Thoughts from a Layman
Publications which inform my daily reading, in hard copy if the truth be told, are the
“Wall Street Journal” and the “New York Times.” I hereby request forgiveness for not littering everything below with footnotes; besides, an occasional thought is unique to the undersigned.
Weaving every discussion item into a logical flow, replete with extended examples, is a challenge suitable for a book format, not for this modest essay. One would have to figure out which comes first, the chicken or the egg, the good intention or the unfortunate outcome, the theory or the evidence, mental health challenges or the consequences thereof.
Moreover, as a well-known advocate of school choice once said, and it’s true about many policy debates, “it ain’t about the research, it’s about the will.”
Most often, conversations about meaningful reforms simply beg the unwritten but pervasive question: do those with money/power, living in a different world, care? Are they are only energized when an issue hits close to home or they begin pondering whether they want to be the richest person in the cemetery.
Drug Reform
Drugs as defined here are those whose usage traditionally has been deemed illegal. Excessive consumption of legal drugs has its own downside, but historically that has suggested a separate set of factors. However, as the lines increasingly become blurred, that prior separation will be a distinction that is not much of a difference.
Data Points
*Drug overdoses in the past 24 years have killed more Americans than all its wars combined. There are an estimated 48 million individuals with a substance disorder; one in 20 are getting help.
*Half of those in criminal court and half of those in jail or prison have a substance use disorder. Some 15% of inmates are said to have an opioid use disorder specifically. (Meanwhile, the Sackler family is content with the $10 billion they took out of Purdue Pharma in 2008-17; the debate about who gets what from its settlement money of $6 billion does not touch the prior withdrawals. The Sacklers should not receive lifetime immunity, given the deadly consequences of their marketing of opioids.)
Discussion Comments
*There should be a clear acknowledgement that prior large-scale efforts, both in this country and elsewhere, have been a waste of money, with no impact on drug addiction. This is the negative lead.
*The positive lead is that there is knowledge of what works programmatically yet there is insufficient money and staffing for that success. Medication, behavioral therapy, and counseling are reportedly as effective as statins are for cholesterol or aspirin regarding heart attacks.
Methadone (introduced in 1972) is proven to be effective; however, doctors and pharmacists can only prescribe it for pain. Addicted individuals must go to a specialized clinic. P.S. It would be helpful for medical schools to require addiction training.
*There is a choice to be made: treat all the social ills that perhaps foster addiction (admittedly a desirable goal) or call it a health issue and proceed accordingly. Only the latter makes sense in terms of a direct approach, inclusive of evidence-based programs and reasonable timeframes.
*Accompanying the health-based approach to drug reform should be on-going, clear, succinct publicizing of the dramatic negative statistics associated with addiction. Probably a coalition of healthcare and police professionals should produce the document to avoid it being politicized. PSA material should be provided to all forms of the media.
*A distinction must be made between usage and addiction.
*Health insurance coverage, inclusive of Medicare and Medicaid, will be needed without squabbling. Society pays either way.
*There should be no hesitancy on funding treatment programs of all kinds, including those based in churches which do not use mainstream approaches, or others like AA which have a spiritual component.
*A special program is needed for those whose addiction is directly tied to a conflict-based PTSD diagnosis. It must be organized, managed, and led by veterans and specialists in the field.
*The existence of different states having different laws with respect to marijuana should be recognized as a positive. This diversity, properly researched (control group test comparisons), should shed light on the impact of marijuana usage, its relevance as a gateway drug, specific results regarding addiction, connection to mental health, and ties to improper driving. (People crossing state lines and entering different jurisdictions may confuse the data a little, as would inconsistent legal enforcement.)
*Clarity on what is a crime and what is an illness is a necessity.
*There is no safe usage amount for fentanyl; there are no long-term users, unlike the case with heroin.*While it is controversial whether drug addicts must be compelled to seek treatment, it seems logical that if addiction leads to negative social behavior, the public has an interest in requiring treatment. Similarly, if insurance is to play a pivotal role in thinking about addiction as a health issue, it is fair for the insurer to have some requirements, e.g., enrollment in a rehab program. The latter should have length to it; history indicates that short-term stints are highly correlated with relapses.
Police Reform
Somewhere along the analytical and social policy line, there should be thought given to the impact of single-parent families, more specifically, the absent father situation and its connection to other reforms. Prisons are not populated by large numbers of educated, non-drug using individuals from intact families.
Data Points
The FBI’s classification called Violent Index Felonies (murder/non-negligent manslaughter, robbery, rape, aggravated assault) has a 45% clearance rate. Property Index Felonies (burglary, larceny theft, motor vehicle theft, arson) have a 17% clearance rate. Who said that crime does not pay! The irony is that it is not uncommon for people who are jaundiced about the police in general to simultaneously want them to be more forceful in their neighborhood, protecting the stores which they patronize and which may be owned or at least managed by individuals known to the community.
Drug law offenders comprise 15% of state prisoners, which in turn are 90% of total prisoners in the country’s system of incarceration. About 20% of drug offenders are out within six months; another 25% are out in months seven through twelve. (Obvious note: drug reform and police reform are inextricably linked, as is gun reform (and approaches to interacting with the homeless population).
The rate of prisoners having Anti-social Personality Disorder (ASPD) is ten times the average for all adults. Rates of substance use disorder (SUD) are similarly far above the average. See above comment plus the need for more mental health counselors in general. There is something called the criminogenic effect: incarceration which leads to more crime after the release of the prisoner. With the above changes, this should be reduced.
Over 40% of Americans either own a firearm or live with somebody who does. Gun reform is therefore a related necessity. Maybe the lawsuit brought by a group of nuns will prove useful; the death of innocents seems to have no effect on the NRA and gun manufacturer executives. Perhaps some police departments would welcome different gun laws or simply stronger enforcement of existing regulations, given the underpublicized nature of single fatality gunshot situations.
Discussion Comments
Acknowledge the poor reputation that police departments have among the minority population, particularly African Americans. The root causes of this disaffection are multi-layered and multi-generational. This writing is not intended to be a deep dive into the history of policing in America. Suffice it to say that anybody who does not realize there is a problem is living a sheltered, advantaged life. The creation of trust is critical.
*Have an annual Report to the Public that is discussed at an Open House. This report would be from each police department, making it readily understandable by the relevant constituency.
*Establish an internal disciplinary threshold, based on frequency and severity, that elicits the public release of a policeman’s status.
*Create a position for a Mental Health specialist pertinent to the use of red flag guidelines. Mental health is right there at the police department intersection of drug and homeless reform.
*End the practice of paying bonuses based on the number of traffic or parking tickets issued.
*Implement as many neighborhood patrols without guns as feasible.
*As a policy, there must be extended talking preceding any use of guns, unless a life is threatened.
*Similarly, police must be trained to shoot to incapacitate, not to kill.
*Oversight boards must have direct access to, e.g., footage from police videos. Many had thought the routine use of cameras would reduce the number of “awkward” police-individual interactions, but often the police have been reluctant to release the video on a timely basis or even at all.
Homelessness Reform
In a separate essay, an update on UBI (Universal Basic Income) enumerates the many ways in which a UBI would be beneficial. While it does not specifically discuss an impact on homelessness, the significance of a UBI is apparent. Between requiring a homeless person to access a long list of social services as a requirement for financial assistance and providing that person UBI funds for their own decision-making, the preference at the outset would be the latter. Only if the chosen path were clearly negative would the homeless person be pulled back into a set of required social services.
Data Points
“The federal programs for public housing, including Section 8 and Housing Choice Vouchers, serve 287,000 fewer households than they did at the peak in 2004.” The number of eligible households without aid has grown dramatically. Even subsidized apartments built with Low Income Housing Tax Credits are above the affordability level of former prospective occupants.
*What is “affordable” housing? It’s simply math, with a bunch of variables. If the rent limit is 30% of income and the latter is $20,000 per year, then the monthly rent has to be a maximum of $500. The only way that a builder can put up such a structure is if there is a waiver concerning a dizzying array of zoning laws and building regulations, none involving a definition of safety that a low income person would care about. Tax incentives are part of the mix, but here again there is the core question: does society care enough to absorb some discomfort in treating the issue of homelessness. The pervasiveness of NIMBY suggests the answer is negative.
*New York City’s Department of Social Services has an astounding 600 sites operating under non-profit contracts. The count of specialized mental health shelters is 37. There is a mental health data base, PSYCKES, but shelter workers cannot access it.
Discussion Comments
*Acknowledge that the reasons behind a person, or a family, becoming homeless are incredibly complex. A safe place to live is the necessary but insufficient condition to “solving” homelessness.
*There need to be zoning changes, with easier access to permits for mobile homes and the new category of tiny homes. This is particularly critical outside of tight urban areas. Factory-built housing is cheaper and can be done faster, but thus far accounts for a tiny segment of total housing production.
*Mental health facilities must be expanded at the community level and they must be accommodating to those with drug addiction health issues. Presumptively, the more that homeless people have a safe abode, their stress level will decline somewhat and their mental situations will be improved. That many will still need relevant social services, and job training in many instances, is a given.
*If a homeless person is receiving financial assistance for their residence, they must abide by any mandatory social service requirement.
*Analytically, as always, there is the challenge of patient privacy versus the public’s right to information needed to evaluate the pros and cons of different reform efforts. Understaffing leads to triage decisions, but evidence-based decision-making is still the goal.
Under Kendra’s Law in New York, doctors can petition a judge to force mentally ill people into treatment if (1) they have lashed out once within the prior four years or (2) been hospitalized twice in three years for failing to follow their treatment plan. If the petition is granted, the person gets medication and monitoring by specialists. Without this, there can be no medication against a person’s will.
*SCOTUS has taken on a case in which “it will decide whether it is constitutional for municipalities to prohibit homeless people from camping in public places when they have nowhere else to go.”
*Education — broadly defined as everything from a one-week course on being a restaurant server to enrolling in a four-year college, from learning to run a rudimentary machine to getting updated on the profession that once might have been relevant to the homeless person — should be required if a homeless person is receiving financial assistance.
*Homeless families have the right to keep their children enrolled in their initial school, even when families move. (It’s interesting that this category of families in effect has school choice, while the non-homeless family does not have that right. But that’s for a different essay, about education reform.)
*In the new residence, no guns should be permitted. (There is a broad reform area not discussed in this piece, namely that of guns overall.)
Relevant Programs
The brainchild of a committed individual, Austin has a Community First! Village, consisting of 200 sq.ft. homes. Bathrooms and kitchens are communal. The goal ultimately is to have permanent housing for half of the city’s homeless population. Rent is $385 per month, a low number except not in the context of average incomes of $900/month.
Single-room occupancy (SRO) facilities have a mixed to negative reputation. A modernized version called PadSplit rents rooms for $100 a week; median income is $30,000; average age is 35. Since 28% of households are single-occupant situations, PadSplit makes sense. Whether it has great relevance to homelessness per se is not yet evident.
Nevada Cares Campus is comprised of a large tent and low-priced modular living quarters. The homeless count in Reno has been reduced, but the residences alone would not have moved the needle; help in finding jobs and/or accessing social services is part of the program.
Houston is labeled a homeless success story. Its lack of regulation means a $200,000 one-bedroom house can be built, a fraction of the cost in most major cities. Its approach includes services designed to keep formerly homeless people in their new residences. And apparently, the political powers and the non-profit community are more in synch than is typically the case. The estimated cost of reducing the homeless population is $13,000 for the residence and $7,000 for case management. Landlords receive an incentive fee of $1,600 per unit. The Way Home Houston has 100 of these units.