Health Care Costs amongst the Chronically Homeless

Loved this article (although somewhat dated now) by Malcom Gladwell about homelessness and the cost of giving them health care, one emergency room visit at a time:

"'O'Bryan and Johns called someone they knew at an ambulance service and then contacted the local hospitals. 'We came up with three names that were some of our chronic inebriates in the downtown area, that got arrested the most often,' O'Bryan said. 'We tracked those three individuals through just one of our two hospitals. One of the guys had been in jail previously, so he'd only been on the streets for six months. In those six months, he had accumulated a bill of a hundred thousand dollars—and that's at the smaller of the two hospitals near downtown Reno. It's pretty reasonable to assume that the other hospital had an even larger bill. Another individual came from Portland and had been in Reno for three months. In those three months, he had accumulated a bill for sixty-five thousand dollars. The third individual actually had some periods of being sober, and had accumulated a bill of fifty thousand.'"

His remedy is really simple but incredible. The fact is the soup kitchens and the homeless shelters are not working because they assume something about homelessness that isn't true. Most homeless are not chronic. The chronic homeless make up a small percentage and they are the toughest cases.

"'If it's a medical admission, it's likely to be the guys with the really complex pneumonia," James Dunford, the city of San Diego's emergency medical director and the author of the observational study, said. "They are drunk and they aspirate and get vomit in their lungs and develop a lung abscess, and they get hypothermia on top of that, because they're out in the rain. They end up in the intensive-care unit with these very complicated medical infections. These are the guys who typically get hit by cars and buses and trucks. They often have a neurosurgical catastrophe as well. So they are very prone to just falling down and cracking their head and getting a subdural hematoma, which, if not drained, could kill them, and it's the guy who falls down and hits his head who ends up costing you at least fifty thousand dollars. Meanwhile, they are going through alcoholic withdrawal and have devastating liver disease that only adds to their inability to fight infections. There is no end to the issues. We do this huge drill. We run up big lab fees, and the nurses want to quit, because they see the same guys come in over and over, and all we're doing is making them capable of walking down the block."

The solution is surprisingly simple. It turns out it would be much cheaper just to put these chronic homeless people up in an apartment and have a nurse check up on them. Provide enough of a support system that they keep their lives stable enough that they don't fall back onto the streets.

But this solution is unsatisfying in our political culture.

"The current philosophy of welfare holds that government assistance should be temporary and conditional, to avoid creating dependency. But someone who blows .49 on a Breathalyzer and has cirrhosis of the liver at the age of twenty-seven doesn't respond to incentives and sanctions in the usual way. "


"That is what is so perplexing about power-law homeless policy. From an economic perspective the approach makes perfect sense. But from a moral perspective it doesn't seem fair. Thousands of people in the Denver area no doubt live day to day, work two or three jobs, and are eminently deserving of a helping hand—and no one offers them the key to a new apartment. Yet that's just what the guy screaming obscenities and swigging Dr. Tich gets. When the welfare mom's time on public assistance runs out, we cut her off. Yet when the homeless man trashes his apartment we give him another. Social benefits are supposed to have some kind of moral justification. We give them to widows and disabled veterans and poor mothers with small children. Giving the homeless guy passed out on the sidewalk an apartment has a different rationale. It's simply about efficiency."

And these are the kind of solutions I love, ones that don't fit easily into political ideology, but political ideologically driven solutions rarely work - they are usually solutions that solved yesterday's poorly understood problems.