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Brian Lehrer: Brian Lehrer on WNYC. When people who are not homeless talk about homelessness in New York City, they're often talking about street homeless, people who often have problems with mental illness who are living on the streets or sometimes in shelters, but sometimes on the streets, people who are not homeless find threatening. That's where the conversation often lives.

Often it does come down to what to do for and about people who are homeless and living on the street and have mental health problems. Well, New York is failing homeless people who live with serious mental illness according to Maya Kaufman who covers the business of healthcare for the business news publication Crain's New York. She has dug now into the failures of the system here with respect to them, and that fails the mentally ill homeless themselves, and that fails a lot of people who don't like having the mentally homeless around.

Among the problems she identifies are chronic shortage of hospital beds for psychiatric patients, underpayment to hospitals, and deinstitutionalization where hospitals refuse to admit people with serious mental illness in favor of giving those patients a supply of medication to subdue their symptoms. Joining me now to talk about all these cascading issues and possible solutions that many providers say would improve the system is Maya Kaufman, reporter at Crain's covering the business of healthcare. Hi, Maya. Thanks so much for joining us for this. Welcome to WNYC.

Maya Kaufman: Thanks so much for having me, Brian.

Brian Lehrer: What question did you set out to answer with this investigative report?

Maya Kaufman: I wanted to answer the question of why after the death of Michelle Go in January of this year. She was a woman who was pushed in front of a subway train by a man who had been living with schizophrenia and who had been homeless. Why did this issue that we've had for decades seem to never have been getting better where homeless New Yorkers who have mental illness far still not getting the care that they need? Anecdotally, there were reports that it seemed to be getting worse. There was more attention to the issue by the city and by the governor and so I really set out to explore what's happening here and why are we continuing to fail this population.

Brian Lehrer: Your story begins with an account of the psychiatric treatment that Martial Simon, the man who pushed Michelle Go to her death, got in the months before he did that, a tragedy, of course, that left the city reeling. You write that it wasn't surprising to the healthcare workers who would have recognized his name because they had tried to stop him, obviously, not by pulling him back from the subway platform, but in the weeks or months leading up to that. What was Martial Simon's interaction with a psych system in those months?

Maya Kaufman: This was something that really seemed to be a failure of the mental healthcare system to help Mr. Simon who had, for at least two decades, been hospitalized for symptoms of schizophrenia. At least two dozen times is what I've been told by sources who are familiar with the case. Just before the death of Michelle Go, he had been in a state psychiatric hospital, which is something that's for more long-term stays.

He had been there for several months and was resistant to treatment, was still experiencing delusions, and yet he was discharged anyway. He was assigned to an apartment and supportive housing, meaning that there are on-site services. They gave him medication, they gave him an appointment with a psychiatrist and he ended up walking out and essentially, disappearing for months until he resurfaced and pushed Go onto the tracks.

Brian Lehrer: You imply another serious and complicated problem because you mentioned he was moved from a hospital to supportive housing, but he walked out of there and committed his crime. Well, a lot of people say supportive housing is the answer because you don't want to hospitalize more people than you have to hospitalize and homeless people on the street with serious mental illness probably can't maintain an apartment on their own in many cases, and so they need supportive housing, as it's called, which is housing, but with supportive services to help them manage their conditions. Why did supportive housing fail in the case of Martial Simon?

Maya Kaufman: Supportive housing units are really limited in what they can do. They do have on-site services, but people are living independently. As in Simon's case, he was able to walk out. They tried looking for him but were never able to find him. It does work for a lot of people. In my reporting, I spoke to a man named Andrew who had a similar experience. He had been in and out of hospitals for a long time, he lives with schizophrenia, but he is responsive to medication. He was placed in supportive housing earlier this summer, which is where I met with him.

He found it really incredible that he could have someone who would make sure he took his medication every day so that he wasn't listening to voices that told them not to take his medication. He had someone who was monitoring him for that and he had that supportive environment. A lot of critics of the system say that these supportive housing units aren't supportive enough for a lot of people who have serious mental illness and in cases when someone is resistant to medications, such as in Martial Simon's case, they might not be supportive and structured enough.

Brian Lehrer: Listeners, we can take your calls on the state of psychiatric care for unhoused New Yorkers with serious mental illness, 212-433-WNYC. If anybody has any personal experience with this as an unhoused person handling mental illness yourself, or in the case of someone you know, or if you work in this field, in any related job, 212-433-WNYC with Maya Kaufman who covers the business of healthcare for Crain's New York and has dug into this topic in a comprehensive investigative story, 212-433-WNYC. If you want to help us report this story, or give us a thought, or ask a question, 212-433-9692, or you can tweet @BrianLehrer.

Going back to the hospitals. You report that one factor is the lack of hospital beds in psychiatric units. You spoke to someone who works for a hospital lobbying group and she said that hospitals have been underpaid, under-reimbursed for treating the psychiatric patients they admit. I'm curious if those two things are related. If hospitals feel they're losing too much money on psychiatric inpatients, that that's why there's a shortage of beds. Are those two things related at all based on your reporting?

Maya Kaufman: The hospital industry will largely deny that, but certainly advocates think that there is a correlation there. It's clear that beds in other kinds of specialties are much more lucrative. We've seen hospitals for a long time closing psych units or reducing the number of beds and opening units that are more lucrative generally like cardiology or they offer outpatient surgeries that are-- They get more money reimbursing for those than they do for psychiatric services since a lot of the patients who come in for these services are on Medicaid, which is paying hospitals less than commercial insurance might.

The governor has recently said that she's raising reimbursement rates on Medicaid for psych beds. There's been an effort to increase psych beds, but we still see that a number of the hospitals psych beds that we have are still offline, whether that's due to COVID or staffing shortages. It's actually about 15% of psych beds across the state in acute care hospitals that are currently offline. That's hundreds of beds that just aren't available, but do technically exist and could be used.

Brian Lehrer: That's about the quantity of hospital beds. Let's talk about the quality. This is part of why hospitals are so important. You report that providers say hospitals aren't doing enough for people with serious mental illness when they're inside. What did you learn from them about the care people with serious mental illness are receiving in hospitals and in particular the ones who are unhoused?

Maya Kaufman: There is a tendency of hospitals, according to people who've experienced this firsthand, other providers, advocates who spoke to me, that hospitals will simply have someone in an emergency room for observation for a couple hours, maybe overnight, give them some calming medication. I might be sedative, and they keep them overnight or some antidepressant and basically just cut them loose.

That a lot of patients have trouble finding access to hospital services that last for longer than just a day or so, that there's this resistance to admitting them. Part of the problem is that these units are often running at capacity. I spoke to one person at a hospital in Brooklyn, NYU Langone, and the director of psychiatric services there told me that patients recently have been staying longer than they did before the pandemic. They only have 35 beds in that unit. They're typically at capacity. That's one of the issues.

Then, especially when you're talking about the homeless, if you're going into an emergency room because you're in crisis and you need psychiatric help and you're being essentially turned away just in a matter of a couple of hours after an evaluation, then that's putting you back on the streets or sending you back to your shelter, you're more at risk of really falling through the cracks because you don't have a set place to go necessarily.

Brian Lehrer: Let's take a phone call. Michelle in Harlem, you're on WNYC. Hi, Michelle.

Michelle: Hey, Brian, and Maya. I'm so glad you did this investigative reporting, Maya. Absolutely agree with you. I have intimate personal knowledge with this over the last 50 years. My mother was chronically mentally ill with schizophrenia. When I was little, there were large state psychiatric facilities. My mother was cycled in and out of them when she had per periodic breakdowns.

As she got older, she was in Rockland State for over 20 years. During the Pataki administration, I was harassed, I was hounded, I was called at at my workplace to get her to be moved out. What was happening was, as a result of deinstitutionalization, what Pataki did was, so there was some clever idea to move them off the state coffers, move these long-term psych patients into private nursing homes in far-flung states, Pennsylvania. My mother was given the option of two of private nursing facilities in deep New Jersey.

My sister and I toured them and took the one that was closer to New York City. They were not set up to care for these patients, and they were essentially like prisoners. I was there. I saw it for six years. What's happened is as and Cuomo continued the defunding of the mental institute the mentally ill.

Brian Lehrer: Psychiatric hospitals.

Michelle: I don't know what-- Yes. You never saw this in New York City. You never saw mentally ill patients roaming the streets. I live in central Harlem. Marcus Garvey Park is full of mentally ill homeless people. I know why, it started with Pataki. It started with deinstitutionalization. It was supposed to be a good thing where these patients could go into community, except there was no funding. There was nimbyism.

The chronically mentally ill wouldn't take their meds. Like Maya just said a while ago, Martial Simon just simply walked out. I saw it, I've witnessed it. I was harassed. My mother was a victim of it. I'm so sorry for these homeless mentally ill people who have absolutely no mechanism and it's continued. Until someone, until the New York City electorate rise up and demand funding for the mentally ill and the reopening of these large psychiatric facilities. I'm not talking about the Willowbrook with the Geraldo Rivera investigation.

Brian Lehrer: That was back in back in the '60s.

Michelle: Yes. Rockland State was a prime example. Large, beautiful campus. My mother and other patients, they had passes to go off the ground. They went to the local deli. The guy, the owner allowed my mother to have credit because he knew I could pay. I'd settle up, every other week when I would go up. They had large, campuses where the patients could walk around and breathe and get fresh air.

Brian Lehrer: Michelle, let me leave it there because our time is limited and I want to get some other folks on. You paint such a clear and personal picture. Thank you very, very much for that. Maya, before I even get your take on that because what she laid on the table, there was a timeline that put it a lot on Pataki for deinstitutionalization without the funding to have the supportive housing in the community. Plus, Nimbyism not allowing the supportive housing to spring up in a lot of places. She mentioned her Geraldo Rivera and Willowbrook.

For people who don't know that history, that's how Geraldo Rivera first came to prominence. It was as a reporter for local television station, I think Channel Seven on treatment at a psychiatric hospital on Staten Island. I think our next caller, Irling in Brooklyn wants to go back that far. Michelle went back with her experience with her mother to the Pataki administration. That would be late '90s, early 2000s. Irling in Brooklyn, you're on WNYC and you want to take us back to the 1960s with your experience, correct?

Irling: Yes. I had finished college around '68 and I was hired by the New York State Department of Mental Hygiene. I was hired as a program-- I toured the mental health facilities offering a program to teach supervisor, classes to the subordinates. It was quite a large state department. It was one of the largest departments in the country. I think we had about 40,000, 50,000 employees. It was quite a thing.

They offered programs for people who worked with the mentally ill directly in the hospital so they could get nursing degrees and master's degrees and go on to become program analysts, which was a very high, well-paid position. When I began to read, I've forgotten what years that would be, maybe in the '80s, they were cutting back on the mental hygiene budget. I was horrified. Then we began to see people, crazy on the streets in Manhattan. Now it's terrible.

Brian Lehrer: Thank you very much for your call. Let me ask you one follow-up question. On the Willowbrook question. If you started working for the State Department of Mental Hygiene in 1968, that was around the time of that Geraldo Rivera investigative report that made it look like the inpatient treatment of people at that psychiatric hospital. By implication, others in New York state was pretty bad and it led in part to the push for deinstitutionalization. Do you have memories of that conversation springing up in your, area in your department at that time?

Irling: No. At the time [inaudible 00:18:18] a safety officer's convention, that was probably in August of '68. That issue did not come up, although it should have. It was a safety officer convention. We had many people from the fire department and others New York City departments to talk about safety officer conduct and codes and stuff like that.

Brian Lehrer: Thank, Irling. Thank you very much for your call. Maya Kaufman from Crain's, there with those two callers is about 55 years of history, with their takes on what has led up to the current moment with unhoused people with serious mental illness problems not getting the services they need. That also, of course, making a lot of other people unhappy when they feel put in danger by those people. Or just don't want so many on the subways or whatever. What were you thinking as you listened to those history calls?

Maya Kaufman: That's exactly right. It actually even starts long before what the callers were talking about, where about in the 1950s, New York really started this push to de-institutionalize to close state hospital beds pretty aggressively and move psychiatric patients into the community. To give you a sense of that, today, we have about 3,300 beds at those state mental hospitals that are currently available. In 1954, at just one hospital, the largest one, pilgrim State, there were nearly 14,000 beds so that really gives you a sense of how much this has shifted.

That was facilitated by new medications for things like schizophrenia that the thought was would enable people to live in the community. They didn't need to be in these hospitals that were shown as in the case of Willowbrook to be inhumane and had really just not places that you wanted to have anyone there. That pendulum has swung pretty far to one side and the de-institutionalization movement was really dependent on building up other services to replace it and we didn't really see that happen.

We saw a lot of the people who were discharged from those hospitals flock to SROs in New York. Then, of course, a lot of those were converted and we basically saw the people who were living in SROs the newly discharged psych patients, and be thrust out onto the streets.

Brian Lehrer: Last question. The premise of your article is homeless New Yorkers with serious mental illness keep falling through the cracks despite billions in spending, that's what your article headline says. Is it a question of billions in spending being misspent and there's enough money in the system but it's ineffective or there isn't enough money in the system and we have to have the political will to tax and spend effectively or enough in this area in order to really solve the problem?

Maya Kaufman: It's really all of that and part of it is certainly a lack of political will and also an attitude even sometimes among the organizations and providers that help this population. There's really this attitude of passing the buck and not wanting to really take full ownership over helping someone in this population. I'll give you an example of one of the issues that I saw which is we're spending all of this money a lot of times on these community programs meant to keep people out of the hospital so they don't need to be in these facilities basically institutionalized, imprisoned. For example, the governor just allocated $14 million and one example for a program called Assertive Community Treatment.

These are teams of providers that work with people with serious mental illness not all homeless, but certainly, quite a number of homeless New Yorkers and she devoted $14 million for 14 of these ACT teams. Each team only has a bunch about several dozen people so it's meant to be high-intensity or meeting with clients multiple times per week, it's much more structured and supervised.

The idea is you won't need a hospital, but the $14 million for 14 teams, as providers told me, just doesn't really translate, they said 1 million per team is less than we spend on a team. Especially now with chronic staffing shortages in the healthcare industry. That's just not enough for us to find the staff that we are required to have for these teams which, again, are high intensity so they require a large team of providers.

They were saying, "Well, we needed to consult more with the state because this math just doesn't work, we would've liked more than a million per team." It's both a matter of putting more funding into the system, but also being more calculated and how exactly you're spending that funding and how much is being allocated to each program.

Brian Lehrer: I want to thank our callers for your oral histories in this segment and I want to thank Maya Kaufman from Crain's for your reporting. Thank you so much for sharing it with us.

Maya Kaufman: Thanks so much for having me.

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