On May 1, 2021, residents of the City of Austin voted to reinstate and expand an ordinance banning camping, loitering and panhandling in specific areas of Austin, and at certain times. Opponents of the ordinance have argued that it will not end homelessness in Austin. This is true. Until we address the root causes of homelessness, the number of people living unsheltered will continue to grow, wherever they are. The root causes of chronic, unsheltered homelessness are mental illness, substance addiction, habitual criminal behavior, and intellectual and physical disability. About a third of the chronically homeless have lifetime mental illness. We will not end homelessness for this population until we address the need for mental health treatment.
How did we get where we are today in the management of people with mental illness and intellectual disability? I practiced family medicine in east Texas in the late 1980s. My partner and I took care of more than 500 patients in two nursing homes. About half of those patients had previously been residents of Terrell State Hospital, but had moved to the nursing homes as the hospital reduced its inpatient census from about 2000 in 1976 to 525 in 1988. Most of these patients required 24-hour supervision, but not because they were dangerous to others. It was because they would not have been able to understand the danger in pushing a shopping cart across an eight-lane highway (a homeless man in Austin was recently struck by a car and killed doing just that).
Why did state mental institutions reduce their populations in the 1960s and 1970s? The population of patients in state and county mental hospitals actually peaked at about 569,000 in 1955, and has declined ever since. There were a number of reports of institutional abuse, mistreatment and disturbing experimental treatment (frontal lobotomy) during the 50s and 60s. In 1963, President Kennedy promoted and Congress passed the Community Mental Health Act. The Act provided funding to states for the construction of outpatient mental health centers. With the success of antipsychotic medicines first developed during the late 1950s, there was optimism that many patients institutionalized with mental illness could move into the community. I would argue that because of the mismanagement of population mental health over the last 60 years, we do not know to what extent this is true. In any case, states saw an opportunity to cut funding for expensive (and unpopular) inpatient care in state hospitals. Unfortunately, many of the proposed community mental health centers were never built, and those that were built had no federal funding for sustained operation. States barely kept the doors open. Commercial health insurance, Medicare and Medicaid provided limited coverage for mental illness, so there was universal limited access to care.
Institutionalized patients who were disabled and eligible for Medicaid long term care coverage were gradually transitioned to nursing homes. Long term care facilities (nursing homes) were not, and still are not, staffed or experienced to care for patients with serious mental illness, like schizophrenia. Many long-term care facilities do not accept patients with serious mental illness, or they limit the number of residents with serious mental illness. Most families are also not equipped to care for someone with serious mental illness (which is why these patients were institutionalized in the first place). Group homes and other residential facilities are generally not covered by Medicaid, and disability payments may not be enough to cover room and board cost in those facilities. The result is that people with serious mental illness often end up homeless. This was exacerbated by court decisions in the 1970s that determined that patients with mental illness could not be institutionalized unless they were a danger to themselves or others, or gravely disabled. This meant that patients, who in many cases did not have the mental capacity to make decisions about their own welfare, could not be confined if they did not want to be. The courts have further established that patients cannot be required to take medication for mental illness, unless they meet the requirements for involuntary confinement.
All of the factors driving people with mental illness into the streets in the 60s and 70s still exist today: inadequate access to treatment, limited institutional support for those who need assistance with activities of daily living, laws and legal precedent that favor individual rights over the need for treatment, lack of affordable housing and social programs. So how do we get people with mental illness off the streets?
Many of the mentally ill homeless population probably meet the requirement for permanent disability. Once they are disabled, they are eligible for Social Security Disability Insurance, or if they have not worked enough to be eligible for Social Security, they may qualify for Supplemental Security Income disability. Either program provides a monthly disability benefit payment, which can help with housing costs. If people with serious mental illness qualify for disability under either of these programs, they can become eligible for Medicare and/or Medicaid. A case manager should be able to help homeless individuals with an application for disability.
Social Security Disability Insurance or Supplemental Security Income disability payments may not be adequate to cover housing and all other costs of living. In addition, many people with mental health disability may be unable to manage their own affairs, including maintaining housing and personal property, paying for utilities, buying groceries and getting health care. If someone with a mental health disability has been living on the streets for years, it is likely that they will need Permanent Supportive Housing. Once again, case management can assist with housing.
Many advocates for the homeless suggest that Permanent Supportive Housing with voluntary support services (meaning no active intervention) will be adequate for this population. I do not believe this is true, and I will argue that position in a future article. The City of Austin is purchasing motels as Permanent Supportive Housing for the chronically homeless, based on the advice of homeless advocates who intend to manage these facilities. The City proposes to have one person per motel room at a cost of $25,000 a year – just for lodging. This is the cost of a luxury 2-bedroom apartment in Austin, which would include a full kitchen. It is a ridiculously excessive cost even if these units are used only as transitional housing, as the City has now proposed. And it does not provide for mental health or substance addiction treatment or for the cost of health care.
Ultimately, we will need to rethink the concept of institutionalization for people disabled by mental illness who require Permanent Supportive Housing. Another option would be to expand Medicaid to cover residential and group homes for those with mental health disability. In any case, permanent supportive housing needs to be funded by the federal and state government. This should not be funded at the local level. Communities with fewer resources will end up dumping their homeless population in the larger cities, which we know already happens. It is not just about who pays. Relocation can result in the loss of any family relationships and support that might be a help to a disabled person.
We also need to redefine the commitment standard of danger to self or others. This can be easily be applied more broadly to include the inherent danger of living unsheltered on the streets without active treatment. Homeless advocates have defended their clients by claiming that they are not dangerous to themselves or others living on the streets without treatment. This is clearly false. A person predisposed to psychosis can become dangerous or endangered at any time. In addition, substance abuse, which is highly prevalent in the mentally ill homeless population, is definitely associated with violent behavior. We have seen multiple examples of this with mentally ill homeless persons committing homicide, assault, arson and becoming victims of those same crimes. Numerous homeless persons have frozen to death, drowned in the lake, over-dosed, and been hit by cars on the highway. These individuals need active engagement and life-time treatment, not only to maximize their quality of life, but just to live.
Waterloo to Austin 