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Comment by fusiongyro | Hacker News Reader

This fatalistic attitude isn't wrong, but it is manifestly unhelpful and surprisingly expensive. Being homeless is not a zero-cost alternative to real treatment; in many cases, the cost of lavish treatment is far lower than the cost of ER visits and criminal proceedings that would otherwise be incurred. I believe Malcolm Gladwell wrote an article about chronic homelessness a few years ago, about Denver rolling out a program to take some number of homeless folks and set them up in an apartment free of charge with on-site nursing 24/7, and it was saving the city millions just by keeping them out of the ER. I believe the program ultimately came under fire because of how essentially un-American such a system is, even when it makes both ethical and financial sense.

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It's 2012 - no one in the world should go homeless, unclothed, or hungry. It's inhumane.

But I don't think that's what this article was about.

The author is arguing that his son would not be homeless if institutional care had not be shut down, not that his son would be a productive member of society. It's practically tautological.

"The author is arguing that his son would not be homeless if institutional care had not be shut down"

Actually, he isn't. The only institutional care he mentions in the What I realize now section is "supportive short-term and long-term community housing and treatment", which doesn't sound like institutional care, in the sense of "When he was in jail, with its regular routines and meals, Tim usually stabilized". There was a reason why total institutions were, well, total.

In fact, his "if I were a legislator today" comments are essentially the same as the "I jumped at the opportunity to" do actions in the 1980's.

That's a good point. The article begins with him discussing the shutdown of institutional care in favor of integrative approaches. But you're right, the solution he's promulgating at the end isn't really the same thing.

And that's what shocked me as well. He made the right diagnosis with the right title and the right observations, but jumped to the wrong conclusions :-/

He made the right conclusions and these programs have already been implemented. (at least in my state)

There are many community-based mental health providers. They are private-sector companies, usually nonprofits, that provide treatment paid for by state funding (medicaid, etc.).

No, it contradicts his own title and facts : When he was in jail, with its regular routines and meals, Tim usually stabilized. But when he was released (...) he destabilized right away

The "humane reforms" may not have been just for the good. More details in http://news.ycombinator.com/item?id=4662700

The point I was trying to make is that these smaller community-based facilities do provide the stability that clients need to compensate. In fact they do a better job than a large impersonal institution.

It's actually not a good point, see my reply above.

Upvote for using the word 'promulgating' though. Good show :o)

Saying "that's a good point" has as much or more to do with social courtesy than "winning" the conversation. (Have you seen this? http://www.newyorker.com/humor/2012/09/03/120903sh_shouts_si... )

I say it's a good point because it may be worth making a distinction between early-mid 20th century institutional care in an asylum and early 21st century institutional care through a variety of assistance programs. You have presented a good case that the distinction is either meaningless or that there is a direct relationship between the former and the latter, but either way, the article doesn't spell out the link between the two.

That's true, the article really didn't explain much about the programs he would like to see. I could have done a better job of explaining myself but it was late.

These residential programs are providing the type of solid routines that allows a client to stabilize and are actually doing a better job than the large institutions (according to my data). Think of the difference between how well most students do in a large impersonal lecture hall vs. 1 on 1's with teachers who take a real interest in their education.

> "supportive short-term and long-term community housing and treatment", which doesn't sound like institutional care

But it is. The housing/treatment he is referring to covers a range of facilities from supported housing to crisis centers to residential and secure residential treatment facilities based in the community. The goal of these facilities is to provide the stability necessary for a person to compensate and, ideally, re-enter society.

Some folks need to enter a crisis center for a short stay during a time of instability. Some simply need a place to live (supported housing) with just a little more structure. There are also people who are chronically ill and do well (some not so well) in a residential or secure residential treatment program, but will never leave because they are unable to function without the stability of an institution.

Mental illness is a spectrum, hence the array of different support tools. The programs the OP was if'ing about exist, and are progressing. For instance, there is new legislature in my state that expands these programs to include general medical and dental care.

Just curious, which state are you in?

Oregon, specifically Multnomah County.

Part of my job includes tracking (arguably) quantifiable data on how clients respond to community-based residential treatment. I have not been in this space long, and I'm still learning about the underlying process/politics that our business model exploits. But I do have the data to show that residential treatment works, sorry I can't share.

pretty bold claim... source? below you said it was tried on "tens" of people. both ethics and finance differ quite a bit at any larger scale.

Aha, I found it: http://www.gladwell.com/2006/2006_02_13_a_murray.html

> when it makes both ethical and financial sense.

It saves money on a small scale because no one's trying to defraud it yet.

On the other hand, you have to ask whether the cost of trying to make sure not a single dollar is given to the undeserving outweighs both the monetary savings and benefits to society overall. Don't throw the baby out with the bathwater.

I envision this to be a lot like crime. You'll never get rid of it completely, so you put into place some (ostensibly) cost-effective measures to mitigate the worst of it.

> On the other hand, you have to ask whether the cost of trying to make sure not a single dollar is given to the undeserving outweighs both the monetary savings and benefits to society overall. Don't throw the baby out with the bathwater.

based on no data, what-so-ever? I believe the parent claiming that there would be no monetary savings at-scale or in the long term

And you believe that, based on no data what-so-ever? ;)

Right now, we spend a lot of money and get very little. If we chose to spend more rather than passively leak money, we'd at least be able to exercise some control over how it's spent, benefit from economies of scale, and so on.

To be explicit, I'm drawing a distinction between efficiency of dollars and raw quantity of dollars. Given the choice between spending $250 and getting nothing versus spending $500 and receiving something of substantial value, I'd opt for the latter. And that's what the qualifier about "benefits to society overall" is about; there's more value to be had from this than some dollar amount.

But if all we're thinking about is a) how many dollars it costs (and not how we're wasting money now), and b) that some small subset of people might game the system (which will always happen, regardless of counter-measures), I think that's self-defeating.

The article I'm remembering actually addressed that. The program was limited to a very small number of people--tens, or fewer. They actually had one that wrecked his apartment every week, and still it was cheaper to fix it back up than to let this guy back on the street, where he would incur about $1M a year in ER bills. One of the big objections to this program came from the fact that the scale was so limited.

One of the big objections to this program came from the fact that the scale was so limited.

You would think that this kind of operation would get cheaper at scale. You might not need 2X wrecked-apartment-repairmen for 2X people housed.

The fraud that jumps to my mind is a hypothetical person taking a free apartment, when they are perfectly capable of supporting themselves and would do so if the alternative was homelessness. That's certainly not cheaper.

I make no claims about how common this kind of fraud would actually be.

This argument irks me. Have you been on the inside of a homeless shelter?

The constant bed bug invasions, bunking right next to a paranoid schizophrenic, living in constant fear of rape (yes, even for men)? Treated like a social pariah on a good day, non-existent the next? This isn't even the tip of the iceberg, I assure you.

Life inside the system is not nearly as rosy as you might think.

Often I feel like people should be made to work directly with the homeless before letting them spout off on this particular topic.

Nothing in the GP post says anything about the rosiness of life inside the system.

Your post suggested that the system wouldn't scale due to fraud - the implication being that people would take advantage of the free housing being provided.

What I said was that the conditions in these institutions is so inhumanly bad, that no one in their right mind would voluntarily do it. So what kind of fraud are you thinking of?

People running shelters taking advantage of government funding perhaps? Still seems the money is too little to make much profit through fraud, but there's no shortage of bottom-feeding hustlers and slumlords to try...

Banks combat fraud by investing in fraud prevention. They make it work because the margins are greater than the expense of the fraud prevention.

Without calculating the expense spread between the criminal justice system and the mental health system, I'd wager that the savings will be great enough that we can afford fraud prevention too.

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