t work or can’t work much through no fault of their own supposed to get by?

        1. Krystyn Walentka

          Yes, and thanks. It is hard to imagine what having little money is like when you have enough or way too much. And the social aspect as well. even spending $3 on a coffee just to be around people becomes a decision you have to make everyday.

    5. Yves Smith Post author

      Not all are addicts. The mental health wards were emptied all over the US, including in the communist state of New York, long ago. In the 1980s, I saw some people on the street who were clearly mentally ill. One distressing spectacle was a middle aged woman who would scream so loudly you could hear her blocks away. She’d then start crying and pound her head with both fists.

    1. divadab

      Well if what you say is true, and I would say rather that mentally ill people have diminished agency rather than none at all, then a solution is at hand – involuntary commitment to a mental health facility. Now if only all the local mental health facilities hadn’t been shut down under reaganomics………the root of many of our current ills: the Reagan/Thatcher destructor brigade, continued by Clinton/Blair and other corrupt entities…

      1. Harold

        Your formulation is much better. Thanks! Involuntary was too harsh and prison like, but as so often, we went way too far in the other direction because it was so much easier — and cheaper – seemingly.

      2. John

        Involuntary committment in horrific conditions inspired the move to open state warehousing institutions in the 1970’s. Reagan and neoliberalism cut off the funding for localized support when these people were returned to their localities. Our society selects for and rewards the worst sociopathic behavior as long as it presents a clean nice pretty face. We treat the weakest and most vulnerable like crap…especially if they can’t get a shower every day.
        We already do involuntary commitment for the mentally ill… the American Gulag prison system. It’s just not completely thorough…yet.

      3. Krystyn Walentka

        Oh my. I have a mental illness and I am on permanent disability and my lack of agency is not determined by my health, it is constrained by the economic system.

        That sort of thinking needs to be ended.

      4. Yves Smith Post author

        You really need to bone up. You can’t involuntarily commit people in NY unless they are a danger to themselves or others. The most you can do is lock them up for 72 hours to observe them. And that standard appears to be not uncommon:

        Commitment of people with mental illness is usually avoided unless the person is “dangerous”….

        Dangerousness is a hard standard to meet

        The mental health bar continually argues that someone must be ‘imminently’ and/or ‘provably’ dangerous before the state can exercise its powers and remove the person’s freedom. For example, the Civil Liberties Union once brought in an expert witness to testify that just because a homeless mentally ill psychotic woman was eating feces, that it would not kill her and therefore she was not in imminent danger of being a danger to herself. Others may argue that an individual should only have to exhibit a condition which will predictably lead to dangerousness before they can be confined

        And per my comment above, the overwhelming trend has been NOT to keep people in psych wards at state expense. They’ve been dumped on the streets on a widespread basis.

        1. Krystyn Walentka

          Yves, I wish to correct you on this notion because I was involuntarily committed in NC which has the same rules. All it took for me was mentioning that I had suicidal ideations to an ER Psych doctor (I was not even suicidal!) for them to commit me. There was no evidence nor threat of me hurting myself or others. I was kept against my will and against the wishes of my psychiatrist in a private mental health facility for 10 days. Why 10 days? Because I had Medicare and that is how long they would pay. There were others without insurance who were actively saying they wanted to kill themselves who were released after 3 days because they had no insurance. If you have the time take a look at the reviews for the hospital I was in. It was a neoliberal torture chamber that gave me PTSD. And look at these reviews from people who worked there.

          There was a woman I met in the hospital who was committed after her drug addicted daughter called the cops on her saying that she was mentally disturbed and she had zero history of mental illness. I sat with that 69 year old woman everyday to help her through the experience.

          To say it is hard to be involuntarily committed is a vast understatement. And involuntary commitment does not mean long term institutionalization anymore. It is just a way to make sure people do not hurt themselves of others in the short term.

          1. Yves Smith Post author

            I’m sorry you had such an awful experience. However, I hate to tell you, but the plural of anecdote is not data. It is not unreasonable for a mental health professional to be concerned that “suicidal ideation” = suicidal tendencies in a patient new to them and therefore require further assessment, particularly in an ER setting where they don’t have access to records. They could easily regard it as a lawsuit waiting to happen to act otherwise. As a result, your experience does not disprove the general thesis. And you don’t say how long the woman you met was held. As I pointed out, in NY, you can commit someone involuntarily for 72 hours to assess them. How long can they be held for assessment in NC?

            In NY, I personally know a woman who was repeatedly held for the 72 hours of observation and released. And she’d even been belligerent toward her husband and the cops, but they deemed her belligerence not to = danger. She was an ugly drunk and once she sobered up, she was well enough behaved that they had to release her.

            And the bigger issue is jrs argued above that mentally ill people should be involuntarily incarcerated, when even your example of giving information that could be and was used against you, you were held only 10 days.

            This has the code state by state following the section I cited. This document is as of 2019:

            Important note about involuntary commitment:

            1. Having a law, does not mean a state makes use of it. Very few states make use of involuntary outpatient commitment (Asssited Outpatient Treatment, AOT) laws.
            2. When inpatient commitment is used, most states still rely on the “dangerousness” standard, and rarely use the other standards they have available to them. Further “dangerous” is often interpreted very narrowly to mean “imminently” dangerous.
            3. No state law includes all the provisions in the model law on this site, and therefore all states can improve their law.
            4. All states could improve care and save money wby making greater use of the options they already have available to them.
            5.Do not rely on the following before checking to see if the law has changed and how courts have interpreted it.


            See a layperson recap of NY standards in this movie clip: “Arthur” is a bipolar star litigator who is off his meds. George Clooney (Michael) is the law firm’s fixer who is tying to get him to go back on his meds and stop sabotaging the case he’s been working on for years. See @ 2:50 if you don’t have patience for the whole thing.


            If you look at the section on NY in the link higher up, you’ll see the protections in case law are strong.

            1. Krystyn Walentka

              Even being held 72 hours is an involuntary commitment. The length of time does not matter. So I do not understand your anecdote, it kind of proves my point.

              All I was trying to emphasis is that

              You can’t involuntarily commit people in NY unless they are a danger to themselves or others.

              is technically true but not practiced in reality. The doctor did not believe I was not a danger to myself. That is all it took. They would not listen to me or my psychiatrist when they said it would not be in my best interest. How do i know the ER doctor was not getting kickbacks from the private hospital? IC is not decided by a judge in NY, it is decided by two doctors.

              So unlike “Arthur” I did not have access to a judge or an attorney before that decision was made. Note that I never objected to being hospitalized, I just wanted to choose my best care. The public hospital had no beds but I was forced to go to a private hospital. After staying overnight in the ER I woke up feeling a bit better but they just said too late. They transported me 40 miles away handcuffed in the back of a police car (because that is the law) to a VC backed hospital.

              I had ZERO legal protections. I was only contacted by an attorney after I was held for 5 days. I was never even told what my rights were. Plus, they take away your rights and give you no treatment.

              See this from NH if you think it is anecdotal: Lawsuit filed against state over involuntary psychiatric boarding

              And this in Texas: North Texas Mental Health Hospital Indicted For Holding Patients ‘Involuntarily And Illegally’

              And this spike in ICs in Florida of minors. See, the loop hole is that the lower impact treatments do not exist because budgets.

              They also say you can refuse treatment. Well I tried that and the doctor said “The longer you refuse treatment the longer you will say here.” So, not voluntary. I called the state about what was happening and they told me “I just want you to know they are probably listening to this phone call.”


              To say I was held only 10 days.. I do not know what to say about that. Only being in prison for 10 days…only being tortured for 10 days…I cannot repeat enough that it was in no way any kind of hospital. I would not have minded IC if I, or my friends and family, had any choice about the care that I had. But once you are IC you are in care of the state.

              The reason I am explaining all of this is to make clear that it is way more complicated and nothing like any movie.

              And I want to add this, why is the risk of suicide from a mental illness treated differently than the danger of someone dying from heart disease? The heart disease patient can refuse treatment when there is a clear fact that their disease is a danger to their life. They do not get thrown in jail for not caring if they die. So it is just stigma.

              1. Yves Smith Post author

                I’m sorry, I don’t agree at all with your point of view on heart disease. Suicide is a voluntary act. Many people who have suicide plans decide not to go through with them and even people who actually attempt suicide (swallow a bottle of Tylenol) then try to reverse it. Heart disease is a long-term process. It is not voluntary. Some people who are vigilant about exercise and diet drop dead young because it runs in their family (Jim Fixx is a famous case). Modern advice about diet is largely crap (cholesterol buildup in major arteries is more likely an effect than cause; high cholesterol is not caused by eating cholesterol, your body makes it; the total cholesterol level in women correlated with the lowest all factor death rate in women is 270). Some of the “treatments” like statins for people who do not have actual heart disease and the overuse of stents. Refusing medically unwarranted interventions isn’t in the same category as preventing suicides.

                And even though high BMI is a contributor to heart disease, don’t tell me people choose to be fat.

                1. Krystyn Walentka

                  Death from depression is also the end of a long-term process. I did not wake up one day and say “Go walk out in the cold winter and freeze to death.” For me, the choice to die was not a choice, it was a delusional certainty. Also I did not choose to have depression, so how can anyone assume I choose to attempt suicide?

                  People may die from suicide, but the cause of the suicide was a mental illness. People may die of a heart attack, but the cause of the heart attacks is arterial sclerosis.

                  Heart disease was a touchy comparison that was misunderstood and complicated things. Many of the things you said about the causes of heart disease can be replicated with mental health. Like I said, it is along term process that is unique to every individual.

                  Thanks for your response and the blog as usual, I know you are always busy, I do not wish to be confrontational and take up your time.

  5. Carla

    Can’t remember if this has been linked on NC or not:

    Our public county hospital system (which has been increasingly privatized, but that’s another story) is now fully engaged in trying to be a local government, since the actual government is non-functional. The hell of it is, Metrohealth CEO Dr. Akram Boutros appears to be a much better political leader than anyone else in Cuyahoga County, or for all I know, in the state of Ohio.

    1. John

      Dr. Boutros has no constraint on the taxes he levies…thus he can get things done. Give the local politicos the taxing power of the American health care system and you’d see all sorts of things happening.

      1. Carla

        Don’t the funds have to be raised via Cuyahoga County health & human services levies that must be approved by voters?

  6. StrayCat

    In the midst of a commendable report, Malcolm Gladwell made the seemingly lucid, innocent observation that:

    “That is what is so perplexing about power-law homeless policy. From an economic perspective the approach makes perfect sense. But from a moral perspective it doesn’t seem fair. … When the welfare mom’s time on public assistance runs out, we cut her off. Yet when the homeless man trashes his apartment we give him another. Social benefits are supposed to have some kind of moral justification. We give them to widows and disabled veterans and poor mothers with small children. Giving the homeless guy passed out on the sidewalk an apartment has a different rationale. It’s simply about efficiency.”

    Such lucidity cuts in all directions. To offer just one of many examples, our government has over the last 20 years offered billions in tax incentives to MNCs to repatriate profits, under (rather specious, as far as I can tell from the historical results of such) expectations that such incentives would stimulate productive investment. And supposedly this too has been about efficiency. Let’s back up a second: US multinational corporations were hoarding about $700 billion offshore by 2005. They were granted a 5.25% tax rate if they repatriated those earnings and applied them to productive investments. They brought about half of the $700 billion back—but made proportionally little productive investment. Instead, they used their cash-flushness to fund massive stock buybacks and dividend payments which didn’t produce any jobs, financed mergers and acquisitions of their competitors which actually reduced jobs, not to mention the likelihood of the inequalitarian, destabilizing effects that such speculative investment may have actually had on the macro-economy. Similar provisions in the Trump tax regime are likely on their way to producing a similar outcome.

    One might characterize such policies as both unfair and inefficient.

    1. Jeremy Grimm

      Definitely unfair … but inefficient I’m not so sure. Our system is configured to transfer wealth to the wealthy.

  7. JBird4049

    From what I can gather, there is enough vacant, unused housing, often bought as an investment or too expensive, to house every homeless Californian. All forty thousand of them.

    Of course, we could go all evil and do what Vienna started, and continues to do, a century ago and build enough high quality, affordable housing for everyone of all classes. Those “public” housing look awfully nice.

    But that’s the evuhl communism. It is much more American to let people die on the streets or spend so much for housing that they go hungry even if they are entire families. Because the Gods of the Free Market, or somebody, would be oh so terribly offended.

    1. jrs

      Where people actually live or far in the exurbs though? Because periodically a ridiculous plan to house the homeless in some far exurb appears (partly because noone wants a homeless shelter in their community), but of course it’s entirely unrealistic that all the homeless will move out there. No housing L.A. homeless in Lancaster doesn’t actually make sense for instance.

      1. JBird4049

        Fair point. Not all the housing is in the cities themselves or anywhere near the homeless. However, an awful lot, perhaps the majority, is in the cities were the greatest concentration of the homeless are. Still, if much of the homeless can be housed, finding a way to make accessible this unused housing would be very good.

  8. teacup

    Is housing (a place to sleep) a right? It’s only on the bottom slice of the pyramid in Maslow’s hierarchy of needs. Oh, but wait, housing/land is a commodity so others use legal privilege to deny others equal rights to housing. The mother of all monopolies is the monopoly on land. Unless the unearned increment of the economic rent of land and natural resources is taxed away for the communities’ needs, this problem will never go away. Classical political economy saw this plain as day, but then neoclassical economics was born to defer intellectual attention away from the concept of a free lunch (economic rent). As Michael Hudson has pointed out, the John Bates Clark Medal is given out every year to an economist under forty that best conflates land with capital as factors of production. ‘Capital Gains’ is the inverse euphemism of the ‘unearned increment’. This is lying by historical omission to today’s students and deliberately hidden to the public at large by the vast public relations (propaganda) networks of the finance and real estate sectors.
    An updated version of the Ralston-Nolan bill proposed in 1920 should be attached to any Green New Deal.

  9. Tim

    and had medical costs, on average, of $12,945 per month. In the nine months since he got a roof over his head and health coaching from Brenner’s team, Steve’s average monthly medical expenses have dropped more than 80%, to $2,073.

    So even at the tail the core issue is still self care and basic necessities.

    This is a great reason to go for single payer. Like an HMO it suddenly becomes in the best interest of everybody except the healthcare industry to keep everybody as healthy as possible, and even dare I say providing social accountability for unhealthy actions.

    (e.g. “Stop smoking, you’re killing me with taxes!”)

    1. Bob Hertz

      It does not really cost $2,700 to put a homeless person in the hospital for a night.

      The hospital building is already there. The nurses are on salary. A homeless drunk does not require expensive drugs.

      The marginal cost of treating such a person might be $27 or $270, not $2700.

      The hospital will send a bill for $2700 because in America, we expect hospitals to be funded entirely by user fees.

      The solution is to go back to taxpayer funding for urban hospitals. This would now have to be federal funds, because most urban counties have severe limits on raising taxes.

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