Manhattan Institute senior fellow Stephen Eide joins Brian Anderson to discuss new plans from Eric Adams and Kathy Hochul to combat homelessness and mental-health problems in New York.
Audio Transcript
Brian Anderson: Welcome back to 10 Blocks podcast. This is Brian Anderson, the editor of City Journal. Joining me on today's show is Stephen Eide. He's a senior fellow at the Manhattan Institute and a contributing editor of City Journal. He's been on the podcast before.
He researches homelessness, mental health issues and other social problems and does so in a very informed way. This month he published a Manhattan Institute report on crime and mental illness in New York City. He's recently written several pieces for City Journal, on what the city's new mayor Eric Adams can do to help ameliorate the city's homelessness problem. Steve, thanks very much for being back on the show.
Stephen Eide: Thanks for having me, Brian.
Brian Anderson: Last week, Mayor Adams released a new subway safety plan. It was designed or is designed to address homelessness and crime in the city's transit system, which has become a big problem. Under the plan, the city will deploy teams of police and social workers on the subways. They plan to increase social services outreach and reinstate a policy that will require all passengers to exit trains at the end of the line. It seems at least on paper to be a good start. Would you agree with that assessment?
Stephen Eide: Yeah. I mean, I think it's early days yet with the Adams administration and these homelessness, mental-illness related, public-disorder challenges have vexed mayors going back for decades by this point. Sincere efforts were made under, for example, the Koch administration to do something about this.
We can't say that they succeeded in a permanent way. But I would say particularly in contrast to the former de Blasio administration, he really seems focused on problems such as serious mental illness in a way that seems encouraging to me personally. At the moment I would say I am hopeful.
Brian Anderson: Now during Adams's predecessors, Bill de Blasio's tenure as mayor, city officials seemed to think that they could solve the homelessness issue basically by spending more on it, throwing money at it and as you wrote in City Journal, "Viewed scrutiny with a luxury."
A New York Post analysis estimated that the de Blasio administration paid, I think, over $4 billion to homeless service providers and that the records were questionable at best. As a result, a wave of corruption also swept homelessness services. There were a lot of reports about this. What can the Adams administration do to tackle this more prudently from the standpoint of government contracts and better oversight and spending money in a more efficient way?
Stephen Eide: Yeah. When we talk about homelessness, mental illness that's a package of problems, there's disorder, there's violence. There's also corruption when it seems to be the case and we've had a lot of experience with this going back to the sixties and the scandals related to community action programs, the so called poverty pimp scandals. Tom Wolfe wrote a book called Radical Chic: Mau-Mauing the Flak Catchers about this stuff.
When government ramps up spending on social services very rapidly, there's a temptation for outcomes to be overlooked in corruption, self-interest to really take control. And based upon coverage, based upon oversight by some state authorities, lawsuits filed, there was a lot of corruption in homeless services towards the end of the de Blasio era.
This really does a lot to, I think, delegitimize the social services system. If you think that we need to be investing more, then you're not going to have as much public support for that, if people think it's going to essentially line the pockets of some providers. I don't know how much of a priority this is for the Adam's administration, but I definitely think that it deserves a closer look from city officials than it received during de Blasio's second term.
Brian Anderson: We'll come back to de Blasio in a minute to talk a bit about your new report, but in terms of current homelessness policy, there's been action on the state level, too. We have a new governor here in New York, Governor Kathy Hochul. And she recently announced a $27.5 million investment in inpatient psychiatric care, which will fund more than 600 psychiatric beds in general hospitals.
Since the seventies, states have closed asylums, they've cut thousands of psychiatric beds. Meantime, structural incentives in federal healthcare spending, discouraged states and localities from investing in this area or building out inpatient psychiatric capacity.
Could you just give a brief overview? This is obviously a big topic. A brief overview though, of how deinstitutionalization has really created massive problems in New York. And will Hochul's new investment of slightly under $30 million be enough to reverse the trend or do we need to do a lot more?
Stephen Eide: Well, the traditional asylum system or system of mental institutions that was initially targeted by what we now call the deinstitution of the mentally ill, were massive specialized psychiatric hospitals run by state governments. Over the decades beginning in the fifties but really hitting an accelerated pace in the 1970s, state governments in New York and elsewhere cut lots of beds and also closed facilities. In hopes that people with serious mental illness would receive better treatment in community-based modes of care.
Beginning in the eighties with the advent of modern homelessness, there's all always been a debate over whether or not that went too far, that was an overcorrection. We now have this problem of a very large number of seriously mentally ill people in jails and prisons, which didn't seem to be a pressing social challenge back in the 1950s.
Brian Anderson: The prisons and jails have become a de facto asylum.
Stephen Eide: Yeah. I mean, it doesn't seem like we had, this was a major topic of debate like what to do about seriously mentally ill people on Rikers Island back when we had a very large psychiatric hospital. It seems like what happened was this trans-institutionalization and also putting people "in the community" and for all practical purposes meant putting them into the street. That's what the streets are the community, that's the form that took.
Yeah. Then and that has continued to pace. We've been debating it. People have been concerned about it. We've been calling for some sort of a revival of the asylum system but state governments have kept cutting beds and Cuomo never really got as much criticism for this as he deserved.
All the focus on mental health was on de Blasio because de Blasio made this grandiose plan, claim that he was going to solve the mental health crisis with ThriveNYC. He didn't and all the criticism went to him. More of it should have gone to Cuomo for cutting inpatient psychiatric care beds.
What Hochul is trying to do, in the case of Hochul, she's a mystery to me in a lot of ways, like I think is the case with other people. What I'm trying to go by now is just on this particular issue, judge her against her successor. In my view, a low bar as far as inpatient psychiatric care goes. She's taken modest steps to stabilize psychiatric care. This is an effort that you mentioned this investment in inpatient psychiatric care. Not focused at the moment on the state system, but focused in general hospitals, psychiatric care beds, and general hospitals. And so they're going to up the Medicaid reimbursement rate to motivate hospitals to provide more inpatient psychiatric care. Again, I think it's an encouraging step, a step in the right direction. Yes, more will have to be done but right now I'm really glad to see it.
Brian Anderson: In your view, do we need to reconstitute something like a modernized asylum system? Do we need more, something more akin to what was replaced with deinstitutionalization?
Stephen Eide: Well, I definitely think we need to start building back the stock of beds that we lost, both in general hospitals and in specialized psychiatric facilities. Some people clearly need more than a few days to be stabilized, which is what a lot of people get in a hospital setting. That's for various reasons we need to be exploring that.
But just the pendulum has just swung so far that something like restoring the system that we had in the 1950s is not even realistic to contemplate at the moment. We need to start just thinking about how we reverse the wrong headed fiscal incentives in the systems like Medicaid. And just start affirming our commitment to the idea that inpatient psychiatric care is a vital intervention that is life saving, stabilizes people. It's not the same as sending someone to jail or prison and we need to just affirm that commitment and start adjusting policies accordingly.
Brian Anderson: A lot of the problem with many of the psychotic homeless is that they've gone off medication, right?
Stephen Eide: Yeah. What you do to stabilize someone with a serious mental illness like schizophrenia, it's a complicated question. It's going to have to be taken on a case by case basis, even when you're talking about people with the same diagnosis. But one thing that people say but medication would have to be part of the package for anybody, especially someone who we see involved in these gruesome incidents in the subway.
One thing people say about inpatient based care is that it takes a while to figure out what medication regimen is going to work with somebody. It's not something that you can figure out within just a day or two, 72 hours. You need to really work with that and figure out what's going to keep somebody stabilized, alleviate their symptoms. Because for some people the patience that's going to be needed to figure out the right medication regimen is just not practical to make that work outside of a hospital. It really needs to happen inside of a hospital.
Brian Anderson: Let's go back to the de Blasio years and talk about your recent report for the Manhattan Institute, which looks at de Blasio's overall legacy on crime and homelessness. During his two terms as mayor of the city, the number of mentally ill people in jail fell but the number of seriously mentally ill, homeless adults in the city went up.
And in 2015, de Blasio launched this program you mentioned earlier, Thrive New York City or ThriveNYC. It was a community mental health initiative, with a goal of providing comprehensive health services, mental health services to homeless New Yorkers. I know you're a fierce critic of that program, but could you describe what have been the ups and downs of the de Blasio efforts to address homelessness? And then maybe say a bit about ThriveNYC and what Adams' position should be regarding these programs?
Stephen Eide: Yeah. Well focusing especially on the mental illness angle of all of this crime and homelessness package of issues, what de Blasio and his allied policy makers at the state and local level did throughout his two terms, it was a wish list of progressive priorities.
We've been talking about these problems of mental illness related crime and homelessness for many years. What are we going to do about it? Well, all the things that people would want to do, many of them were done. The 2010s it was just a long stream of policy wins from the progressive perspective.
And focusing on one particularly important measure, the number of seriously mentally ill people in jail. Well, there are far fewer people with serious mental illness in jail, in New York City right now than during the early de Blasio years. But that's mostly because there are fewer people in jail period because of to some extent the crime reduction but bail reform and related progressive reforms just keep people out of jail. That's what it means to succeed in criminal justice reform, fewer people in jail.
The rate of serious mental illness is just as high as ever. It's this 15 to 20 percent rate that's been with us for a very long time. You find it everywhere across the country even in very non-progressive jurisdictions. What that means to me is that the policies, the interventions that were really targeting the mental illness, the problem of mentally ill offenders, trying to keep them out of jail because jail's no place for a person with schizophrenia, et cetera, those don't seem to have worked very much.
You can release a lot of people from jail, we've learned that, but what happens when they're not in jail? I think that to some degree, the violence and disorder on the streets and subways is likely the result of that.
Brian Anderson: How much in your view, has the experience in the city of the pandemic aggravated some of these problems?
Stephen Eide: Well the homeless, there was a big controversy over what to do about the homeless population in shelters during the first, especially the pre-vaccine era of the pandemic that caused a lot of disturbance in neighborhoods. Really created a lot of just ugly, just controversies in places like the Upper West Side. Previously harmonious neighborhoods became just at each other's throats over these arguments, over hotels . . .
Brian Anderson: Hotel meaning places that were being used to house homeless people, right? Yeah.
Stephen Eide: Yes. The situation on the subways, I think most people would say has gotten worse in terms of the level of disorder. It was very bad in the early months when the subways, even more than before, were turned into daytime homeless shelters, the transit authorities, the city has tried to make efforts to do something about that. But ridership is still below where we would like it to be and I don't think it's just tabloid hysteria, you could say at this point, that is contributing to fears amongst people who don't want to be on the subways.
The disorder, the violence, a very large proportion of it depending on what type of incident you're talking about pushing is probably all of it, is as a result of our inability to stabilize people with very serious mental illnesses. My impression is that this has picked up. And I think that there is to some degree, government data that supports the idea that there are more people just out, not receiving any type of treatment or supervision. This is something that if we really need to return systems like subways to a more stable condition, we really need to do something about it.
Brian Anderson: But I asked about Thrive New York City, just a bit on that. You were an early critic of it. And how much of that program is going to remain in place during the Adams administration and how much of that is just gone with de Blasio?
Stephen Eide: Yeah. Well again, so New York City, Bloomberg, and this is the case with many systems, Bloomberg was not some sort of skinflint mayor. Okay. New York City has always had a very robust social services and mental health care system. So de Blasio was beginning with a big system, lots of spending, lots of programs, but he said, "It wasn't effective. It wasn't what it needed to be."
He was really going to become to some extent, the mental health mayor. He really wanted to own mental health, make New York City in exemplar for mental health care. And so he put out this program, ThriveNYC that was announced as trying to do for mental health what Bloomberg did for smoking that is a public health approach. A public health approach to mental health, meaning especially prevention.
We're going to prevent serious mental illnesses from developing. We're going to go upstream, so we're going to focus on various disorders, anxiety, depression that maybe don't look as serious right now. But because they're afflicting teens, because these are disorders that are in their early stages, they're going to become serious down the road.
This was a very well-funded program because it had so much mayoral support. De Blasio put his wife Chirlane McCray in charge partly because they were priming her for a future political run that never materialized. But so it was always like, where are we going to prevent these disorders? We're going to move upstream from serious mental illness.
At the end of the day, nothing's ever seemed to be done about serious mental illness. Though it took years to develop, we at the Manhattan Institute but many other city officials and lots of Democrats began to take notice. That the situation on the streets with homelessness, that the jails just didn't seem to be getting any better, which is what you would've expected if we were going to succeed at preventing serious mental illness.
But though it was really hit hard by lots of criticisms. They rebranded it, they got rid of the name ThriveNYC. The funding, which was 200 to 250 million was never cut and in fact, it continued to increase right up to the end of the de Blasio era. The future of the program is uncertain. Technically it still exists as I think it's called the Mayor's Office of Community Mental Health.
It's this package of community-based programs that Mayor Adams will have to decide what he wants to do with. There's probably something you could do with it if you wanted to really use some of that to focus on serious mental illness. Because community-based programs certainly can benefit seriously mentally ill people in important ways. But what Adams does with that as well as in other questions, will send an important signal as to how much things really have changed from the really misbegotten approach of the de Blasio era.
Brian Anderson: A final question, Stephen, just about where in other municipalities, you might be seeing more effective approaches to the homeless problem taking place. There does seem to be a big difference between what's going on in say San Francisco and what's going on in San Diego. They just seem to have different approaches and different levels of the problem. What's your sense of that? Is there any model out there for best practices when it comes to homelessness policy?
Stephen Eide: Well, when you're talking about like for example, street homelessness and New York City that's street homelessness is not, it's really like subway homelessness especially. I don't know of an example of a city that has allowed the problem to swell to the crisis proportions seen in San Francisco and then gotten it way back under control.
The real, best approach is just to not let it get out of control to begin with. I think you have seen that to some degree in Western cities such as Austin. And then and I think it was Denver, Colorado, which had the opportunity to greenlight more street encampments, but the voters really resoundingly voted against that because people understand that they don't want Austin to go down the route of San Francisco and L.A.
That's really what I see in terms of effective policies. San Diego, it looks to have been more successful than its peers, but you are looking for, I think, years of progress to undo the damage. In California, everything is so regional and everything seems so chaotic. San Diego's a situation that I'm taking more of a wait and see approach and see how much they can sustain that progress over a few years. But I mean, San Francisco and L.A., it's just sometimes it's, I mean, what is a realistic standard for success at this point?
Brian Anderson: All right. Well, thank you very much Stephen Eide. You have a book coming out called Homelessness In America. When is that published?
Stephen Eide: It looks it's going to be coming out in May.
Brian Anderson: Okay. Well, we'll be sure to have you back on 10 Blocks to talk about the book, which really is a comprehensive history of the homelessness problem in America. I think it'll be a very important contribution to debate over this issue.
Don't forget to check it out Stephen Eide's work on the City Journal website, that's www.City-Journal.org. We'll link to his author page in the description. You can also find City Journal on Twitter @CityJournal and on Instagram @cityjournal_mi. If you like what you've heard on today's podcast, please give us a rating on iTunes. Steve, thanks very much, it's great to talk with you as always.
Stephen Eide: Thanks for having me, Brian.
Brian Anderson: Thanks for joining us for the weekly 10 Blocks podcast, featuring urban policy and cultural commentary with City Journal editors, contributors, and special guests.
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