TEDxUCLA 2014: Open 2.0
Can homelessness be solved?
Homelessness sucks. It really does.
On my way here today, I counted about 20 homeless people in Westwood Village just a few blocks from UCLA, in the shadow of this great university on the west side of Los Angeles, one of the wealthiest areas in the country, and we have some of our poorest citizens living on the streets.
I spent the last 27 years working in the nonprofit housing and human services field, the last 14 at OPCC in Santa Monica, serving chronically homeless people with multiple disabilities, including severe and persistent untreated mental illness, chronic medical conditions, as well as victims of domestic violence.
The people we serve are often the sickest and most vulnerable of our neighbors, and yet as a society we haven’t been able to solve what seems like a huge, intractable problem.
Homelessness has become all too familiar in cities and even in many rural areas across this country, and we’ve become accustomed to seeing many of the same people languishing on our streets as we go about our daily business. And we think, well, that’s a shame, but it’s just too big of a problem to fix.
My own thinking about these issues crystallized many years ago when I was invited to be part of a host committee for a group of academics from Western Europe who had come to the United States to study homelessness. And they’d been to New York and Philadelphia and Chicago, and they were coming to LA to see Skid Row.
And I spent the day sitting next to a man on the bus who was very quiet and extremely intense as he was studying the street scene, seemingly endless encampments, shopping carts brimming with people’s belongings, several people passed out on the sidewalks or in the gutters, a sea of humanity and pretty degrading and deplorable conditions, but frankly, a common sight for anybody who’s familiar with the area.
And so at the end of day, I I turned to him and I said, “You know, you’ve been very quiet. And I’m, I’m curious. What are you thinking?” And he looked at me with this expression of shock and disgust and he said, “I’m horrified. Absolutely horrified. The richest country on Earth and yet you let your citizens live like abandoned animals on the streets. In my country, this would never be tolerated. We would overthrow the government.”
Wow. Talk about a teachable moment. To this day, I will never forget the look on his face and the tone in his voice as he expressed the same moral outrage that I also felt but had never directed towards real change.
It wasn’t enough to understand the problem from an intellectual or even an emotional perspective. I knew then that we needed to change the way we were doing business and radically shift the paradigm for long-lasting and positive change.
It’s no mystery how we got here. While we’ve always had very poor and homeless people as part of our society, wide-scale homelessness as we see it today has only become prevalent in the last 30 years.
There are many reasons for this. Policy decisions decades ago that shut down many mental institutions. The loss of jobs and declining wages that help people obtain and keep their housing. The widening income gap that’s pushing more people into poverty. The proliferation of highly addictive and very cheap street drugs like crack cocaine and crystal meth. Veterans returning from war without adequate support to keep them from falling into homelessness. The high cost of housing, especially in our urban areas, where low-income people simply can’t afford to pay their rents. As well as jails and prisons and foster care which continue to discharge people into homelessness.
Now it’s easy to blame one administration or another for these problems, or one political party or another for how we got here. The challenge is not to understand what created the problems. The challenge is to understand how do we get out of this mess?
One of the arguments that’s used for why we haven’t been able to move the needle on homelessness is a lack of resources. We need more money. If we just had more resources, we could do better. Well, of course, resources are important and we can’t do our work without them. So, yes, resources are a critical component in the solution.
But is it a lack of resources that’s really at the root of this problem? Over the last 30 years, we spent billions and billions of dollars to the McKinney-Vento programs at HUD funding homeless services across the country. We spent billions more in health care dollars treating homeless people in hospitals, law enforcement dollars incarcerating them, mental health dollars treating them. Added together, we’re talking about billions and billions of dollars, and yet we haven’t made significant progress. And in Los Angeles, the numbers are increasing. Why?
It’s not a lack of resources. It’s the lack of a holistic, fully integrated, comprehensive service system that addresses all of the multiple and complex needs of homeless people and then uses our resources in a targeted way to meet those needs. Just as we know that humans are comprised of body, mind and spirit, we also know that it’s impossible to make lasting change without a holistic system.
Homelessness is not separate from domestic violence or physical illness or mental illness or substance addiction. That’s not to say that every homeless person experiences every one of these problems, but every one of these problems is connected to homelessness.
And here’s where we need to be honest and change the way we’re doing business. If we believe that a system is a group of integrated parts forming a complex whole, then there is no health care system or mental health care system or homeless service delivery system. There are health care programs and providers, mental health care programs and providers, homeless service programs and providers. But integrated on a large, consistent scale across the country? It doesn’t exist.
Well, by now we should all be pretty discouraged and depressed. Decades of work by smart, dedicated people spending billions of dollars without great results. So before you head for the exits, let me share with you a model of what works, can be scaled up and sustained, and really begin to move the needle on solving homelessness.
Now I know, I know, the poor will be with us always. True enough. But the poor don’t have to and shouldn’t live like abandoned animals on our streets. Instead of having silos of programs serving homeless people as if they’re one-dimensional, why don’t we create holistic systems of care that are genuinely fully integrated and address all of their needs? Until we have a fully integrated system, we are never going to solve this problem.
Let me give you a specific example of what I’m talking about. At OPPC we work with two local hospitals in our community and, like all hospitals, they have many homeless patients coming into their emergency rooms. Now, as soon as these patients are medically stabilized, they’re discharged back to the streets. And usually within a few days or a few weeks, they’re right back in the emergency rooms.
Now, it’s not the hospital’s fault that these folks don’t have a place to live. They’ve done their job by getting them medically stabilized, and that’s a good thing. But it doesn’t address the fundamental issue, that what those people need is stable housing with the ongoing services: health care, mental health care, substance abuse treatment, domestic violence intervention, whatever is needed by that individual in order to help them remain housed and stay out of the emergency rooms. The ER has become the default solution, which is no solution at all. It’s a temporary fix that’s extraordinarily expensive and ineffective over the long haul.
Several years ago, we went to these hospitals and we said, rather than discharging your homeless patients to the streets, please discharge them to us. We’ll take responsibility for housing them and providing all the services they need so that the only time they come to the hospital is when they really need that level of intervention, not because they don’t have a place to live.
So after one year of the program, here’s what we found. The average cost of the hospital emergency room visit dropped from about $1800 per patient down to less than $500. The number of days hospitalized dropped from six days a year to two, and the average inpatient costs dropped from over 34,000 dollars to under 3100 dollars. One hospital alone saved over 300,000 dollars in a random sample of just ten patients. And there were hundreds more who were served by this fully integrated system of care.
It didn’t cost more to provide permanent solutions. In fact, it cost significantly less and had far better outcomes for the people served. And by the way, all of those people are still housed and doing very well.
So you multiply the one-year savings by several years and you begin to understand that this is not a problem because of a lack of resources. The challenges facing homeless people are not isolated one-off situations, they’re interrelated and interacting all of the time, usually to the detriment of the individual. But we don’t treat them holistically. Instead of seeing homelessness as just a lack of housing, we need to embrace radical change in how we connect all the dots.
Here’s a great example of a fully integrated system that most of us in this room use every single day. Regardless of how good any of the individual applications are on this smartphone, the power and effectiveness of this system is how they’re all connected. We’ve been working for decades on many huge social problems, but acting as if they have no relationship to one another.
I can’t tell you how many times I’ve talked to a health care provider or a mental health care provider or a domestic violence service provider who’s complaining about serving a homeless person. And in the same sentence, they’ll say, “Well, you know, we’re really not in that business.” Hey, here’s a newsflash: you are in that business, whether you like it or not, and you will continue to be in that business and still complaining until you figure out that these are not isolated problems.
Now, I can tell you what it looks like when we have a holistic system because we’re doing it every day at OPCC and it works. First of all, it makes a huge difference in the lives of homeless people. They’re housed and off the streets, their health improves, they have an opportunity to become contributing members of the community and have a sense of purpose and well-being.
Our first responders, police and paramedics, are not using very limited and expensive resources to transport people to hospitals or jails where they’ll be for a few hours or maybe a few days, and then be right back on the streets, recycling in and out of expensive facilities that cost all of us an enormous amount in tax dollars and don’t solve the problem. It’s not even a lousy Band-Aid, much less how it perpetuates people’s misery and suffering.
And communities across this country would look very different. We don’t need to have people living on the streets, walking around in full psychotic episodes, passed out in the gutter or begging for money. We know what works, what homeless people want and what’s cost-effective.
Now I said earlier that this is not a problem because of a lack of resources, because we’re already spending billions of dollars. But it’s also true that we continue to serve homeless people on the cheap. That is to say that we create buckets of funding for one problem or another — health care, mental health care, domestic violence, substance addiction — and we continue to insist that these individual services on their own are adequate to address their needs. They are not adequate on their own, and they never will be.
You may have noticed that I’ve used the words “neighbors” and “homeless people” a lot today. That’s because I hate to describe homeless people as “the homeless,” as if they’re a homogenous group. They’re not. They’re is diverse and complicated and passionate and inspiring as any of us in this room.
They don’t need our pity and they certainly don’t deserve our scorn, because regardless of the twists and turns that have led to their current situation, they are not beyond help. They want what we all want: a sense of belonging and connectedness to others, a chance to live with dignity and hope, and the opportunities to share their gifts and talents.
Homelessness is a huge, complex problem. But it’s solvable. We have the data, the resources, and best practices to eradicate this blight from our society. What we’re lacking is a collective moral outrage that my European colleague expressed so eloquently and the political will to get it done.
If you think that leaving people on the streets isn’t costing you anything, you’re wrong. We are spending a fortune in police, paramedic, jail, and hospital costs, most of which is covered by your tax dollars. We could be spending far less and having much better outcomes for homeless people and at the same time creating much healthier communities across this country.
And TED is about big ideas, dreams, and wishes. So here’s my wish: I want to see this holistic model scaled up and implemented in every community on this planet so that all of our homeless neighbors go from this… to this. Thank you.