Tuesday, March 14, 2006


Cutting-edge Billings plan to end chronic homelessness

I admit I was surprised to see a Bush appointee advocate a cutting-edge plan that would actually help the chronically homeless.
The solution Mangano has been recommending is giving the chronically homeless a place to live, and providing them with a full-time case manager who makes sure that clients are eating right, staying on medications, looking for work and so on.
Spending so much on the chronically homeless is actually cost-effective. Without a place to live and constant supervision, these homeless tend to rack up medical bills in excess of a million dollars over the course of a lifetime. While the plan doesn't rehability the homeless, giving them an apartment and personal case worker keeps the visits to the emergency room to a minimum. Does this argument look familiar? It should. It was the same homeless plan advocated by Malcolm Gladwell in a February issue of The New Yorker, "Million-Dollar Murray." According to Gladwell:
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,” [researcher Dennis Culhane] 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.
Furthermore, Culhane tracked these 2,500 chronically homeless and discovered they cost the city of New York $62 million a year to shelter. In Boston, a group tracked the medical expenses of 119 chronically homeless.
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.
In pilot programs, cities gave these chronically homeless an apartment and case worker. There were problems. (One Denver man invited his friends home to regularly trash his apartment.) But the biggest problem with the program is its guiding priciple: unlike current homeless care, "power-law" homeless policy creates dependency on the system. And not only that, it's not fair.
There isn’t enough money to go around, and to try to help everyone a little bit—to observe the principle of universality—isn’t as cost-effective as helping a few people a lot. Being fair, in this case, means providing shelters and soup kitchens, and shelters and soup kitchens don’t solve the problem of homelessness. Our usual moral intuitions are little use, then, when it comes to a few hard cases. Power-law problems leave us with an unpleasant choice. We can be true to our principles or we can fix the problem. We cannot do both.
Ultimately the plan may never work. Not because it's not based on sound policy, but because both ends of the political spectrum find it distasteful:
Power-law solutions have little appeal to the right, because they involve special treatment for people who do not deserve special treatment; and they have little appeal to the left, because their emphasis on efficiency over fairness suggests the cold number-crunching of Chicago-school cost-benefit analysis.
In the end I agree with Gladwell that this may be a chance to end homelessness as we know it. While I agree that it doesn't solve poverty, the homeless families living out of cars, the too-low wages for working-class people, it will solve up a problem and free monies for other programs.
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