Saturday, September 27, 2008

compassionate conservatism that works

Seen much about homelessness in the news lately? Neither have I. Not, of course, that homelessness has gone away. But the press only focuses on problems when they are getting worse, and the problem of homelessness in the US is actually getting better. Given the Bush administration's terrible record on almost everything else, and the overall increase in poverty in recent years, it is worth pondering why that has happened.

A big part of the answer is the administration's point man on homelessness, Philip Mangano.

Mangano was inspired by the example of St. Francis to give up his career as an agent in Hollywood and devote his life to helping the poor. He has made homelessness in the US his mission for 30 years now. But he brings a hard-headed, un-Franciscan, thoroughly modern attitude to his work. He sees his mission as not helping the homeless as ending homelessness altogether. He bases his approach on an understanding of homelessness developed by sociologists over the past 20 years, especially Dennis Culhane. As Malcolm Gladwell wrote in a great piece for the New Yorker:

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. [i.e., the curve is shaped like a hockey stick.] "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 than anyone had ever anticipated. Culhane estimates that in New York at least sixty-two million dollars 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." Boston Health Care for the Homeless Program, a leading service group for the homeless in Boston, recently tracked the medical expenses of a hundred and nineteen chronically homeless people. In the course of five years, thirty-three people died and seven more were sent to nursing homes, and the group still accounted for 18,834 emergency-room visits—at a minimum cost of a thousand dollars a visit. The University of California, San Diego Medical Center followed fifteen chronically homeless inebriates and found that over eighteen months those fifteen people were treated at the hospital's emergency room four hundred and seventeen times, and ran up bills that averaged a hundred thousand dollars each. One person . . . came to the emergency room eighty-seven times.

"If it's a medical admission, it's likely to be the guys with the really complex pneumonia," James Dunford, the city of San Diego's emergency medical director and the author of the observational study, said. "They are drunk and they aspirate and get vomit in their lungs and develop a lung abscess, and they get hypothermia on top of that, because they're out in the rain. They end up in the intensive-care unit with these very complicated medical infections. These are the guys who typically get hit by cars and buses and trucks. They often have a neurosurgical catastrophe as well. So they are very prone to just falling down and cracking their head and getting a subdural hematoma, which, if not drained, could kill them, and it's the guy who falls down and hits his head who ends up costing you at least fifty thousand dollars. Meanwhile, they are going through alcoholic withdrawal and have devastating liver disease that only adds to their inability to fight infections. There is no end to the issues. We do this huge drill. We run up big lab fees, and the nurses want to quit, because they see the same guys come in over and over, and all we're doing is making them capable of walking down the block."

Once you understand what homelessness is, you can develop programs to fight the problem. Most people who end up in homeless shelters are just going through a rough spot -- divorce, job loss, mental breakdown -- and what they need is some transitional assistance to get back on their feet. Since over the past 15 year we have re-oriented our whole welfare system around providing such assistance (rather than long-term benefits), help is available for many of these people.

The hard core homeless need much more help. Part of Culhane's insight was in recognizing that these people already cost the government so much in medical care that getting them off the street, at almost any price, still saves money. So, says Mangano, let's give them free apartments and all the other help they need, spending whatever it takes, because that's what they need and what we're doing effectively pays for itself anyway. People have resisted Mangano's approach to helping these chronically homeless people because it seems unjust. Why give those who have only moderately screwed up their lives a meal voucher and a pat on the back while giving those who have really screwed up free apartments and intensive help from social workers? But, to quote a certain out of fashion philosopher, to each according to his needs. I don't need special help from the government and I don't want any. Some people need a little help from time to time, and I think that help should be there for them. Some people need a lot of help, all the time. Unless we are going to let these people die at the hospital door (which I hope we won't), we are going to be paying out a lot of money for them anyway, so I agree with Mangano that we ought to be spending that money in a way that will help at least some of them put together livable lives.

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