NYC’s Controversial Plan for the Homeless

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New York City Mayor Eric Adams’ controversial plan to address homelessness would allow police to involuntarily remove people with mental illness from the street and bring them to the hospital. He calls it the moral thing to do. Is it, or is it a violation of people’s constitutional rights? Are there better ways? Andy speaks with reporter Maya Kaufman about how the plan is getting rolled out and the reaction so far. Then he turns to mental health crisis responder Ben Adam Climer, who explains why this approach won’t work and lays out more successful alternatives.

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Andy Slavitt, Maya Kaufman, Adam Climer

Andy Slavitt  00:00

This is IN THE BUBBLE with Andy Slavitt. Across America, in urban areas coast to coast people are crowding doorways, creating encampments, or otherwise seeking shelter. Homeless encampments are growing in major cities, a levels we haven’t seen in decades. Now, there’s a lot of reasons for homelessness, high rents, economic displacement, inability to hold a job, and mental illness, certainly a pending recession. Today, this conversation is about a fairly dramatic plan, and a controversial plan coming from New York Mayor Adams that would allow police to involuntarily remove people with mental illness from the street and keep them involuntarily in the hospital. He calls it the moral thing to do. But is it? Or is it a violation of people’s constitutional rights? Not to mention the EPA and many other laws and regulations meant to protect people? And is it a good solution for people with severe mental illness? Are there better ways are there better ways in other cities are better ways in other parts of the country? And by the way, I should point out, he’s not alone, New York is not the only place that has been putting plants like this in place. So that’s what our conversation is going to be about today. And as always, with me are two great experts to talk about this. But Adam Climer works to help create mobile crisis teams across the country. He was a crisis counselor and an EMT in Oregon for five years and 10 years of experienced social services. Ben Adam, welcome to the bubble.

Adam Climer  01:54

Thank you. Appreciate it. It’s good to be here.

Andy Slavitt  01:57

And Maya Kaufman is a healthcare reporter most recently at cranes, New York Business, she is doing some of the best reporting on this issue out in New York City. So glad to have you here.

Maya Kaufman  02:08

Thanks so much for having me.

Andy Slavitt  02:09

All right. Can you tell us about the recent news out of New York about this policy coming from the mayor’s office?

Maya Kaufman  02:16

Recently, New York City Mayor Eric Adams made an announcement that the city is issuing a directive to certain first responders, including police and paramedics, that if they see someone who they believe to be a danger to themselves, because they’re unable to meet their basic needs due to a mental illness, that person can be involuntarily transported to a hospital for a psychiatric evaluation. And this is an interpretation of state law that says that if you’re a danger to yourself or others, you can be involuntarily removed to the hospital. And in this, the mayor was charging responders with basically understanding the authority, a bit wider than they had previously. So that’s the gist of the directive that went out. And so now we have to see basically how this will be implemented on the ground. And there are a lot of questions about that, because the training has just been rolled out. But it’s remains to be seen how this will play out in practice.

Andy Slavitt  03:34

So yeah, he made a comment, that this would be the case, even if they are not a threat to others, which is you said, the criteria that a first responder, often a police officer has to go by is different than when they’re normally looking at a crime or criminal situation. So how will a police officer judge in this type of situation? What is the criteria they’re supposed to use?

Maya Kaufman  04:04

So the determination is going to be made on a case by case basis. So it’s hard to say, and the city said that they had started rolling out training to first responders that day that they issued this directive, but we haven’t seen those training materials. So it’s unclear how exactly they’re explaining this basic needs standard to people who would be charged with implementing it. There are some examples that are cited in the directive that the city has issued. One example is a serious untreated physical injury. And then another example is delusional misapprehension of physical condition or health. But again, those are things that are going to be interpreted on a case by case basis, and that’s where a lot of the criticism of this has come in.

Andy Slavitt  04:56

Yeah, one of the examples he uses is somebody shadow boxing, which strikes me is kind of very telling example, Ben Adam, one thing that’s very important for people with a mental illness is a degree of agency, and that their mental health is very much impacted by their ability to have agency. And I think that’s also true for people with all sorts of disabilities who are part of the unhoused population. So how does it strike you?

Adam Climer  05:25

So I think the first thing that that it strikes me as is that this really seems and looks the same way that we see all the time, which is a somewhat of a conflation of homelessness and the experience of homelessness with the experience of severe and persistent mental illness. And there’s this effort to, to essentially try to get the people who maybe, for lack of a better word appear worse for the wear out of sight, out of mind. And the hope is that this process will do that. And then it gets smoothed over covered up as this is the right thing to do. It’s the just in the moral thing to do. When we have, you know, now we have decades of data showing us that it really isn’t. But we do have a lot of data showing that when good outreach workers, solid case management and housing first aren’t employed, it doesn’t matter how sort of bad off somebody is, they can move into a secure and safe space and thrive in that area. And when doing so it saves cities and counties and the state government lots and lots of money. And a lot of times I’ve been hearing more and more people say that the housing first model and the things that I just described have been ineffective, when in reality, they haven’t been implemented universally. We haven’t had enough housing case management and outreach efforts to actually give every single person who’s experiencing homelessness a place to live. The sort of deep irony of not trying to do that is that when we don’t do that, we end up doing what Eric Adams and you know, also to some extent in California, Gavin Newsom are proposing Gavin Newsom’s care courts, Eric Adams’ involuntary treatment policy, what they’re proposing is, you know, we have to get these people off the street. Well, they’re banking on a very long process being initiated by this, that will end up with the person being in a secure and safe location. they’re banking on that happening. And that’s a long and arduous and very difficult legal process. So the idea that they’re just going to, you know, shuffle people off the street into the hospitals, and then that process is going to start and then it’s all going to work. And to some extent, to me, it’s sort of magical thinking, it’s just going to end up with people taken into hospital, the doctors assessing them and saying this person is within their cognitive ability to take care of themselves. And then they’re going to be right back out on the street.

Andy Slavitt  08:09

Maya, what is your reporting tell you about the psychiatric care capability, and scalability inside New York to handle this? I mean, the mayor is making a claim, which I think, you know, Ben Adam talks about, which is, there’s a moral obligation. And I want to get into that in a minute talk about the morality. But just a simple question, you know, that will people be better off at a minimum, there needs to be a humane and fully capable treatment capacity in the city that is ready to accept people and get the kind of outcomes that will improve people’s lives, is that the case?

Maya Kaufman  08:50

What I’ve found in my reporting is that there are services that exists, but there are not enough spots for the people who need them. And so what we often see is that people will come to the emergency room, voluntarily or involuntarily, and then often be discharged in a matter of hours after getting some sort of stabilizing medication, and then the right back where they started. And that could be a homeless shelter. That could be the street. And so there’s a whole continuum of services that the mayor has said, We’ll transport people to the hospital and then they’ll be stabilized and connected to services. But we often don’t see that happening in part because hospitals are really overburdened and understaffed, their psychiatric departments especially. And so there might not be a bad for someone even if the hospital says, well, we think we should admit this person after evaluating them in the emergency room and those units might not have enough psychiatrists. And so we see hospitals sometimes say we don’t want to go through the court process of continuing to treat someone involuntarily after a certain amount of time the hospital needs to get a court order to be able to medicate or treat someone involuntarily.

Andy Slavitt  10:22

That’s what I want to ask about. The mayor has said that hospitals will be able to keep people basically against their will. And, you know, I’m curious how far this goes. Because one of the treatments for people with schizophrenia, bipolar disorder, are these long lasting injectables, which, you know, if people decide to do voluntarily, you know, can have some positive impacts. But of course, they also have, like a lot of things side effects. And so it’s you suggesting that those kinds of treatments should be able to be given to people against their will?

Maya Kaufman  10:58

A hospital would still need to get a court order to be able to continue to treat someone and medicate someone involuntarily. The city has a series of what they’re known as mental health courts, where hospitals basically have to go and argue their case for the necessity of this against a lawyer who is appointed to represent the patient. And then a judge has to sign off. And what I’ve seen in my reporting is actually a lot of hospitals don’t always go through that process, because they’re really long backlogs for those kinds of cases. So even if a psychiatrist at a hospital says, we really do actually think it’s necessary to go through this process, there’s a hurdle there, too. So it’s not quite as simple as the mayor has making it seem.

Adam Climer  11:55

It’s not even remotely close to as simple as, as he’s making it seem and something like in Vegas shot or a long lasting Abilify shot. If you give that to somebody, and then their asset and their ability to comprehend and their, you know, delusions and their hallucinations reduce after you give that to them, they’re gonna get in front of a judge, and the judge is gonna say, This person is fine. I don’t know, you know, they’re just in a bad economic circumstance. And that’s why they’re on the street. There’s no way we can take away this person’s civil rights for a prolonged period of time, they have their full faculties. And just a point, I mean, if I had a nickel for every person that I thought, you know, needed long term commitment, which is not a ton, but there’s been a few in my life in my work. You know, just to give you a good example, there was a woman that we were seeing when I was working in Oregon on Cahoots, who stood in one spot for three days straight, she did not move, she turned and looked and she was right next to the University of Oregon, this person was very sick, she could not shower herself, she could not, you know, she would get into people’s cars and sit in them for days. Good Samaritans would help her she would defecate all over herself. She was very, very, very unwell, she had dementia, she had everything in anything, she got infections in her feet. And we after all of that, she got in front of a judge for a commitment hearing. And the judge said she was smart enough to go stand by the students who gave her money, which means that she’s well enough to understand that she can get money for food and feed herself. So that means she’s fine. She can take care of herself. And she said go.

Andy Slavitt  13:39

Let me take a quick break. And we’re gonna come back and talk about why we think Mayor Eric Adams is really doing this. Okay, without getting too far into it. The history of the mental health system in this country is a mental health system that was not created for people with mental illness, but was created to keep people with mental illness away from the rest of us. Yes, that’s what asylums essentially are. Out of sight, out of mind. So, look, there’s two reasons why the mayor could be doing this. There’s two views or this. One is, as he says he cares deeply about making these people better. You can take him at his word, and the other is that he wants to remove the sight of these encampments. So the rest of us don’t have to see them. And look, I’m friendly with Gavin Newsom, the governor of California. I know he takes the homelessness problem seriously. I can also tell you that it’s a political problem, you’ll get the LA mayor’s race people are bothered by seeing unhoused people around them, it feels like a public safety issue. And so is Mayor Adams doing this for the benefit of people who he believes have mental illness that are […]? Or is he doing this for the benefit of all the rest of us?

Adam Climer  15:22

I think they know, good, and well, that what they’re planning is not going to solve or resolve any problems. I think that this is a 100% an effort to say, see, we put in a policy, and we did exactly what people wanted. And that was to increase enforcement. So Pat, on the back, go us. And then when it fails, they’re gonna say, this is the fault of the hospital system, and the judiciary system. And then they’re going to be able to look like they did something really proactive, while at the same time, completely avoid accountability for anything that they did problematic wise, because they’re going to be able to say that they did what they were supposed to do, but the other systems didn’t.

Andy Slavitt  16:07

Well, it sounds like you’re saying they’re not even really gonna be able to keep people off the street for very long.

Adam Climer  16:12

No, they won’t there’s no possible way, there’s no legal avenue for that. They might catch one or two people that end up getting on long term commitments and go into sort of long term care under state authority. But it’s not going to be anything that’s significant enough that it really changes how the, you know, visible poverty looks in New York City.

Andy Slavitt  16:33

Maya, what is your reporting tell you is driving the mayor here?

Maya Kaufman  16:38

So I find the timing, interesting of when this was announced, because what I noticed is that this wasn’t paired with an announcement on investment into other kinds of mental health resources. This was really a policy driven announcement. And one of the reasons for that probably is the state is starting to put together its budget when a lot of policy is made, that process is going to wrap up around April 1. And so it’s on the top of mind for a lot of lawmakers here in that the timing is interesting. And it was rolled out with an 11 point policy roadmap, they call it that is essentially a list of policy changes that the city would like for the state to make in the new year. And some of those things are, for example, easing communication between hospital providers, and community based providers regarding a psychiatric patient, and things like that, that can’t be done at the city level. So there’s a broader mental health plan that they rolled this out with. But again, I think it’s worth noting the timing of this. And especially because we know, there isn’t capacity. And a lot of the programs or even the hospitals where people who are involuntarily transported under this directive would end up next.

Andy Slavitt  18:15

Okay, let’s go right to the heart of the mayor’s comment. He says there is a moral obligation to do what he’s doing. And I look, I think, Ben Adam, I have a sense of kind of your view on that already. But I do want to explore it in a little bit more depth, which is what is the morality here. And when we think about people with mental illness, who are a danger to others, I think you can make a public safety case that there at least ought to be some policy to address that. But that’s not what we’re talking about here. We’re talking about people who have severe mental illness and are judged to not be able to take care of themselves. And I’m just wondering, kind of how we kind of frame that morally. On the one hand, it feels like that is what the Constitution is supposed to protect us from that, you know, you’re taking away people’s agency that is discriminatory. And so, you know, that’s the moral case against that you can make a moral argument for this by saying, you know, there are good treatments available evidence based standards available for people that they’re not in a state of mind to be able to take advantage of I presume that’s what he would say the moral cases. So I think maybe put aside for a second, the system issues, the resource issues, all the reasons why I think you’ve said that you’re cynical, and just get it that moral question. If you’re in a situation where what does the morality tell us, based on your experience, you know, frankly, as a first responder and working in this field for so many years?

Adam Climer  19:56

Yeah, so I think I think even though you told me to put aside systems I’m going to talk Little systems here. Okay, so I think one thing that I like to say or people have said recently is that budgets are moral documents, right. And if we look at how the United States has funded public housing in the last 50 years, what we see is that in 1978, HUD housing and urban development who provide section eight and public housing in the United States had a budget of $32 billion by 1982, that had been slashed 70% down to 6 billion. It is now at about 65 billion, which is still half of what it would be if we adjusted for inflation compared to 1978. And it was that budget decision that created the explosion in homelessness that then developed into the Stewart McKinney act in 1987. To fund homeless shelters across the country, the Stewart McKinney act grants at about $900 million for shelters for people. So what we have generally is a very anemic public housing infrastructure, which then leads to people not having enough money to afford rent because rents are skyrocketing, because private equity firms and landlords are finding out that they can charge more and more for rents and make more money by keeping different spaces empty. So the question becomes, do we have a moral responsibility to people who are experiencing homelessness? And I think absolutely, yes, I think that we have not only a moral responsibility to the people experiencing homelessness, but we you bring up me being a first responder, we have a moral responsibility to the first responders, who are tasked with day in and day out. And this is police officers, EMTs, paramedics, firefighters, crisis workers, who are tasked day in and day out with going out and having to talk to folks who are experiencing crisis after crisis after crisis, emergency after emergency after emergency, because of this infrastructure that we have sort of bled dry, which is affordable housing. And I think we have a responsibility to them, as well as the people on the street, to change that system so that we are able to respond to other things rather than just.

Andy Slavitt  22:17

Sort of moral obligation to fund housing and social services safety net, for sure. You get somebody just put a finer point on it before going to our final break, is if you are a first responder and you are running into someone who clearly needs help, but isn’t in a position to know that they need that help or to ask for it. Do you feel at that point as a first responder, like the right thing to do is to get them help, even if it’s against their will? Or do you feel like that’s never appropriate?

Adam Climer  22:44

At cahoots, and then also personally, I think that we always want to work collaboratively with the person who’s experiencing the crisis or the emergency, and that forcing them into assistance is going to traumatize them in ways that are not going to be good for them on a long term basis. So I don’t affirm that there are times in certain circumstances where it is very clear that somebody’s dementia or their other sort of disabilities are at a point where they can’t live independently. And they’re not really capable of being aware of that. And they don’t have advocates in their family or their friends circles. To assist them with that. That’s when it really gets to a point where yeah, they need state assistance. But the people who are like that, that are living on the street in visible poverty in New York City, LA is very small portion of that population.

Andy Slavitt  23:32

Okay, let’s take one more break. And we’re going to come back and talk about where this goes and also what some of the better solutions might be that we’ve talked about already with my invent help. So a motion was filed for a temporary restraining order to stop the mayor from implementing this policy. Tell us a little bit about that and what we think the prospects are from the courts here.

Maya Kaufman  24:18

So some advocacy groups and some civil rights activists filed a motion seeking for a judge to basically enjoin the city from implementing this directive. And they argue that basically that this is unlawful. They note, here’s the way that they phrase that they say it lowers the standard for involuntary detentions and hospitalizations to such a point that individuals can be forcefully committed to a psychiatric hospital solely because an NYPD officer perceives them to have a mental disability and nothing more. So that’s what this challenge will I basically depend on it was whether or not a judge agrees that that interpretation is fair or not.

Andy Slavitt  25:07

Let me close by talking about solutions that do work. And maybe I’ll start with you, Ben Adam, you talked about housing first. And I think people probably can intuit what that means. But when you think of sort of state of the art knowledge about what the most effective way to deal with, I guess I want to know about chronically homeless populations. But in you know, in particular, as we talked about people with mental illness and substance abuse, Are there best answers out there that you would point us to, instead of necessarily just looking at the kind of situation we have in New York?

Adam Climer  25:47

Yeah, I think there’s two sides to that, too. I think there’s one is preventing people from ending up homeless, and then the efforts to help them get back into housing, once they get off the street. The efforts to prevent people from getting from becoming homeless is almost purely policy based things like rent control, increased wages, you know, a variety of other different remedies that you can make toward making housing just more affordable for people. I worked as a case manager helping people with both mental health and substance use issues, get off the street for a couple of years. And in that process, you know, what we found is that is that you really need to base that off of solid relationships, helping people who have been ignored by society, people who have been hurt by society, people who have been day in and day out, made fun of insulted, robbed her physically, all those types of things, they need trust, they need somebody who’s there who will be, you know, a solid person that they can rebuild that sense of, yeah, human beings are actually good. It’s a trauma informed approach, the belief that that people can heal, and they heal best when they’re in community. And really taking that in running with it. As my old boss, Molly Lowry, used to say, you know, whatever it takes for as long as it takes. And what that really means is, we’re going to work with this person, who everyone else has given up on and we’re going to help them know that they there are people that care about them. And when that happens, it doesn’t really matter whether or not they’ve got severe, persistent mental illness, or if they’re abusing meth every day, I live next right next door to a person who was a chronic meth user, who was the worst of the worst, and has been in that house for over 10 years. Now. There’s a lot of a lot of personal experience that I have, and a lot of empirical data showing that when we treat people that way, and we offer them housing first, which is housing first, not housing only means that they get housing first. And then we work on things like their mental health, and then we work on things like their substance use. It’s very effective.

Andy Slavitt  28:01

It was explicit, or implicit in what is in housing first, maybe it’s explicit, maybe it’s implicit, I don’t know is that the housing isn’t dependent upon following rules, following rules around sobriety, following rules around drug use, following rules around sexual relationships, just like the rest of our housing isn’t dependent on those things. So you know, as novel as it is, it’s actually treating people like people. Finally, I’ll go to you, Maya, as you’ve sort of studied this issue, and you, you’ve heard critics of this policy, you have to say, some extent to those critics, the problem is still here. Right? The mayor is trying to do something you may not like it. But we also have to kind of admit, as a society, we have not been effective in solving this problem. We’ve talked about some of the reasons why lack of investment in housing, lack of the right types of resources, etc. But what do you hear from advocates and others who are critical of the mayor’s policy? What solutions are they pointing to? Or if they are?

Maya Kaufman  29:07

One of the problems that I kept coming back to in my reporting is that despite decades of de institutionalization of shrinking and closing down these large mental institutions that were set up, asylums to basically warehouse the mentally ill, that the way that we treat people with serious mental illness, still, in many ways, really revolves around the hospital as this kind of gatekeeper to other services. So for example, in New York City, a lot of people with serious mental illness, particularly people who experience homelessness, or perhaps are in and out of shelters there on the street or doubled up with other folks. They struggle to access care because so many of the services that exist for people with serious mental illness. Basically, you’re referred to a list to get to the services by a hospital. A lot of shelters either don’t know how to do this, or they don’t think they have the authority to do these referrals. And so, because of that, we see a cycle happening again and again, when people are in and out of hospitals. And the directive that the mayor issued is still directing people to hospitals, and still putting the hospital at the center of this because what we often see as people are in the hospital, and then if they’re fortunate, they can get a spa and a community based service because the hospital has decided to refer them to this list by sending in their medical paperwork and filling out the criteria. And then those providers will help the person fill out an application for housing with supportive services on site. And so getting all of these things really depends on each step in that continuum going the way the best way that it possibly could go. And again, still, depending on the hospital to be that front door. Because so often, people with serious mental illness are actually not given a chance to have a housing, housing placement with supportive services on site, they’re passed over for someone with less serious mental illnesses. And so it becomes really important to have those community based providers in your corner helping you fill out those applications and advocating for you and those are often only accessed if you’re first in a hospital setting because of understaffing and also lack of capacity. I reported recently that the community based services like this, there’s 1000 plus people waiting for just the services alone for people with serious mental illness right now in New York City.

Adam Climer  32:05

And not to mention, even if they do get into it, and they’re still living on the street, well, you’re spending most of your day trying to find food, trying to find a place to go the bathroom trying to play and find a place to stay warm, all that kind of stuff. You’re not sitting there thinking, Oh crap, it’s Tuesday at one o’clock, I’ve got to go down to my appointment. Like that barely even registers.

Andy Slavitt  32:27

Well, a complex problem, a very controversial solution, I thank you both for the insight you provided into how we ought to be thinking about this, this story is going to continue to move along. The solutions are hard, and you know, politicians who have taken these issues on, I think I just closed by saying, I think it’s really important to try to get in some insight into what they are really, really trying to accomplish, and understanding how they are resourcing the rest of the system and the whether it’s housing system, the mental health system, the downstream things that Maya refer to, are all provide signals into what’s happening here. And it is not because there aren’t people in New York City, who don’t care about mental health, don’t care about the mentally ill. And I don’t care about the unhoused. But it’s because we have a policy that really doesn’t seem to reflect those things. At least that’s my conclusion from this conversation. Give each of you a second for a quick last word. If you have one. My anything else to say we didn’t cover?

Maya Kaufman  33:35

I think it’s just going to be really important to watch how this ends up playing out.

Adam Climer  33:43

When I got the text message from my sister with the headline about this, about Eric Adams, this policy, I immediately responded, he just bought himself a whole bunch of lawsuits. And I think that they’re going to have litigation up to the IRS, and their policy is going to provide no help to anyone. I think it’s gonna stress everyone out. And I just don’t think it was a good decision. And I think it was made to try to look like they’re being proactive. And I think that they’re, they knew that it wasn’t going to work. And they’re going to be able to blame the hospital system and everyone else on the back end sort of thing.

Andy Slavitt  34:18

Well, Ben Adam, Maya, thank you for joining me in the bubble really appreciated having you to explain this issue to us.

Adam Climer  34:25

Thank you. It’s great.

Maya Kaufman  34:26

Yeah, thanks so much.

Andy Slavitt  34:42

All right, tough issue. Thanks to my guests for coming on. We got holiday coming up more shows. Of course. Monday, we are going to talk about how 15 million people could be about to lose their medical insurance. And we’ll tell you about that. And more coming up. Have a great weekend. Thanks for listening.

CREDITS  35:08

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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