The Bureaucratic Nightmare of Incrementalism

America’s patchwork system of social services makes it hard to care for ourselves.

A panhandling sign in San Francisco, California, March 14, 2010. BrokenSphere / Wikimedia

In 2006, the New Yorker ran a story about a man nicknamed Million-Dollar Murray, a military veteran and a homeless alcoholic who came into contact with social service providers on a daily basis. The city of Reno, the article showed, was paying far more in social services expenditures to keep Murray on the street than it would to simply house him — that is, it cost more money to manage the problem than to solve it.

One major reason why Murray’s situation was so expensive for the city is that he went to the emergency room several times a week. The United States Interagency Council on Homelessness estimates that the state spends $30-50,000 per unsheltered person per year, vastly more than most people pay in rent. Emergency room visits make up a huge share of that cost, since people living without shelter are three times more likely to visit the ER, and well under ten percent of homeless people who visit the ER have private insurance. It’s actually less expensive to spend public money on shelter instead — and meanwhile, people who receive shelter see significantly better health outcomes, which can help them attain overall stability.

Some cities and states have recently acknowledged this calculus. Salt Lake City’s enormously successful Housing First initiative has reduced chronic homelessness in the city by 91 percent by providing housing to homeless people without requiring proof of employment, treatment, or counseling — the principle being that housing comes first, making other services easier to administer. Houston, too, has seen major improvement in both homeless people’s health outcomes and the city’s budget with its Integrated Care for the Chronically Homeless program, which uses Medicaid funding to provide permanent supportive housing units to homeless people who make at least three emergency room visits over two years.

These initiatives are a big step in the right direction, since they take into account the close relationship between health care and housing security — issues that are usually siloed to detrimental effect. But programs like these face serious obstacles. In particular, it’s extremely hard to coordinate among a kaleidoscope of separate federal, state, and local agencies, social program stipulations, and funding streams. As Politico reports, on Houston’s initiative:

Agencies that pay for housing and health are governed by their own particular sets of financing, regulations and organizational practices, differences that are difficult to bridge. For example, working with federal funds creates a puzzle for city officials like those in Houston. Medicaid money can’t be used for room and board unless those are provided by a nursing home, while federal housing vouchers can be used only for housing, not health care. To complicate the matter, the funds wind up in different places. Medicaid dollars go to the state and funds from the Department of Housing and Urban Development are directed among dozens of local housing agencies. Plus, working with Health and Human Services and HUD means contending with complex sets of regulations that often are at odds with each other: HHS and HUD literally have two different definitions of chronic homelessness, with the HHS definition being more broad and the HUD definition being more strict.

In their attempts to deal with their populations’ mutually related housing and health care needs, cities like Houston and Salt Lake City are fighting an uphill battle. That’s because the patchwork nature of social services in the United States makes care harder to administer — even when politicians and bureaucrats have the right idea.

The United States has a uniquely balkanized welfare state. As Colin Gordon writes in Growing Apart: A Political History of American Inequality, it emerged in the early twentieth century out of “a patchwork of scattered public programs, charitable relief, and various forms of mutual aid.” Despite the efforts of ardent reformers during the nation’s progressive periods, it never really cohered into a raft of comprehensive, straightforward programs that were easy to navigate and premised on social solidarity rather than philanthropy or largesse.

Although the Great Society era made some strides toward fulfilling the universal promises of the New Deal — especially with the creation of Medicare, a unitary, fully federal program — the old pattern reasserted itself with Nixon’s “new federalism,” which decentralized power and gave states the prerogative to scale back social programs altogether. This shift was closely followed by Reagan and Clinton’s subsequent assaults on welfare, driven by neoliberals’ fixation with imposing means testing, that is, ever-changing eligibility thresholds, and their further devolution of authority to the states. Means-tested programs are confusing, unpopular, and especially vulnerable to political attack, as the last few decades have repeatedly shown.

As a result of its politicians’ enduring resistance to universal social programs, the United States has a fragile and fragmentary safety net, one in which public services are provided variously by the federal government, individual states and cities, publicly subsidized nonprofits, and nobody. Without guaranteed housing, health care, and employment or income, people don’t just fall through the cracks — they free-fall into a yawning void. This leaves well-intentioned policymakers in places like Houston and Salt Lake City playing catch-up, cross-referencing qualifications and classifications to create new eligible subgroups, and assigning new bureaucracies to those subgroups, all while pleading with legislatures not to cut their funding.

Trying to get two agencies administering fragmented and heavily conditional programs to come together and provide holistic social care is like trying to get two cats to tango. It would be far simpler (and likely cheaper) to care for people in need if we had transparent, national, universal social programs instead of a hallucinatory maze of restricted stipends and eligibility requirements.

Single-payer health care would be a good place to start: after all, medical bills are the number one cause of personal bankruptcies in the United States, making them a leading cause of homelessness. Unfortunately, Democratic Party neoliberals still haven’t gotten the message: their latest idea is to patch up the health care crisis with yet another “Medicare Part X” mini-program limited to people aged 50-64 “who do not have employer-sponsored insurance and were not offered it” — yet another blizzard of pointless paperwork.