Homelessness and Health

Homelessness and Health

When I was completing an MPA I took a couple of classes out of the MPH (Public Health) program. In one of the classes our professor assigned a group of us to a project focused on ways in which public agencies can access Medicaid funding for housing assistance programs for homeless individuals. The basic idea was that homeless individuals utilize healthcare resources and are unable to pay for any services they receive. The government, usually the local city or state government, ends up covering the cost of care provided to homeless individuals. The alternative would be that homeless individuals cannot access healthcare, and that they become more likely to spread communicable diseases or to die from preventable causes wherever they manage to find shelter.
This means that local governments end up paying a lot for the healthcare needs of their homeless (Malcolm Gladwell once wrote a story about “Million Dollar Murray” who happened to live in my hometown of Reno). Our project was to see what was permissible under Medicaid guidelines to allow hospitals and local public health entities to access Medicaid funding to provide housing for individuals who would otherwise drive huge healthcare costs. Accessing Medicaid funding would shift part of the costs to the federal government and bring in more federal funding to allow more individuals in the area to receive support. The ultimate goal was to get people established with basic housing and in the long run cut down on the number of emergency room visits and medical services that people would need.
Being homeless can drive up healthcare costs by driving people into worse health states. This is something that is often overlooked when we think about the homeless. As Elliot Liebow wrote in Tell Them Who I Am, “In many cases, the very conditions of homelessness produced poor health care as well as poor health. On the one hand, the women sometimes failed to tell the doctor that they were homeless; on the other hand, even when doctors knew their patients were homeless, they often failed to appreciate the significance of that fact.”
As my small team of fellow graduate students completed our project, we focused a lot of thought on housing individuals with diabetes or asthma. If you are homeless and have either condition, managing your health becomes dramatically more challenging. Doctors have to spend additional time with homeless individuals to help ensure they know how to use their medications and have secure and temperature controlled places for them. But as Liebow’s quote notes, this doesn’t always happen, even if a doctor knows the patient is homeless. A person without a fridge may not have a place to store insulin without it going bad. They may not then be able to access insulin when needed, and may end up in the ER for an emergency that would never happen if we had simply ensured they had a place to live and keep their medicine. Homeless individuals with asthma may find themselves sleeping in a car in a parking lot, or under a freeway overpass. This means they are in a place where they are exposed to more car exhaust and dust, potentially triggering a severe asthma attack and necessitating another entirely preventable ER visit. In both cases if the had been given a place to live that wasn’t densely inundated with vehicle pollution or had a way to safely store their medication, they wouldn’t have had to go to an ER. Society could have have paid the cost of their housing, but instead we chose to let them be homeless and pay for thousands of dollars in medical costs after they had a problem.
The question our team looked at is how many ER visits does it take to offset the costs of simply providing a house first? And what types of services will Medicaid allow to be billed that help secure and individual in the housing they are provided? As it turns out, Medicaid does offer assistance for housing search, coaching on how to be a successful tenant, and other basic services to help ensure someone can live within any housing they are provided. It doesn’t, however, allow any reimbursement for rent or direct housing costs. Nevertheless some hospitals and some local governments are beginning to invest in housing first strategies. Any efforts that keep people out of the ER will save money in the long term, even if it is more expensive up front to provide someone with a place to live. The returns and benefits to a persons health ultimately outweigh the costs of providing housing as fewer healthcare services are needed.
Homeless Boredom

Homeless Boredom

In a recent episode of his podcast, Tyler Cowen interviewed a man experiencing chronic homelessness in Washington DC. He refers to himself as an NFA (no fixed address) and goes by the name Alexander the Grate. He was introduced to Cowen by James Deutsch, a Curator at the Smithsonian who had profiled Alexander in past scholarly work.
One of the questions that Cowen asked Alexander was how he spent his time as an NFA. He responded with a number of free things he could take part in around DC. There are Smithsonian exhibits and events that are free to attend, numerous small film festival events throughout the year, and various  free public events that he could attend. In his response, he stated, “we were all sober. We had something to do to occupy our time. … We had to do something to fill up the spaces of our sobriety and to satisfy our mind as well as entertainment and keep our mind alive, besides the soup stuff.”
His quote shows that the homeless needed something to do to stay occupied, and luckily for Alexander, Washington DC offered plenty of ways to engage his mind and fill his time. However, most homeless people in our country do not live in Washington DC, and don’t have access to the Library of Congress, the Smithsonian, and all the free public events that take place in our National Capital. For homeless people across our country, boredom, not an overwhelming number of events and activities, is the norm.
In his book Tell Them Who I Am Elliot Liebow writes about the boredom that homeless women face every day. “Along with perennial fatigue,” writes Liebow, “boredom was one of the great trials of homelessness.” Humans are social creatures, but in America the homeless are excluded. People are afraid of them for numerous reasons and don’t want to interact with them. We don’t want to see them around our public events, and we don’t want them to occupy the same public spaces that we occupy. As a result, homeless individuals become outcasts, forced into boredom and isolation. We want them to get a job, to get a place to live, and to re-enter society in an acceptable and respectable way, but we shut them out and leave them with nothing to entertain their minds or fill their time. As Liebow notes when profiling one of the women he met, we leave them to speak with only the birds.
Homelessness, life on the streets, and isolation seems to break people. Once someone is speaking to themselves or the birds they become even more of a social outcast, reinforcing the isolation that has broken them. I think there is an important paradox for us to acknowledge here. We want the homeless to turn their lives around, but we exclude them, force them into crushing boredom, and then criticize them when they break. We can’t expect people to suffer in such boredom and then rejoin society. We can’t expect people to face isolation and then turn things around to re-integrate. Boredom and isolation are not something we should just ignore because people are homeless, they are real problems that make life harder for the homeless, and make it less likely that they will ever become part of society again.
Who Are the Homeless?

Who Are the Homeless

In the United States we have many housing insecure individuals. We have many people who are chronically homeless, and are unlikely to ever get off the streets. We have many people who experience homelessness only transiently, possibly during an unexpected layoff or economic downturn. And we also have many people who find themselves in and out of homelessness. For each group of housing insecure individuals, their needs and desires of people differ. However, when we think about homelessness in America, we typically only think about one version of homelessness: the visibly homeless man or woman living in the streets.
In his book Tell Them Who I Am Elliot Liebow writes, “an important fact about these dramatically visible homeless persons on the street is that, their visibility notwithstanding, they are at best a small minority, tragic caricatures of homelessness rather than representatives of it.” When we think about the homeless we think about men and women who don’t work, who are smelly and dirty, and who appear to have mental disorders or drug addictions. This means that public policy geared toward homelessness is a reaction to this visible minority, not policy geared to help the many people who may experience homelessness in a less visible way.
People do not like the visibly homeless who live on the street. They feel ashamed to see them begging, feel frustrated by their panhandling, and are often frightened of them. The visibly homeless are not a sympathetic group, and are not likely to be the targets of public policy that supports them.
The less visibly homeless, however, are a population we are less afraid of and less likely to strongly dislike. But because we don’t see them, we don’t think of them when we consider policies and programs designed to assist the homeless. Their needs, their concerns, and the things that could help them find more stable housing are forgotten or simply unknown to the general public and the policymakers they elect. We are often unaware of the individuals who are homeless but still managing to work a job. We don’t think about those who experience temporary homelessness, sleeping in a car for a couple of weeks at a time between gig work. We don’t consider those who live in shelters until a friend or family member can take them in and support them until they can find work. Without acknowledging this less visible side of poverty, we don’t take steps to improve public policy and public support for those working to maintain a place to live. We allow the most visible elements of homelessness to be all we know about homelessness, and as a result our policy and attitudes toward the homeless fail to reflect the reality that the majority of the homeless experience.
Participating in Society - Shark Tank - Mark Cuban - Joe Abittan

Participating in Society

I recently read Entertaining Entrepreneurs by Daniel Horowitz. The book is a deep dive into the show Shark Tank, examining the culture that made it a hit, the successful business people who play the investing sharks, and the contestants and their pitches. The book talked about the way the sharks present themselves as sharp individuals whose exceptional work ethic and insightfulness allowed them to become independently wealthy. With Mark Cuban on the show, I was constantly reminded of the stories about him I heard growing up. Cuban owns the Dallas Mavericks NBA team, and as a child who grew up playing basketball, his story was all around me. Cuban reportedly ate nothing but mustard sandwiches as he was trying to make it big, working hard, and living frugally. Now he is a billionaire, and his days of eating mustard sandwiches are behind him, but his discipline in his early days are what allow him to have the fabulous lifestyle he lives today.
Horowitz shows that there is much more to the story than Cuban eating cheap food at home while trying to be the hardest worker in the world. Cuban participated in a complex society, eventually selling his company to a much larger corporation, and eventually building his own massive organization behind the scenes. There is a paradox in the idea of the individual witty sharks, who are all backed up by corporate enterprises and rely on many people to propel and perpetuate their fame and status. No matter how independent they want to be, Horowitz reminds us, the sharks, and indeed everyone connected to the show, is participating in society and relies on other people to live the fabulously wealthy lives that we all dream about.
On the other end of the our socioeconomic status ladder are homeless individuals, and in the case of Elliot Liebow’s book Tell Them Who I Am, homeless women. Mark Cuban and homeless women seem like they would have nothing in common to connect them in the same blog post, but homeless women, just as Cuban, live within a larger society. No matter how poor one is, nor how wealthy one is, participating in society cannot be avoided, and that participation will in-part drive the outcomes one sees. Cuban is able to participate in society in ways that enhance his status, while homeless women cannot participate in society in ways that enhance their status. In fact, homeless women can only play one role in society, the role of the outcast who everyone is allowed to lambast. Liebow writes,
“Since homeless women are not likely to have formal credentials, social status, money, or useful social or business connections, they confront potential employers, landlords, indeed the whole world, with little more than themselves to offer for evaluation. For this reason, and more than for most of us, the way homeless women present themselves – how they look, speak, and carry themselves – makes a great difference in how they are treated by the rest of the world.”
Homeless women are not even given real opportunities for advancement as they participate in society. They cannot be separate individuals defined purely by how hard they work and whether they are willing to eat nothing but mustard sandwiches as they pinch every penny. When they show up looking for someone to help integrate them into society, they cannot change the fact that their appearance and lack of credentials tells the world they are homeless and unworthy of our respect. When this is the only way they can participate in society, it is no wonder that they never seem to improve their lives.
Cuban, and the rest of the sharks, don’t want to present themselves as depending on society in the way that homeless women do. Cuban and the sharks are fabulously wealthy, well credentialed, and well connected, but they need investors, creditors, social connections, and a public that believes the hype in order to participate in society the way they want. In the end, they are not actually that much different from homeless women – they still depend on society and the roles society allows them to play. The difference is that society has deemed them worthy and valuable, and loads them with praise, while homeless women are deemed unworthy and useless, and criticized as they are pushed away. Homeless women are unable to present themselves in a way that society rewards, but as Horowitz explains in his book, the Sharks all go through painstaking effort to present themselves in a specific way that society does reward. They are as sensitive to their presentation as the homeless women are, but they are better able to control and manipulate that presentation.

The Heart of the Social Contract

A lot of my writing lately could be misread as me making excuses for people who have made poor decisions and failed to be good citizens. I have been writing about the homeless and those who face chronic evictions, arguing that their failure is in many ways a larger failure of society to provide a system that will maximize human well-being and provide a reasonable floor from which everyone can rise. I have been more critical of those who dismiss the homeless and chronically evicted as lazy or morally deviant than I have been critical of those who cannot maintain a job, housing, or the support of friends and family. The reason I have been so critical of those who have, rather than those who need, is because I think we focus too much on ourselves, our own wants and desires, and our own challenges. We don’t think about ourselves in relation  to a larger society, at least not in the United States we don’t do enough thinking of ourselves and our dependence on others.
In his 1993 book about homeless women, Tell Them Who I Am, Elliot Liebow writes, “trying to put oneself in the place of the other lies at the heart of the social contract and of social life itself.” It is important that we think about others rather than only think about ourselves. If we only think about our own problems, if we only  think about what would make us look cool, and if we only strive for our own goals, then we will fail in our obligations of the social contract. We have to think about the other people who are in our community, what they need, what their problems are, and how all of us can be part of a solution. We also have to think about the negative externalities that our actions produce in the world. What Liebow writes in the quote above is that the heart of a democracy relies upon all of us coming together and thinking not just about ourselves, but about others and about society.
I’m not saying that individually we all need to be more charitable, altruistic, and to give more of our time and money. I’m saying that we need to think more about others, and as a collective need to invest in institutions that make it easier for us to uphold the social contract. I would argue that recently we have invested in institutions which focus us inward, away from the social contract. Social media asks us to say something about our own lives, streaming services all us to focus our entertainment on our own preferences at any minute, and our current work expectations drive us to long hours so that we can own bigger and better things. The institutions which push us to be more communal have fallen to the side, requiring greater commitments from those involved, and scaring away those who would otherwise look to be involved. As Liebow explains, we need to think about others to be socially responsible and address collective problems, and this requires a shift away from our individual focused mindsets.
Judging, or Explaining, the Homeless

Judging – or Explaining – The Homeless

In his 1993 book Tell Them Who I Am, Elliot Liebow wrote the following in the book’s preface:
“In general, I have tried to avoid labeling any of the women as mentally ill, alcoholic, drug addicted, or any other characterization that is commonly used to describe – or, worse, to explain – the homeless person. Judgments such as these are almost always made against a background of homelessness. If the same person were seen in another setting, the judgment might be altogether different.”
I find this quote about the homeless women that Liebow writes about in his book fascinating. The women who Liebow writes about would generally be considered normal if they happened to have a home, he explains. Their drinking, drug use, poor tempers, and other characteristics are used to explain away their homelessness, and as the quote above hints at, to excuse people from having to feel bad about them or to excuse people from having to help them.
People have trouble fathoming homelessness, and it becomes easier to blame the homeless than to blame society or their own actions that may have contributed to the homelessness of others. If another person’s homelessness can be explained by that person’s particular shortcomings, then the problem of homelessness can be dismissed and the homeless themselves can be ignored until they correct their own problems.
Liebow shows that this idea is a myth. The women he spent time with became homeless for a variety of reasons, but the poor characteristics used to define their homelessness generally were not that different from the poor characteristics of normal every-day people who have jobs, families, and homes. We all hear stories or have known professional people who do drugs, successfully retired individuals who drink excessively, or leaders and business owners whose behavior make us question their sanity. However, because they have homes and don’t need social assistance, their behaviors are dismissed. It is only when someone needs help, when someone has lost a home, that we suddenly judge them based on drug use or apparent mental instability.  As Liebow’s quote shows, this can seemingly be more of an excuse for a person’s state of need, and a disqualifying factor for our concern, rather than a real reason why someone is in the state they are in.
Help Them Build a Better Life

Help Them Build a Better Life

It is an unavoidable reality that we are more motivated by what is in our immediate self-interest than we would like to admit. This idea is at the heart of Kevin Simler and Robin Hanson’s book The Elephant in the Brain and can be seen everywhere if you open your eyes to recognize it. I’m currently doing a dive into reading about homelessness, and I’m working through Elliot Liebow’s book Tell Them Who I am. Liebow writes about American society’s belief that people will become dependent on aid if it is offered unconditionally. In a passage from his book where he reflects on the barriers that homeless women face in obtaining services and aid, and how those barriers can often become abuse, Liebow writes:

 

“One important source of abuse lies much deeper, in a widespread theory about human behavior that gets expressed in various forms: as public policy, as a theoretical statement about rehabilitation, or simply as common sense. Whatever the form, it boils down to something like this: We mustn’t make things too easy for them (mental patients in state hospitals, welfare clients, homeless people, the dependent poor generally). That just encourages their dependency”

 

What is incredible with the sentiment in the paragraph above is how well it seems to justify what is in the immediate self-interest of the people with the resources to help those in need. It excuses inaction, it justifies the withholding of aid, and it places people with material resources on a moral high ground over those who need help. Helping others, the idea posits, actually hurts them. If I give up some of my hard earned money to help another person, I don’t just lose money, that person loses motivation and loses part of their humanity as they become dependent on the state. They ultimately drag us all down if I give them unconditional financial aid. What is in my best interest (not sharing my money) just also happens to be the economic, moral, and personal best thing to do for another person in less fortunate circumstances.

 

This idea assumes that people have only one singular motivation for ever working, making money to have nice things. It ignores ideas of feeling respected and valued by others. It ignores the human desire to be engaged in meaningful pursuits. And it denies our needs as humans for love, recognition, and basic necessities before we can pull ourselves up by our boot straps.

 

Johann Hari’s book Chasing the Scream is an excellent example of how wrong this mindset is and of the horrors that people can face when the rest of society thinks this way and won’t offer them sufficient help to reach a better place in life. Regarding drug addicts and addiction, Hari quotes the ideas of a Portugese official, “addiction is an expression of despair, and the best way to deal with despair is to offer a better life, where the addict doesn’t feel the need to anesthetize herself anymore. Giving rewards, rather than making threats, is the path out. Congratulate them. Give them options. Help them build a life.”

 

Helping someone build a life requires a financial investment in the other person, a time and attention investment, and also requires that we recognize that we have a responsibility to others, and that we might even be part of the problem by not engaging with those in need. It is in our selfish interest to blame others for the plight of society or the failures of other people. From that standpoint punishment and outcasting is justified, but as Hari, Liebow, and the Portugese official suggest, real relationships and getting beyond fears of dependency are necessary if we are truly to help people reach better places and get beyond the evils we want to see eliminated from the world. We can’t go out of our way to find all the ways in which things that are in our self-interest are good for the rest of the world. We have to acknowledge the damages that our self-interests can cause, and find ways to be responsible to the whole, and help other people build their lives in meaningful ways.