Mick Matthews and his girlfriend, Marlene, Terry and Linda Cool, Steve Harris and Mad Dog — they're not just homeless, they're the chronic homeless and they're very, very expensive.
So expensive, in fact, they've caught the attention of the Bush administration.
The chronic homeless — those who've been on the street a year or more or several times in as many years — make up only about 10 percent of the homeless population, but they consume more than 50 percent of the federal, state and local dollars dedicated to fight homelessness. The White House has realized that whether or not the county wants to pay for homelessness, the country pays for homelessness.
President Bush revived the U.S. Interagency Council on Homelessness in 2002 after six dormant years and set its new director, Philip Mangano, on an aggressive tack — to end homelessness in 10years.
"The president's initiative calls on us to 'end,' that's the specific verb, 'end' homelessness. He literally changed the verb when he asked us to end homelessness, not manage it," Mangano said during a phone interview. "The president was specific."
Since the 1980s, vast networks of soup kitchens, shelters and emergency intervention services have met the homeless at their most dire points of need — when starving, freezing or rushed to the emergency room.
The University of California at San Diego followed 15 homeless people through that network. They watched the homeless bounce between mental health providers, emergency rooms, police involvements, before judges, through short jail stays and ultimately back to the street. The cost: $3 million in 18months, or $200,000 per person.
"We could have rented ocean-side condos and concierges to attend to their every whim, and it would have been a less expensive venture," Mangano said. "And these studies are being done all across the country, and the results are basically the same."
The Boston Health Care for the Homeless Program recently tracked 119 chronically homeless for five years. They had more than 18,000 emergency room visits at an average cost of $1,000 per visit.
John Gilbert, director of physician relations and marketing at Emanuel Medical Center in Turlock, said the bare-bones cost for an emergency room visit is roughly $400 and does not include treatment costs.
By their best estimates, Mick, Marlene — which is not her real name — Terry and Linda Cool said they've visited the ER 14 times in the last year. That was before Mick suffered a second stroke Saturday, landing him at Emanuel for a few days. At the conservative estimate of $400 a trip, that's $5,600 and does not include treatment costs for ailments such as open gashes, infections, bronchitis and pneumonia. And it's just the tip of the iceberg. In the past 10 months, Emanuel has spent $17.8 million in unpaid treatment costs for people without insurance.
But perhaps the most disturbing part of all the research was that after the thousands were spent on emergency care, the homeless were no better off.
They were in the same condition at the end of the treatment as they were when they started. They were still on the street. Still in a shelter. Still drinking. Still not taking their psychiatric medication. Still hoping for a food handout.
The matrix of soup kitchens, emergency rooms, acute care psychiatric hospitals and drug rehabilitations simply manages the symptoms of homelessness.
"The central antidote to homelessness is housing, permanent housing," Mangano said. "What we've come to understand is that permanent, supportive housing costs less to the community than people randomly ricocheting through expensive heath care and law enforcement systems."
With the economic argument behind him, Mangano, an exmusic executive and former homeless services director from Massachusetts, has started a national revolution.
Twenty federal agencies regularly meet at the White House, record funding has been collected — $4.2 billion for 2007 — and partnerships have been forged with states, counties, cities, faith-based groups and the private sector. More than 285states, counties and cities have drafted 10-year plans to end homelessness.
The linchpin to success has been getting the chronic homeless into permanent housing. By giving the worst off a place of their own, they come around to treatment for addictions and health problems on their own terms.
The results have been staggering. San Francisco has seen a 28 percent decrease in chronic street homelessness, according to the Interagency Council. In Philadelphia, homelessness is down 50 percent in five years and 20 percent in Portland, Ore. Asheville, N.C. — about the same size as Turlock with 72,000 people — has seen a 26 percent decrease. Quincy, Mass., population 88,000, has seen a 38 percent decrease.
Stanislaus County efforts
Five years ago, a loose-knit group of service providers in Stanislaus County founded the Housing and Support Services Collaborative, or simply, the Collaborative. The Board of Supervisors asked the group to coordinate the county homeless programs. More than 50 agencies and 88 members joined the group, many on the front lines of homelessness, such as the county's Behavioral Health and Recovery Services program and the Housing Authority.
In May of 2005, the Collaborative drafted a countywide 10-year plan to end homelessness. Partners included the city of Modesto, which ultimately built a winter shelter and day facility.
An offshoot was formed in Turlock — the Turlock Community Collaborative, which led to that city's cold-weather shelter. The county Collaborative was supposed to draft and bring the 10-year plan before the nine cities to foster more participation and community support, but that didn't happen.
No mandate holds the Collaborative together; its members are volunteers.
"Our (countywide homeless) plan is almost all permanent housing now," said Glenn Hutsell, manager for the county's behavioral health program and past Collaborative president.
The Collaborative conservatively estimates there are 9,000 homeless people — 900 of them chronically so — in the county. Counting the homeless is notoriously difficult, but every two years the federal government requires a one-day count.
In 2005, an army of social serv-ices providers found about 1,600 homeless on a wet January day. This year's count is Jan. 26.
There are about 175 permanent supportive housing apartments throughout the county. Miller Pointe was built in Modesto specifically for the cause, but in most cases, a social worker finds the client a willing landlord in a run-of-the-mill apartment complex and remains nearby, on-call 24 hours to work through any problems. The rent and social worker's time are paid with federal, state and county dollars.
Fifteen more supportive housing apartments were established in 2006 and 65 are in development, though most are simply funding rather than a building project such as Miller Pointe.
"A lot of the homeless population, when you talk about chronic homeless, primarily has mental health issues or substance abuse problems," said Michelle Gonzalez of the Housing Authority of Stanislaus County and Collaborative president. "So, the services are just as important as the housing. It's a 50-50 thing."
Alletha Chafton, 54, and Patty Young, 51, live at Miller Pointe. Chafton left high school in the 10th grade, married a man she says was abusive, and had children. Young owned her home, had custody of her two children and was a successful dental hygienist in Modesto. Mental illness and addiction brought both women to the brink of despair.
While driving home from work in 1995, a blood clot ruptured in Young's brain. The subcranial bleeding left her on disability, she said. She lost her job and eventually her home. Substance abuse, depression and anxiety cropped up and affected her life to the point that her two children asked to live with their father.
"Everything just kind of snowballed," she said.
She bounced from friends' couches, to spare bedrooms, to family members' homes.
"Everywhere I went, I knew I couldn't stay, I knew I had to go," she said. "There was a lot of depression."
Finally, her social worker put her on the list for a permanent supportive apartment. After a year's wait, she moved into the 15-unit project.
Cindy Kelley, a clinical technician at Miller Pointe, said the transformation has been remarkable.
"Once you get them in housing and wrap services around them, they really blossom," Kelley said. "You really have to see it."
Many streams lead to one pool
No one government agency provides enough money to get all the needed housing, so the Collaborative cobbles together federal grants, state dollars, and city and county redevelopment money. Then the service providers decide what's the largest need and set about addressing it.
For example, in 1999 the state Legislature authorized $10 million for the seriously mentally ill on the streets or at risk of homelessness or incarceration. Stanislaus was in the pilot program, along with Sacramento and Los Angeles. The result was widely successful, and the state now dedicates $55 million to $65 million to the project annually.
It sounds expensive, but the state Department of Mental Health found it reduced hospitalization and incarceration costs by almost $25 million a year.
With that money, the Collaborative started the Miller Pointe project.
The biggest change, as Chafton and Young attest, has been in the lives of the clients. With a roof over their heads, regular meals and a full-time social worker, many mentally ill and homeless have accepted treatment — whether it's 12-step meetings or psychopharmaceuticals — and some are going back to work.
Frankly, most of the people in need of permanent housing will never work a regular job. Mental illness, substance abuse and life on the streets have pushed many beyond hope of a full return to the mainstream. But programs such as Turning Point, a nonprofit mental health agency, are taking those who can push a broom, paint a wall or mow a lawn and letting them earn a check. A portion of that money, upward of 30percent, goes to pay their housing cost.
"All our transitional housing needs to be rehabbed when someone leaves, so we've put together work crews to paint the apartments between the occupancy change-overs," said Pam Esparza, program director of employment services for Turning Point and secretary for the Collaborative. "They've worked on the landscaping, on the buildings."
Permanent supportive housing takes time to roll out. In the interim, old systems such as emergency shelters, soup kitchens and transitional housing, act as fillers and collection points, said Collaborative President Gonzalez. And they are just as essential as temporary stopgaps as housing and services are to meeting 10-year goals.
Fighting the good fight
Even diehard adversaries of the Bush administration have smiled on its homeless plan.
"I disagree with 99.9 percent of what the Bush administration has done," R.T. Rybak, the Democratic mayor of Minneapolis told Bloomberg News. "But Phil Mangano is a godsend."
Mangano's dedication to the cause can be tracked by plane tickets. He's known to drop in on mayors and county executives to ask them where they are with their plan. He spoke to The Bee by cell phone while traveling through Dulles International Airport.
"For a long time in this country, we had hoped that the moral and spiritual reason and obligations we felt for the homeless would be sufficient to create the political will to remedy the issue," he said. "There isn't one place in our country where that line of argument worked."
Mangano, who started working with the homeless through his faith, said government alone can't do it — it takes vast community partnerships organized under a 10-year plan.
"Hospital administrators are stakeholders because their emergency rooms are disproportionately impacted," he said. "Law enforcement has a vested interest, as our police and judges are disproportionately impacted. The businesses community is impacted because of what the streets are like, so the chamber of commerce and downtown business associations are stakeholders.
"Librarians are stakeholders because there isn't a library you can go to in an urban area in this country where librarians aren't on the front lines of this issue from the moment the library opens to well after it closes. Faith communities are impacted — the doors of their parsonage are knocked on, people turn to them for meals.
"The 10-year planning process moves them all from those iso-lated responses to coordinated responses. It moves from crisis interventions to strategic plans."
Mangano likens himself and groups like the Collaborative to abolitionists. They've seen what he calls "the moral vision of the future," where allowing someone to sleep in a field will be morally unjustifiable to future generations the way slavery and segregation are today.
"There were voices that said, 'What do we need the Bill of Rights for?' There were voices that said, 'Slavery, what? That's part of our Constitution. It's been in human history for 6,000years.' These were the voices that said to the suffragists, 'It's the natural order that only white, propertied, males can vote.' These voices were wrong back then, and they're wrong now," he said. "We can get this done."
The results, Mangano said, are speaking for themselves.
Some have criticized the housing-first approach because other federal programs administered by HUD are being phased out. Mangano said transitions are never easy and pointed, again, to the verb change.
"Not 'manage,' 'end,'" he said.
New approach for the new year
The Collaborative in 2007 is hoping to update the 10-year plan and bring it to every city in the county. In the meantime, it's continuing to hunt for dollars for more permanent housing and looking for gaps in the system.
Mick and Marlene, Terry and Linda Cool, Steve Harris — they're all examples of chronic homeless who have fallen through those gaps. All are cogent, articulate speakers, but all have some disability that's prevented them from working and all are wafting through government limbo praying for the day their disability insurance kicks in.
"The closer you are to well on that homeless spectrum, the further away you are from the people who can help," said Hutsell, with the county's behavioral health program. "The problem is, if you stay out on the street like that for too long, other problems start to crop up."