Category: Homelessness

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Funding Homelessness Policy Public health psychiatry

Geriatric Homelessness and Medicaid.

I submitted the following as an op-ed essay, though neither local publication accepted it. (I understand: Many people have many opinions about all the actions and inactions happening these days.) The tie-in with Medicaid is important, though I more want people to know this: There are people who are old enough to be your parents and grandparents who don’t have a place indoors to call home.

A van has been in the same parking spot in South King County for over six months. Inside are unopened water bottles, packages of adult diapers, trash bags—and a man. He is over 70 years old. Though he isn’t sure what year it is or the name of the current president, he knows that he wants to live in an apartment. He just doesn’t know how to make that happen. 

In another city park in South King County, a woman sits alone next to a trash can. Her black wire pushcart is stuffed with plastic bags. The stink of urine that surrounds her keeps people away. The trees are bare, a cold breeze is blowing, and she thinks it is a Saturday in June. She is also in her 70s. She slept outside last night, as she has for several years. The only topic she can speak of with confidence is her pet cat.

These are not isolated tragedies. They are alarms. If Congress follows through on its proposed Medicaid cuts, more vulnerable older adults—including those with dementia—will be forced onto the streets. This is unacceptable.

Older adults with memory problems who live outside seem like exceptions. In fact, they are part of a growing population. The US population is older than it has ever been. The number of Americans over the age of 65 is projected to increase by millions in the coming decades. Increasing age is the greatest risk factor for the development of dementia.

The California Statewide Study of People Experiencing Homelessness revealed that nearly half of single homeless adults were over 50 years old. Of them, over 40% became homeless for the first time at age 50 or older. Many of these older adults are eligible for Medicaid because they are poor. If they had more money or support, they would not be living outside. 

Dementia, like other chronic illnesses, drains savings. The costs of care add up fast. In Washington State, in-home caregiving services average over $31 an hour. Facility-based care, such as an assisted living facility, is also expensive–nearly $7000 per month. Skilled nursing facility costs are even higher. Many older adults run out of money.

This is where Medicaid funding for long-term care comes in. The federal government pays for over half of these Medicaid long-term care services and supports. For many, Medicaid is the only reason they have a place to call home.

Cuts to Medicaid would slash payments to long-term care providers. Staff would be laid off. Facilities would close. What about those with no family support or money? They will have nowhere to go. We will see more older adults, including those with dementia, living outside. No one wants this. Right now, Medicaid is the last safety net catching older adults before they fall into homelessness.

It is possible that Congress will protect Medicaid funds directed towards long-term care. President Trump has said that his federal administration will “love and cherish” Social Security, Medicare, and Medicaid. However, proposals from Congress show a clear desire to divert funds from these programs that thousands of older King County residents rely on. 

The man in the van ultimately agreed to go to a local hospital for brewing medical problems. From there, he was discharged to a skilled nursing facility. He was thankful: This is the first time he’s lived indoors in years. Medicaid made this possible. 

The woman remains outside. Without Medicaid, thousands more older adults will join her. That is the future Congress is choosing if it cuts Medicaid. 

Categories
Homelessness Policy Public health psychiatry

The Word “Mental” in Project 2025. (vi + vii)

The sixth instance of the word “mental” is on page 509 in the section about “First-Day and First-Year Administrative Reforms” for The Department of Housing and Urban Development (emphasis mine):

The Office of the Secretary should execute regulatory and subregulatory guidance actions, across HUD programs and applicable to all relevant stakeholders, that would restrict program eligibility when admission would threaten the protection of the life and health of individuals and fail to encourage upward mobility and economic advancement through household self-sufficiency. Where admissible in regulatory action, HUD should implement reforms reducing the implicit anti-marriage bias in housing assistance programs, strengthen work and work-readiness requirements, implement maximum term limits for residents in PBRA and TBRA programs, and end Housing First policies so that the department prioritizes mental health and substance abuse issues before jumping to permanent interventions in homelessness. Notwithstanding administrative reforms, Congress should enact legislation that protects life and eliminates provisions in federal housing and welfare benefits policies that discourage work, marriage, and meaningful paths to upward economic mobility.

The seventh instance of the work “mental” is on page 516 as a footnote to the paragraph above (emphasis again mine):

The U.S. Interagency Council on Homelessness (USICH) was established in the 1990s, and numerous Administrations have devoted enormous resources to the Housing First model, experimenting with various ways to provide federally financed rapid rehousing and permanent housing opportunities. Housing First is a far-left idea premised on the belief that homelessness is primarily circumstantial rather than behavioral. The Housing First answer to homelessness is to give someone a house instead of attempting to understand the underlying causes of homelessness. Federal intervention centered on Housing First has failed to acknowledge that resolving the issue of homelessness is often a matter of resolving mental health and substance abuse challenges. Instead of the permanent supportive housing proffered by Housing First, a conservative Administration should shift to transitional housing with a focus on addressing the underlying issues that cause homelessness in the first place.

    Long-time readers will recognize that this falls right into my professional bailiwick…

    (cracks knuckles)

    … but I won’t spend too much time on the data because there are excellent summaries elsewhere. For example, the Office of Policy Development and Research published Housing First: A Review of the Evidence. There they describe the stance the federal government took in the 1990s, summarized as “treatment first”:

    housing was available only to individuals experiencing homelessness who were willing to work for it.

    This is exactly what the authors of Project 2025 want. If they know this history, they know that this “treatment first” model did not reduce homelessness, but an alternate model called “housing first” did, and for various populations:

    Overwhelming evidence from several rigorous studies indicates that Housing First programs increase housing stability and decrease rates of homelessness. The best available evidence indicates that Housing First programs successfully house families and individuals with intersecting vulnerabilities, such as veterans, individuals experiencing substance use or mental health issues, survivors of domestic violence, and individuals with chronic medical conditions such as HIV/AIDS. 

    While the authors of Project 2025 argue that “mental health and substance abuse challenges” are the “underlying issues that cause homelessness in the first place”, they again are ignoring data that illuminates the actual underlying issue (emphasis again mine):

    Much of the research looks at the variation in homelessness among geographies and finds that housing costs explain far more of the difference in rates of homelessness than variables such as substance use disorder, mental health, weather, the strength of the social safety net, poverty, or economic conditions.

    Is it true that there are some people who are homeless because of their “mental health and substance abuse challenges”? Yes. However, their common denominator is not having enough money. There are people with “mental health and substance abuse challenges” who are not homeless and that’s because they have enough money, or someone else has enough money, to pay their rent. (Think of the depressed ladies who buy cases of wine from Costco and return to their suburban homes to drink 20 bottles of wine a week….)

    So that’s the data. But, as a psychiatrist who works with people who are or were homeless, let me share some some “n of 1” perspectives about the work.

    Importantly, most people who are homeless don’t need the services of a psychiatrist. Could they use mental health support? Sure: When you don’t know where you’re going to sleep tonight, anxiety is a natural reaction. If you find a place to sleep, but there isn’t a door you can lock (or a door, period), you probably won’t sleep well. Without routine access to a bathroom or running water, you can’t keep yourself as clean as you would like, so you start feeling self-conscious about it. It’s hard to perform well at work if you aren’t sleeping well, you don’t feel your best, and you don’t have a place to call home. You know what solves these psychological problems better and faster than a psychiatrist? Housing.

    A psychiatrist can help people with significant psychiatric conditions (like schizophrenia) who are homeless. Among the reasons some people have shared with me about why they will not move indoors:

    • The aliens will assassinate me if I move inside.
    • I want an apartment, but God tells me that I don’t deserve to be indoors.
    • If I move in, they will turn on the parametric speakers to make me insane.

    Most of these people don’t have jobs because their symptoms get in the way of their ability to show up on time, work with customers, etc. Because many of them have had terrible experiences with the traditional health care system, some are reluctant to talk with me. But, with the essential help of my non-medical colleagues, many will. Some people, with time and relationship-building, will agree to try medication to treat their symptoms. (Yes, this really happens.)

    When you don’t have a stable place to live with a door to lock and easy access to cabinets and calendars, it’s hard to take medication as prescribed. Pills get lost. Other people might pilfer them. Someone might run off with your bag. Plus, if medications make you sleepy, you might only take them when you know you can sleep safely. You know what makes it easier to take medication on a regular basis and manage side effects like sedation? Housing.

    Maybe you’ve heard about long-acting injectable medications. Instead of having to take a pill every day, you can get a shot once a month. This sounds like an elegant solution, right? Some people are cool with shots, but a lot of people aren’t. (Would you want to get a shot every month instead of taking pills?) But let’s say our hypothetical patient who doesn’t have a place to live is willing to get a shot every month. (This really happens, too, but not as often.) The challenge here is finding the person every month to administer the shot. Maybe they will come to a clinic or other meeting spot, but their symptoms can make tracking time (and appointments) a challenge. I can go out and try to find them, but if they move around (because of their symptoms, privacy, safety, etc.), there is no guarantee that I will. You know what helps people receive their medications like monthly shots on a routine schedule? Housing.

    But let’s go to an extreme. Let’s say that I’m working with someone who is homeless whose psychiatric symptoms are severe and dangerous. Maybe they have stopped eating because they are certain that they don’t have internal organs. Or how about this: A man is chasing children with a lead pipe because he believes that the kids are government agents trying to kill him. Here I exercise my coercive power: I go through the steps to hospitalize both people against their wills for psychiatric reasons.

    So now they’re not on the streets, they are in a hospital somewhere. Time passes, treatment works, and they no longer need to be in the hospital. So where are they supposed to go upon discharge? They didn’t have a place to live before the hospitalization. In this Project 2025 universe, they don’t deserve housing because they’re not working, so back out onto the streets they go. And the cycle begins all over again.

    Let me also tell you that most people under my care want to work. Because people who are homeless live in the same culture as those of us who have housing, we are all indoctrinated in the idea that there is value in work, and your value as a person involves work. The jobs they often want are often completely reasonable. The person who thinks the aliens will assassinate her? She wants to work as a bookkeeper again. The person who fears the parametric speakers? He’s open to working in the print shop. The person who hears God telling him that he can’t move indoors? He’d like to be a barber. But when you don’t have an address to put on your job application, or you don’t have the money to apply for classes or a business license, how can you make your employment dreams a reality?

    If the goal is to reduce the number of people who are homeless, then accept the research data and make housing more affordable for all. If the goal is to reduce the number of psychiatrically ill people who are homeless, then ensure that they have stable places to live so they can meaningfully participate in treatment.

    But if the goal is to coerce people, with the threat of homelessness as the cudgel, to live according to the values of the Project 2025 authors, then just be up front about it. Just make sure you follow that line of reasoning to its logical conclusion: Put it in writing that you believe some people deserve to be homeless — and thus deserve to die.

    Categories
    Homelessness Observations

    Tents.

    A tent in the woods is a symbol of defiance. Whether among towering trees, on a rocky beach, or next to an icy lake, it is a marker of someone intruding upon the natural world. Even if the tent and its occupants leave no trace, the tent itself is a trace, a brightly colored sign of someone who is passing through and does not naturally belong there.

    A tent on a cracked sidewalk, underneath a concrete bridge, or tucked into the corner of a parking lot is a symbol of resignation. The tent and its occupants often have no other place to go. They do not belong there and everyone—including them—wishes that they were only passing through. Alas, the tent is their home.

    A tent on a college campus is a symbol of defiance. It is not their home. The tent is a vivid icon of someone who is expressing their displeasure with the status quo. The occupants want progress, they want change. Through occupying their tent in a place where it does not belong, they hope that change will come to pass.

    A tent in a besieged city, its buildings in ruins and its surviving residents terrified, is a symbol of resignation. They, too, have nowhere to go. Alas, the tent is their home.

    I worry how people in power, people who lie, and people who have agendas kept in shadows will manipulate the symbol of the tent. It is much easier to target tents than to recognize the humans within.

    Categories
    Homelessness Policy Public health psychiatry Systems

    Homelessness and the Supreme Court.

    Tomorrow (April 22) the United States Supreme Court will hear oral arguments in the case City of Grants Pass, Oregon, v. Gloria Johnson. This article, 5 things to know about the Grants Pass homelessness case before the US Supreme Court, summarizes the issue well: “The repercussions could have national implications for how cities can regulate homelessness.” In short, if the Supreme Court sides with the City of Grants Pass, it could essentially be a crime to be homeless. (Note: “Homelessness” here refers strictly to street homelessness. The federal definition includes other populations that are not as visible, such as people living in shelters, people about to be evicted, etc.)

    This brings to mind other information:

    California Statewide Study of People Experiencing Homelessness. This came out in June of 2023. It’s one of the few recent surveys that examines mental health conditions and substance use among people experiencing homelessness. Over 3,000 people in various parts of California answered surveys and over 300 people participated in detailed interviews. They didn’t administer technical interviews to determine whether people met diagnostic criteria for psychiatric conditions. They instead asked people if they had ever experienced certain symptoms (e.g., hallucinations, anxiety, depression) or engaged in certain behaviors (e.g., used any substance three or more times a week) in the past or at the time of the interview. More than half of the people who responded said that they either had a mental health condition in the past or were experiencing one now. More than half reported that they had used substances in the past; about one-third reported that they were currently using any substance at least three times a week. (Note that “substance” here does not include alcohol or tobacco.)

    JAMA Psychiatry: Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness. I have yet to read this paper. It’s a review and analysis of past research related to this topic (a research study of past research studies, if you will). It looks like they looked at specific diagnoses, with a call out of 44% of people experiencing homelessness experiencing any substance use disorder. Other highlights included in the abstract include prevalence rates for antisocial personality disorder (26%) (one of my most popular posts—from 2013!—is about this condition, for whatever reason… and I’ve been wondering about this one again), major depression (19%), schizophrenia (7%), and bipolar disorder (8%).

    Open drug scenes: responses of five European cities. This paper is from 2014, though it holds lessons that we in the US can and should learn from. The information within disappoints everyone, which means it is probably a reasonable map to use.

    Open drug scenes are gatherings of drug users who publicly consume and deal drugs.

    To be clear, as evidenced by data shared above and from anecdotes from those of us who do this work, not everyone who is homeless uses drugs. Not everyone who uses drugs is homeless, either. Much of the current discourse about homelessness is related to drug use, though, which is why I bring up this paper.

    The five cities described in the paper vary in size (Zurich, Switzerland, at around 415,000 people to Lisbon, Portugal, at 2.7 million people), though they each use similar strategies to reduce and eliminate open drug scenes:

    • drug dependence is a health problem
    • drug use behavior is a public nuisance problem
    • need for low threshold health services, outreach social work, and effective policing
    • appropriate combinations of harm reduction and restrictive measures

    Law enforcement is needed to address the public nuisance problem. Robust health and social services that include harm reduction are needed to address the health problem. (At least two of the cities legalized heroin so people can use drugs safely in monitored settings, with hopes that they will one day use less and perhaps stop. Recall that this paper came out before the destructive wave of fentanyl overcame us.) Most cities have yet to find the “appropriate combinations” to reduce open drug scenes. (Just to reiterate, these strategies did not eliminate homelessness, only open drug scenes.)

    Textbook Talk: Dr. Van Yu on Housing First and the Role of Psychiatry in Supported Housing. One significant way to eliminate homelessness is to ensure that people have places to live. Lemme tell ya: It is hard to effectively treat someone’s mental health or substance use disorder if they don’t have a stable place to live. If the person can’t or won’t come to you, that means you have to go to them. If you can’t find them (because they don’t have a place to live so they move around a lot), it’s hard to make a connection to help them. Even if they want to participate in treatment, it’s challenging to Do All the Things when you don’t know where you are going to sleep. Can you imagine what you’d do or how you’d feel if you didn’t know where you were going to sleep tonight? Seeing a health care professional likely won’t be your priority. Working in a Housing First or other public setting also changes the way you think about health care: Your interventions don’t just affect one person; they affect a whole community. Conversely, the community influences your interventions as a health care professional. We naturally become systems thinkers. (Full disclosure: Dr. Yu was once my boss. I learned and continue to learn a lot from him.)

    I will follow the City of Grants Pass, Oregon, v. Gloria Johnson case with interest. The problem of homelessness is complex because people experiencing homelessness each have distinct challenges. They are not a monolith. I believe that there are government officials who are sympathetic to their circumstances. I still wonder, though, what problem are they trying to solve? Is it that they don’t want people to live outside? Or that they don’t want to see people living outside?

    Categories
    Homelessness Reading

    Down and Out, On the Road.

    It took me a couple of months, but I finally got through Down and Out, On the Road: The Homeless in American History (first mentioned in this post). Here are the main points I took from the book:

    “Down and Out” refers to people who live in impoverished urban areas. More specifically, people who live on “skid row” are “down and out”. (The term “skid row” likely originated in Seattle. As noted in both the Underground Tour and Beneath the Streets Tour in the Pioneer Square neighborhood, tree logs cut from the hills were pushed down Yesler Way towards the waterfront. Logs skidding down Yesler Way led to the name “skid row”.) These days, “skid row” typically refers to centers of poverty in cities where homeless people often reside. This is paired with…

    “On the Road” refers to people who were homeless and, in trying to search for work, rode the trains. They often did not ride in the train, but rather on or under the train. These same individuals might reside in “down and out” areas upon arriving in a city. During the 1800s, people who were homeless were often associated with riding the rails than living in skid rows.

    The term “the jungle” has been used to describe homeless encampments for nearly 200 years. In recent years here in Seattle, “the jungle” has referred specifically to a large encampment tucked under many trees in an undeveloped area near Interstate 5. This “jungle” was also notorious in the local press for violence (and was subsequently razed, though it seems that there are evergreen efforts to revive it). Over the past 200 years, people who had no place to live set up camp in forested areas (“jungles”) outside of urban centers, which developed into communities.

    Cycles of romanticizing and vilifying homeless people are not new. People with no place to live are poor. Because the working class recognized how similar their struggles were with people who were homeless, they were (and continue to be) consistently more sympathetic, empathetic, and generous to them. Other classes, though, have swung between perceptions that people who are homeless are harmless—perhaps even charming (see Norman Rockwell) to lazy, deviant, and dangerous. (Other indicators include The Way It Is and Mr. Wendal, both excellent songs.)

    Homelessness is a consequence of poverty. When I first received the book, I confess that I was dismayed to see in the index that “mental illness” is mentioned on only four pages of this ~250 page text. Kusmer, the author, provides a compelling historical account that various systems, including government policy (or lack thereof), economic forces, and cultural values are the chief drivers that lead to people becoming poor. Poverty is a major risk factor for homelessness. (I know this from my own anecdotal experience: Most people who are homeless do not have a severe psychiatric illness like schizophrenia. People often develop psychiatric symptoms because of homelessness. Even if every single psychiatrist in the nation worked with people who are homeless, homelessness would persist: There are plenty of people who are unhoused who do not need psychiatric treatment. They need a place to live and ways to have money to pay for living expenses.)

    There was a federal program to address homelessness! Homelessness has been and continues to be a nationwide problem (regardless of the size of the US throughout time) that requires a federal response. The Federal Transient Service (FTS) was the first (and only?) federal agency in US history whose goal was to aid people who were homeless and unemployed. It started in 1933 and only lasted two years, in part because it seemed “successful”: The number of homeless people dropped, so everyone thought the problem of homelessness was solved. FTS funds were swept to support public works and Social Security. (In theory, public works and Social Security seemed like better investments to prevent homelessness.)

    The disproportionate number of homeless people who are Black is not new. This is another legacy of slavery. A number of minority populations (e.g., Native Americans, Mexicans, women) suffer from homelessness because of policies and practices related to economic and class exclusion.

    Down and Out, On the Road: The Homeless in American History was published in 2002. My sense is that the author, when viewing the current state of homelessness in the US, would continue to argue that the forces that contribute to poverty remain the primary driver of homelessness. I think he would continue to view mental illness and substance use as distractions and not significant causes of homelessness. (To be clear, I don’t think he’s discounting psychiatric conditions as contributors to homelessness for specific individuals, particularly since psychiatric conditions, both directly and indirectly, can pull people into poverty.) I appreciate how he ends the text:

    The compulsion to stereotype the homeless as dependent and deviant turns the poorest Americans into an abstract “other,” separate and inferior from everyone else. Although their problems are more severe, however, destitute people living on the streets and in homeless shelters are not so different from the rest of us. They never have been. Any genuine effort to end homelessness must begin with a recognition of that essential truth.