Tag: Homelessness

Homelessness and Health

Homelessness and Health

Posted on by jabittan
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

Posted on by jabittan
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

Posted on by jabittan
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

Posted on by jabittan
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.
Judging, or Explaining, the Homeless

Judging – or Explaining – The Homeless

Posted on by jabittan
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.
Eviction & Poverty - Housing First

Eviction & Poverty

Posted on by jabittan
Housing first is a common saying among those who advocate for the poor and impoverished in our nation. Instead of housing being a capstone to a responsible, socially adjusted, and respectable lifestyle, housing is seen by housing-first advocates as a cornerstone to those things. Without a stable place to live, it is almost impossible for people to rise from poverty, advocates of housing first policies argue.
Matthew Desmond shows support for a housing first approach in his book Evicted by connecting eviction with poverty and a downward life spiral. Once a stable housing situation is taken away from an individual, whether due to their own poor decisions or unfortunate circumstances, maintaining any sort of respectable and laudable lifestyle becomes nearly impossible. Desmond writes,
“Losing your home and possessions and often your job; being stamped with an eviction record and denied government housing assistance; relocating to degrading housing in poor and dangerous neighborhoods; and suffering from increased material hardship, homelessness, depression, and illness – this is eviction’s fallout.”
Eviction is a cause of poverty Desmond argues. When you lose your house and have to scramble to find a new place to live, don’t have a safe place to leave your children, and don’t have a place to store your things, you can hardly continue to work or search for a job. By losing your housing, you often lose your job, eliminating any hope of increasing your financial well-being. Evictions may also cause you to lose government housing aid or the support of neighbors and family members, making it even harder for you to get by. Employers won’t want to hire you if you live in a homeless shelter and you may become estranged from children or relatives. All of this only drives you deeper into poverty and despair.
A housing first approach gives people a stable place to live. It gives them an address that they can use on job applications, it takes away the stress that comes from trying to find a place to rent and gives people time to engage with neighbors or search for a job. Housing is necessary to take steps to better ones life, and can’t be seen as a capstone to reach once one’s life is on track.
The Incredible Cost of Housing in the United States

The Incredible Cost of Housing in the United States

Posted on by jabittan
I live in a town that has experienced a major housing boom in the last 5 years. By car, we are only four hours away from San Francisco and by plane it is only an hour hop to the bay. Reno, Nevada is also located next to Lake Tahoe, one of the most beautiful alpine lakes in the world (if you don’t mind my little brag), and offers a lot of great hiking, skiing, and other outdoor activities. The city has become an attractive place for people in San Francisco, Oakland, or Sacramento who want to buy a more affordable home and have more space for families and outdoor living.
Unfortunately for many people in Reno, what is considered an affordable home to someone who has lived in the Bay Area or Sacramento is not what has traditionally been considered an affordable home to long-time locals and their families. The median price of homes in Reno has soared to over $500,000, placing homes out of reach for many long-time residents. However, with median prices for homes in the Bay Area being over $950,000, homes in Reno are somewhat of a steal.  The end result in Reno is a growing population, a housing supply that hasn’t kept up, and increasing housing costs.
I personally know people who have been renting apartments for roughly the same monthly rate as what I have paid for mortgages on houses. This soaring cost of rents is pushing people in the city into unstable housing situations, and for many, into homelessness. Reno is a great example of the challenges of sudden housing cost increases, but it certainly isn’t the only place where this is happening.
In his 2016 book Evicted, Matthew Desmond writes, “Families have watched their incomes stagnate, or even fall, while their housing costs have soared. Today, the majority of poor renting families in America spend over half of their income on housing, and at least one in four dedicates over 70 percent to paying the rent and keeping the lights on.” For close to a decade the cost of housing in many cities and regions of the country has been soaring at a time when many people were not seeing wages increase. This pushed people to have to decide between working more, moving, going into debt, risking homelessness, or sacrificing time with family, comforts, and necessities.
It is not possible to tell everyone living in a place where rent and housing costs are soaring to move to South Bend, Indiana where homes are more affordable. It is not reasonable to tell everyone to take on a second job, to get more roommates, and to simply downsize into smaller and more affordable places. The problem has to do with the amount of housing being constructed, limits placed on housing construction, and the increasing concentration of economic opportunities to large coastal cities. There are many factors and trade-offs that influence the decisions that are made with regard to new housing construction and zoning regulations, but we should remember that one outcome from failing to provide enough quality housing is homelessness. Homelessness can be temporary, cyclical, and chronic, and it has tremendous costs on society and the environment, and if housing costs can’t be brought down to a level where people are not spending half their income on rent, then it will persist and worsen.
Rent

Rent

Posted on by jabittan
When I was in high school I took a class my senior year that followed the secular personal financial management course from Dave Ramsey. Ramsey provides many practical lessons about money management and financial well-being. One area that he focuses on is how much of your income you should spend on different areas, such as on housing, groceries, and other necessities. Ramsey follows the standard recommendation that you don’t spend more than 30% of your income on housing, a great goal, but one that really isn’t a possibility for many Americans.
Kathryn Edin and H. Luke Shaefer examine the high cost of rent and how it impacts the lives of those living in poverty in their book $2.00 A Day, originally published in 2015. “Between 1990 and 2013, rents rose faster than inflation in virtually every region of the country,” the authors write. This has serious impacts for the lives of those living in poverty. One impact discussed by the authors, that I had not considered, was child custody. In some cities and states there are limitations on how many children can share a single room. At a certain point, too many children, especially of mixed gender, are not allowed to share a room and doing so could constitute neglect and lead to parents losing custody of their children.
Edin and Shaefer continue, “between 200 and 2012 alone, rents rose by 6 percent. During that same period, the real income of the middling renter in the United States fell by 13 percent.” While wages had stagnated and real incomes had fallen for lower class workers, rents across the country were rising. The increase in rent was particularly high in large cities where most of the economic output and job creation in the country has taken place. Renters faced a choice, live where rents are cheap, but where there are no jobs, or live where rents are high, and where jobs can be found. Living in a cheap place may mean an unreasonably long and expensive commute, but living where the jobs are might mean sharing a place with non-familial renters and crowding into living conditions that put renters at risk.
I haven’t studied affordable housing, and I don’t know the solution to rising rents for low income individuals and families. But I think it is important to know the statistics shared by Edin and Shaefer. I live in a city where rents and home prices have skyrocketed (Reno, NV). One consequence of the rising rents is an increase in homelessness, particularly in short term homelessness. We all see people on the streets and notice when there are more people on the street, but we don’t always notice the short term homeless. The chronic homeless overshadow what is sometimes a larger, yet less visible form of homelessness. Understanding the rise in rents, the stagnation of income (which we might hopefully be getting out of as we recover from COVID) and the impact on short-term homelessness helps us think more clearly and accurately about the challenges that renters face, and about ways to help those who are unable to keep up with rising rents. It is important that we think about the obvious consequences of increased rents, like homelessness, and also the less obvious consequences, such as families potentially losing custody of their children. As rents have risen, Dave Ramsey’s advice to keep your housing costs below 30% of your income just isn’t possible for many Americans, and the consequences have been dire for many individuals and communities.
$2.00 A Day

$2.00 A Day

Posted on by jabittan
In $2.00 a Day: Living on Almost Nothing in America, authors Kathryn Edin and H. Luke Shaefer provide an insight into the lives of people living in extreme poverty in the United States. The book highlights a population that is largely invisible in the United States, those living on $2 a day or less, averaged across the entire year. It is hard to imagine that anyone in the United States could live on such a low income or even have such a low income, but Edin and Shaefer show that it is the case for some American’s and explain what life is like for those individuals.
They write, “Two dollars is less than the cost of a gallon of gas, roughly equivalent to the that of a half gallon of milk. Many American’s have spent more than that before they get to work or school in the morning. Yet in 2011, more than 4 percent of all households with children in the world’s wealthiest nation were living in a poverty so deep that most Americans don’t believe it even exists in this country.”
About a year ago I did a mini-dive into a series of books on homelessness and extreme poverty in the United States. Our country prides hard work and makes a lot of our social support programs conditional on individuals making an effort to improve their lives through their own industriousness. Our system is designed to reward those who work hard and put forward the effort to make their lives better, certainly something that is admirable and socially desired. However, one downside of this system is that people who either cannot or will not take the steps necessary to work hard and improve their lives are cast aside with minimal support.
I completely understand people’s dislike (in some cases even hatred) of free riders. It doesn’t feel good to have to go to work every day, to sacrifice sleep or spending time with the people and things we like, and to have to pay for for food, necessities, and pleasures out of hard earned paychecks. It is even worse when we see other people getting by without making the difficult choices that we make each day.
But I think the important thing to remember is that we are all humans, and that our true value as human beings doesn’t come from the work we do, but just from being humans. I think it is important that we all recognize how dependent we are on others, how much we have benefitted from other people to get to the place we are in (even if it isn’t where we want to be), and how much we all want to be respected simply for being ourselves. While we like to be admired for the things we accomplish, at the end of the day we want to be valued for being who we are, and not because of the special things we have done. A system that casts people out, allows them to degenerate on the streets with no support, and blames people who fail without aiding them is a system that has forgotten that our value as human beings is not dependent on our value to an economic or social system.
$2.00 a Day is an important book because it acknowledges an uncomfortable truth that most people try to ignore. For many of us we would rather not look at the person on the street corner asking for money, we would rather not think about people living in abject poverty, and we would not like to bear any responsibility for the poor living conditions of others. After all, most of us work very hard to try to maintain the lifestyles we live. $2.00 a Day reminds us that people living in poverty are still human, shows us that sometimes one poor decision multiplied and placed individuals in situations where making the right decisions to improve their lives was nearly impossible. It helps us appreciate how we got to where we are, and recognize a responsibility to the rest of our society, especially the segment of our society that has failed to the greatest extent. Ignoring the worst poverty in the nation and simply assuming that people are lazy and hopeless denies the humanity of those who suffer the most and can only perpetuate a problem we would like to wish away.