The Mental Health Crisis in America’s Jails, Part II

If you have any doubt about the inverse relationship between the availability of mental health treatment and the population of our county jails, check out this heartbreaking Sacramento Bee article about a woman who, quite literally, wound up in jail because of budget cuts to her local mental health treatment providers. In light of this news, and following up on yesterday’s post, I thought I’d note this excellent post over at Grits for Breakfast detailing a recent tour of the massive Harris County Jail in Houston. The Harris County Sheriff is seeking funding to build a new 1,200-bed mental health ward. The need for some sort of mental health treatment is there — to give just one statistic, of the Harris County jail population of about 8,800 inmates, some 2,500 are on some form of psychotropic meds. But Grits is skeptical of the expansion plan:

There are just a few thousand people cycling in and out of the jail – many of them mentally ill, homeless, addicted, or with other major barriers to successful rehabilitation – who are primarily responsible for the demand for increased capacity. These folks generate high per-person costs over time but as a matter of policy (a de facto if not an intentional one), Harris County is spending money on them at the jail instead of seeking community-based alternatives.

How much cheaper would it be to focus on reducing the number of visits and lengths of stay by frequent flyers than to simply build more capacity to accommodate a dysfunctional system?

These insightful comments reminded me of a New Yorker article by Malcolm Gladwell from a few years back about the problem of chronic homelessness. The article’s title, “Million-Dollar Murray,” refers to a homeless gentleman who — between jail visits and emergency room stays — cost the city of Reno and the state of Nevada about a million dollars over a ten-year period. Unfortunately, the full text is behind a paywall, but here’s a snippet:

In the nineteen-eighties, when homelessness first surfaced as a national issue, the assumption was that the problem fit a normal distribution: that the vast majority of the homeless were in the same state of semi-permanent distress. It was an assumption that bred despair: if there were so many homeless, with so many problems, what could be done to help them? Then, fifteen years ago, a young Boston College graduate student named Dennis Culhane lived in a shelter in Philadelphia for seven weeks as part of the research for his dissertation. A few months later he went back, and was surprised to discover that he couldn’t find any of the people he had recently spent so much time with. “It made me realize that most of these people were getting on with their own lives,” he said.

Culhane then put together a database—the first of its kind—to track who was coming in and out of the shelter system. What he discovered profoundly changed the way homelessness is understood. Homelessness doesn’t have a normal distribution, it turned out. It has a power-law distribution. “We found that eighty per cent of the homeless were in and out really quickly,” he said. “In Philadelphia, the most common length of time that someone is homeless is one day. And the second most common length is two days. And they never come back. Anyone who ever has to stay in a shelter involuntarily knows that all you think about is how to make sure you never come back.”

The next ten per cent were what Culhane calls episodic users. They would come for three weeks at a time, and return periodically, particularly in the winter. They were quite young, and they were often heavy drug users. It was the last ten per cent—the group at the farthest edge of the curve—that interested Culhane the most. They were the chronically homeless, who lived in the shelters, sometimes for years at a time. They were older. Many were mentally ill or physically disabled, and when we think about homelessness as as social problem—the people sleeping on the sidewalk, aggressively panhandling, lying drunk in doorways, huddling on subway grates and under bridges—it’s this group that we have in mind. In the early nineteen-nineties, Culhane’s database suggested that New York City had a quarter of a million people who were homeless at some point in the previous half decade—which was a surprisingly high number. But only about twenty-five hundred were chronically homeless.

Gladwell goes on to explain how much this small chronically homeless population costs local government — for instance, $62 million a year in New York City alone on its 2,500 chronically homeless citizens. He describes a Denver pilot program that connects chronically homeless individuals with an efficiency apartment and intensive caseworker supervision. It costs about $10,000 per client per year at first, and the idea is that as some clients become more self-sufficient and can cover more of their rent, costs will decline to about $6,000 per year — not an insignificant outlay, but cheaper, in the long run, than what Denver taxpayers are already paying for innumerable jail and emergency room stays, and perhaps more effective, too. I am not sure whether there have been any follow-up studies on this Denver program, but would be interested to hear from readers who might know more. With local and state governments more cash-strapped than ever, it may be worth reconsidering the de facto policy that allocates millions to our most vulnerable populations—but only after they’ve been arrested or fallen into some grave medical emergency. Could local government save in the long run by spending more on safety nets in the short run?