HOMELESS FOR THE HOLIDAYS
December 23, 1997
During the holiday season, many donate time and money to homeless causes. But dealing with the basic causes of homelessness is more problematic. According to most estimates, between 75 and 90 percent of homeless are either mentally ill, substance abusers or both. Paul Solman, of WGBH-Boston, has been following what Massachusetts is doing to address the issue.
PAUL SOLMAN: A mock funeral on Boston Common in 1996 for the 175 homeless people who died in Boston the previous year.
A RealAudio version of this segment is available.
May 9, 1996
A debate on whether health insurance reform should cover mental illnesses.
Browse the NewsHour's coverage of Welfare.
National Law Center on Homelessness and Poverty
National Coalition for the Homeless
National Institute of Mental Health
American Psychiatric Association
ACTIVIST: Today we speak the names of those who died in the war against homelessness, some as soldiers and all as victims: Paul F.; Timothy G.--
Privatizing mental health care.
PAUL SOLMAN: To these activists death from homelessness in Boston is not just a matter of too little housing but also too little care for the acutely mentally ill who make up so much of the chronically homeless population. By most estimates some 75 to 90 percent of those who live on the streets are either poor mentally ill, poor substance abusers, or both, in Massachusetts, people for whom the Department of Mental Health is responsible. According to an internal department study deaths of this population rose 79 percent from 1990 to 1994. The significance of that, says the department, is that in this period it began keeping better records. But to the critics who staged this event these were the years when the state was closing its mental hospitals and switching to private, managed care. Macy DeLong.
MACY DELONG, Activist: As the medical system that is supposed to serve people with mental illnesses has become privatized, I have watched people not be able to get into hospitals anymore, and I've watched those people harm themselves and come to a point where they could harm other people within 24 hours after that.
PAUL SOLMAN: Macy DeLong is an activist who spent time on the street, herself, in the 1980's, after repeated hospitalizations for manic depressive psychosis. Before that, she supervised a lab at Harvard University, as she tried to explain to us.
MACY DELONG: Going from someone that can run a lab of 30 people to someone that can't teach a dishwasher how to wash a test tube in six weeks is just devastating. David--
PAUL SOLMAN: Could you let me talk to her. Let me talk to her. No, no, I understand, but--
MACY DELONG: (Talking to Ill Man) David, we can't understand what you're saying.
PAUL SOLMAN: We show this encounter with one of the chronically homeless, mentally ill, in this case also a substance abuser of alcohol, to give you some idea of the enormous difficulty of dealing with people who have such problems.
MACY DELONG: Let me wheel you back over here and let me talk to these guys, okay? Please.
PAUL SOLMAN: We've been on this story for two years now, following managed care of mental health for the poor here in Massachusetts, because this state's been in the forefront of the national move to private public services. It began in earnest in response to the taxpayer pressure of the 1980's, and by 1991, Massachusetts had begun to economize on its mental health care costs in several ways: by shutting down half of the state's eight public mental hospitals; by contracting with private hospitals, clinics, and day centers to assume a lot of its work, by giving one company the job of managing all the private contractors. As a results, costs have been held down but at a huge price, says psychiatrist Matthew Dumont, who we first interviewed in the fall of 1995.
DR. MATTHEW DUMONT, Psychiatrist: What we're having essentially is the devastation of a service system for very disorganized and chaotic people.
PAUL SOLMAN: Dr. Dumont, a former assistant commissioner of mental health for Massachusetts, took us to a hospital he used to work at--Metropolitan State--former home to 500 patients, the kinds of people, he said, who had had nowhere else to go.
DR. MATTHEW DUMONT: People who were sent to a state hospital like this were acutely psychotic; they were suicidal; they were generally people who were poor--you go to a state hospital when you don't have any insurance, or when your insurance runs out--or because they were the kinds of patients who were unacceptable to a private environment because they were too violent or because they were too messy.
PAUL SOLMAN: Dr. Dumont now works at one of the state's last poor public mental hospitals, places, he insists that, since the reforms of the 60's, have been providing better care than you get with managed care.
DR. MATTHEW DUMONT: I have never been told that I can only have four sessions with an abused child, or that this depressed person should be put on a drug and seen only three times. And I have never been told at a hospital I'm working in now that I'm sorry, this patient's insurance has run out; the patient has to be discharged.
PAUL SOLMAN: We took Dr. Dumont's complaint to the state's current commissioner of mental health, Marylou Sudders. Outside this big building she works in, an uncomfortable reminder of the problem, a homeless person sleeping. Commissioner Sudders was Dr. Dumont's boss back in 1990, when she ran Met State and oversaw its closing.
MARYLOU SUDDERS, Commissioner of Mental Health: Closing that hospital was absolutely the right thing to do. Half of the people who were in Metropolitan State Hospital transferred to other state hospitals. The other half moved to new community residential services, with case management in the community. That physical plant was rotted. It never could have met national accreditation standards.
PAUL SOLMAN: Now, Remember, this was when the taxpayer revolt was in full swing. Bringing hospitals up to code would have been very expensive. Just running them as is cost a bundle. As to Dr. Dumont's charge that privatization meant stinting on important services, the state's Michael Bailitt countered that without cost controls, the state might encourage too much medical care.
MICHAEL BAILITT, Division of Medical Assistance: Supply drives demand in health care. The more doctors you have, the more therapists you have, the more hospitals you have, generally the more care is delivered. Now, sometimes that care is appropriate to the patient's need, but not always.
The case of Mr. M.
PAUL SOLMAN: All right, then, according to the state, privatization was helping more than it hurt. But at the private Deaconess Hospital, now treating state patients, the doctors thought care was being cut to the bone. We weren't allowed to tape patients but could listen in as the staff fretted over sending them back out into the world, patients like Mr. M..
STAFF MEMBER: Mr. M. continues to be on razor restriction, and people were wondering if we could get some clarification around that.
PAUL SOLMAN: Although not to be trusted with a razor, Mr. M. was to be discharged in just a few days.
SECOND STAFF MEMBER: He's got a hotel that takes weekly--it's, you know, done in weekly rates--and he set this up himself, and so he'll be doing that. He's also set up Social Security to be getting back payments that he was do, so--
DR. MARYANN BADARACCO, Deaconess Hospital: And he has a doctor following him on the outside?
SECOND STAFF MEMBER: He does, yes, so--he'll follow him--maybe. It depends.
PAUL SOLMAN: Mr. M. will be followed up maybe. It depends. The hospital was reluctant to release people with no resources, like Mr. M., but, in fact, the financial pressure to do so was increasing. That had the head of this private unit, Dr. Maryann Badaracco, worried about the future.
DR. MARYANN BADARACCO: Anybody who works with people with major mental illness knows that the treatment of the acute illness is important, but what makes a big difference is how much continuity of care the person can have over time and, yes, we all are worried that over time the resources that we have available now for shelter, free medication, availability of nurses, doctors, to treat the patients outside of here, good social work, that we're worried about whether that's still going to be available.
The role of the Partnership.
PAUL SOLMAN: In July of 1996, Massachusetts went further into privatization, contracting much its budget for the care of the indigent mentally ill to this man, Richard Sheola, whose private company, the Partnership, would manage the program by sending the business to places like the Deaconess.
PERSON ON PHONE: And she sees a psychiatrist?
PAUL SOLMAN: The emphasis would be on efficiency, Sheola insisted, not arbitrary cost-cutting.
RICHARD SHEOLA Massachusetts Behavioral Health Partnership: Less than a third of any earnings that can occur in this contract occur because of cost savings. Fully 2/3 of any potential earnings in the contract occur because we will hit performance standards, and there are 10 of them that have been established by the commonwealth. If we hit all of those performance standards, we will earn a reasonable return on the investment.
PAUL SOLMAN: Managing the state's mental health care contracts, Sheola's performance standards were explicit.
RICHARD SHEOLA: Timely admission to an out-patient setting within three days of a discharge. Timely decision making in a crisis. Within two hours of getting a call, we have to make a disposition on the case and arrange for admission.
SPOKESMAN: I had a case as a matter of fact that I put in yesterday, and I just got an answer a couple of hours ago.
PAUL SOLMAN: Now this is the essential argument for privatization--a level of efficiency that in theory only private firms have enough incentive to provide. In addition, Sheola put the squeeze on health care providers, doctors and hospitals, because that's now managed care saves most of its money.
RICHARD SHEOLA: Less psychotherapy, shorter hospital stays, fewer admissions, fewer trips to the emergency room, better opportunities to live in community settings that are less expensive, more responsive, and generally what consumers want. Consumers don't want to be in hospitals.
PAUL SOLMAN: Okay. It's now been more than a year since Sheola took over. What's happened? Well, the state has been saving money--almost $8 million this year--that's gone back into community care services, like this so-called clubhouse, a day rehab program in Boston. But Center House has been around for years. New community settings, a key promise of the partnership, have yet to be established. Partly as a result perhaps, Boston's chronic homeless population hasn't dropped, which suggests the mental health system hasn't got its clients off the streets. In fact, on any given night, more of the poor mentally ill and/or substance abusers are now at Boston's main homeless shelter, the Pine Street Inn, than in all the state hospitals combined. There's also evidence that an increasing portion of the commonwealth's prison population is made up of the mentally ill. Finally, there is that controversial study with which this piece began--that death rates have risen by 79 percent since the advent of managed care.
DR. MATTHEW DUMONT: Do we want to save money at a time of unprecedented wealth by allowing people to perish? They are perishing!
PAUL SOLMAN: Dr. Dumont says that things have gotten worse and replacing public institutions with free market privatization is to blame. Even at one of the remaining state hospitals, Westborough, where Dumont now works, he emphasizes that a former halfway house for patients re-entering the community has just been turned into a lock-up facility for juvenile offenders. The commonwealth now rents out his former hospital, Met State, as a movie set.
DR. MATTHEW DUMONT: I think the market has caused the mentally ill to be treated as if they were items of no importance. Their livelihood; their life; and by the way, the life of the community in a very profound way has been seriously compromised.
PAUL SOLMAN: Dr. Maryann Badaracco also sees her earlier fears coming true; that the state would cut back its services, hoping that private hospitals and clinics would simply pick up the slack.
DR. MARYANN BADARACCO: And I think the state may also be thinking that this isn't going to become--isn't going to be very interesting to people because a group of people who are not going to be served have no advocates.
PAUL SOLMAN: Well, in fact, the poor mentally ill do have some supporters, like Advocates for Quality Care. This group's recent survey of 100 providers found that more than half claimed at least one of their patients was put in life-threatening danger due to premature hospital discharge since the partnership took over.
But when we asked advocates early on to help us come up with an example to dramatically document their case, they couldn't. There were issues of privacy, of course, and the worst off may simply have been too disorganized, too far gone to interview, like David, our interrupter at the mock funeral last year. He died on the street during the course of our research. But, in fact, when we called an advocacy group made up primarily of parents, the Alliance for the Mentally Ill, they told us that for them, things had improved.
A success story.
JOHN BOVE, Alliance for the Mentally Ill: In one year we had less than five telephone calls, complaints against the Partnership.
PAUL SOLMAN: According to former Alliance President John Bove, that's a big change from the days when the state's Department of Mental Health ran the entire show.
JOHN BOVE: They were the enemy and they were doing everything wrong, and we tried to--you have to clean up your hospitals. You have to clean up your houses. You need more beds. Don't you do anything right? Don't you hire good people?
PAUL SOLMAN: And now it's not like that?
JOHN BOVE: Not anymore. No way, that system is long gone.
PAUL SOLMAN: And these guys, the private guys, are doing a better job?
JOHN BOVE: The private guys are doing a very good job.
PAUL SOLMAN: A very good job of responding to at least one portion of its clientele.
KATHRYN WOLFE, Former State Hospital Patient: I can give you a freshly-made cup of coffee or a diet soda.
PAUL SOLMAN: Kathryn Wolfe was hospitalized for 13 years with a psychotic disorder--de-institutionalized when privatization swept in. She's also John Bove's step-daughter. He credits new medications but also the new managed care firm with Kathryn's improvement.
JOHN BOVE: She hasn't been in the hospital. There's the proof right there. She's--this is her apartment. She works 15 hours a week.
KATHRYN WOLFE: Eight hours.
JOHN BOVE: Eight hours a week. She gets a paycheck. She does her own grocery shopping. She has a TV. She has music. She can have friends over. I don't see her back in the hospital. That's success to me.
PAUL SOLMAN: Success?
KATHRYN WOLFE: I get to see my parents on the weekend, and it's really nice. It's a lot of fun. I just wish I had a car; I could get up to Plymouth by myself.
PAUL SOLMAN: To critics, though, the problem is that those without family support like this fall through the cracks. And Kathryn's mother, Jean Bove, agrees that those with only the state and Partnership to rely on are still in trouble.
JEAN BOVE, Alliance for the Mentally Ill: Many of the people who are in the program are going into emergency services; they're getting their few days of stabilization; they're being put out; they're going back; they're being put out; they're going back; they're being put out. Not everyone that I have known in my experience has been as fortunate as Kathryn to state out continuously.
PAUL SOLMAN: So you're one of the lucky cases here?
KATHRYN WOLFE: Yes. I'm a lucky case.
PAUL SOLMAN: But what about the unlucky cases, those who don't have families like this, the indigent mentally ill and substance abusers who make up such a disproportionate share of the homeless? We put that last question to the Partnership's Richard Sheola.
RICHARD SHEOLA: In the final analysis it's a public policy issue. It's not a managed care phenomenon.
PAUL SOLMAN: Forget managed care. Whose responsibility is it?
RICHARD SHEOLA: The responsibility for responding to the needs of the seriously mentally ill who are homeless. I view it as a responsibility of the state ultimately that this is a population that requires care and treatment and should not be languishing in the absence of same.
PAUL SOLMAN: But the state budget keeps getting cut for these kinds of services?
RICHARD SHEOLA: Tough choices are being made, and that's not a population that has a great voice and a great constituency.
PAUL SOLMAN: Okay. After all this time where are we? Well, there isn't a clean answer perhaps because there are no clean answers to the problems of the indigent mentally ill, especially once you include substance abusers. Yes, taxpayer money has been saved but mainly by paying less to mental health care providers. Yes, the system is more efficient, but the real beneficiaries seem to be those who have family or other support to help them take advantage of it. The fact is the number of homeless mentally ill has remained constant since privatization began in the early 90's, making the question of managed care's ability to care for them as urgent as ever.