Expanding forced commitments to hospital is wrong Rx for the homeless — and for most people

Originally published in The New York Daily News

Gov. Cuomo’s perennial preaching on homelessness is meant to reassure us all that he knows just what to do about a seemingly intractable problem. But, as with so many other issues, our state’s chief executive too often shirks his own responsibility for contributing to the problem.

Cuomo’s homelessness policies have been plagued by false starts, deliberate under-funding of local needs, and heavy-handed policing with far too little investment in the solutions proven to work. He shamelessly sends more than half of those released from state prisons to New York City directly to shelters, rather than provide adequate reentry planning.

He has once again proposed a bad remedy, this time in his executive budget proposal. The governor wants local police to pick homeless people up off the streets against their will and take them to hospitals or new crisis centers using an extraordinarily broad expansion of legal involuntary commitment powers to detain those who are homeless, and who may or may not actually have a mental illness.

It is difficult to understand why Cuomo wants the police to take people against their will for mental health services that few can obtain on a voluntary basis. His push for Medicaid managed care has left us with a profoundly dysfunctional system, as evident in state data regarding utilization and payment for mental health care. State Office of Mental Health data for New York City show:

  • As of 2018, the most recent reporting year, the city had nearly 950 fewer psychiatric inpatients on average each day than it had in 2012 (3,171 vs. 4,115).
  • As of 2019 and averaged across all inpatient facilities, one in five psychiatric inpatients was readmitted within 30 days, and nearly one in three was readmitted within 90 days.
  • Similar rates exist for readmission to emergency departments as for psychiatric visits, and at five hospitals the 90-day ED psychiatric readmission rates ranged from 53 to 64%.

These data paint a picture of a system that does not adequately address the needs of those with serious mental illnesses, instead relying too heavily on short-term, emergency responses. Correspondingly, access to community-based mental health care for those with the most serious mental illnesses has been abysmal. As of Jan. 19, 2021, only 2,270 of the 92,480 unique eligible adults in New York City (2.5%) had received any of the specialized Medicaid services for which they were eligible in the past twelve months.

Unfortunately, instead of reducing barriers to voluntary mental health care, Cuomo is proposing to greatly expand the use of involuntary commitment, a policy that usually relies on the detention of people by the police, even if they have not committed a crime. The governor’s latest involuntary commitment proposal is perplexing, not only because his own lawyer once had to admit the idea isn’t legal, but also because not so long ago, the governor himself seemed to understand exactly why ideas like this are so counterproductive. In an impassioned, seemingly impromptu answer in a 2018 debate with Cynthia Nixon, Cuomo said:

“The law is you cannot incarcerate a person involuntarily or take them into a mental health facility unless they are an imminent risk to themselves or others … that is a basic civil rights law.

It’s not going to work if the police have to force a mentally ill person into a shelter, because even if you take them into the shelter, you can’t keep them there as a matter of law. That would be involuntary institutionalization. We need a shelter system and a mental health shelter system that works…

We know how to do it. They are called safe havens … mental health professionals who develop a relationship with a person on the street and slowly you develop trust and you bring them into a safe, clean, decent shelter…

We need a better shelter system, we need more mental health beds. We need more community residences for people who are mentally ill on a permanent basis…”

That is exactly right. There are three profound errors in the logic and design of Cuomo’s new proposal. The first is the idea that dragging people who may not even be mentally ill off the streets is helpful: It is not. It is traumatizing, and will cause people who are ill to further withdraw from the support they need, at a time when we all know we should reduce, not increase, police interactions with people in psychiatric crisis. The second faulty premise is that the law would only affect dozens of those sleeping on the streets when it could actually affect thousands, given the breadth of the proposed language. Last is the precept that this group of people is dangerous to the point that their civil liberties and due process rights should be suspended — a perilous precedent.

Under current law, such extraordinary measures are carefully limited to transportation to a hospital, and a temporary hold there, for psychiatric evaluation to determine if the person has a mental illness and if they pose a real threat. People — even those in distress — cannot be hospitalized unless they have an apparent mental illness and likely present a serious immediate risk of danger to self or others. And they have due process rights, including the opportunity to have a judge decide about their continued confinement. The governor’s proposal would erode those rights and damage the trust that social service providers work to build with unsheltered New Yorkers, pushing them further away from help.

The more urgent area crying out for reform is the mental health system itself: Regrettably, it has largely been dismantled through the commercialization of mental health care as a “managed care” Medicaid benefit that benefits few. People in psychiatric crisis far too often encounter insurmountable obstacles when they seek inpatient or outpatient mental health care on a voluntary basis.

So what is the alternative? The governor can fund Home Stability Support housing subsidies for those who are homeless or at risk; he can fix the broken mental health system and expedite the development of permanent supportive housing; he can open new crisis centers for voluntary patients; and he can fund those hard-working, patient, compassionate homeless outreach and street medicine teams that actually build the trust he knows is vital to engaging people sleeping on the streets. In other words, Cuomo should listen to his own advice from 2018.

Nortz is deputy executive director for policy at Coalition for the Homeless.