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"Housing Is Healthcare, Homeless Solutions" SwatTalk

with Josh Green ’92, Lieutenant Governor of Hawaii

Recorded on Thursday, Dec. 12, 2019



Ted: Hi, I'm Ted Abel, class of '85, and a member of Alumni Council. This evening for our Swat talk with Josh Green, who's the class of '92. Josh is currently lieutenant governor in Hawaii. And after Swarthmore, he went to Penn State to do his medical degree there. And then joined the National Health Service Corporation. And that's what got him to Hawaii and rural America. And then what we'll hear about today is one of his initiatives that he started a few years ago, which is housing, and housing is healthcare, particularly the idea that the homeless, many of whom suffer from chronic mental illness, that really can be helped not just with housing, but also with medical care, by providing them with shelter.

What we'll do today is Josh will give a presentation probably for about 30 minutes. I'll share my screen in a second. And then we'll have questions at the end. So if you could please put your questions in the chat window of Zoom, along with your name and your class year. And then at the end, I'll ask those to Josh, and we can have a sort of discussion that way. Josh, thank you for much for joining us tonight for Swat Talks. I'll put your slides up and we can get started.

Josh Green: Aloha, Swarthmore nation.

Ted: There we go. Hopefully you can see the slides, Josh.

Josh Green: I can. That's perfect. Well, thank you, Ted and Emily Ann and Lisa and all the friends out there from Swarthmore that are participating tonight. I really appreciated it. I just wanted to share openly some experiences and thoughts I've had about healthcare, but specifically a concept that I believe in very deeply, which is that housing simply is healthcare. We see in this first slide a gentleman sleeping, sitting underneath his home, which is an umbrella, on the beaches here in Hawaii, drinking water, barely surviving, incredible poverty. And just in the background, you can tell that he's only a couple miles away from of course luxury hotels and what people often think of as Hawaii, the truly beautiful nature of this state.

And it is a beautiful state. And I'm super lucky to live here. It feels like a blessing every day. But there are super duper challenges too. And that's what this man faces. It's not a way to live. It seems really immoral even that we would let him live this way and not take care of this gentleman, his basic needs, housing and so on. So that's what this slide's meant to show, that he lives in utter poverty and suffers. And just a couple miles away, the average condo price is probably, I don't know. $1.5 million for a thousand square feet of a condominium in Waikiki.

So we have this problem in Hawaii and across the nation, and it just said something to me. This guy is emblematic of one of our crises. So I truly believe housing is healthcare. Ted, let's look at the next slide if you don't mind. So there you can see this is some of the data that I'm going to share with you. And I want to share my perspective a little bit. I come at this, after the Swarthmore experience, I did go to med school, and have since served in the legislature here. And I've been seeing things through the lens mostly as a healthcare provider, but also analytically as the chairperson of the human services committee and the health committee over the years. So I've looked at the data, and I want to share kind of what it looks like in Hawaii and also what the impact is on just our human beings here in Hawaii and how it affects us all in our healthcare system.

So Hawaii's homeless challenge, it's got gigantic implications for our nation. We're the highest per capita homeless rate in the country. Right now on any given day, we have 10,000 to 12,000 individuals in Hawaii, out of 1.4 million citizens that are homeless. And the fact that we have that many people that are homeless, it hurts. It's somewhat shocking. There are many reasons for that, a lot of socioeconomic reasons, of course. And there are economic justice questions posterized all over this problem. But Hawaii, you would think, a lot of people think it's paradise, there's no way this would be a problem.

Well, people come here because it's warmer. They can be protected from the environment. They don't have to suffer so much of the cold, and sorry that you're experiencing that right now in Philadelphia and New York and elsewhere in the East. But that's what happens, so people come here. And when I say housing is healthcare and that homelessness is a medical condition, I mean it because the average lifespan for an individual in Hawaii is somewhere between 51 and 53 years. We've had both 53 and 51 respectively in two of our demographic studies. And we have over 2500 people who are unsheltered homeless. The rest are living somehow in a shelter or in another state in and out of housing.

So we see this, we see this average life expectancy where people have lost two and a half to three decades of life. And the one common factor always is that they are without a home. I would also add that, you can see this in coming slides, that there's extremely high rate of mental illness and addiction among our homeless citizens, our brothers and sisters. The combined rate's about 70% of all individuals in Hawaii who are homeless have either addiction, often to methamphetamine, or mental illness, or both. And PTSD is very, very common. After six months, it's almost 100% of our individuals suffer PTSD.

Needless to say, being on the streets is catastrophic. We'll hit the next slide. So it's also very costly. Not only is the human impact enormous for being homeless in Hawaii, and frankly, elsewhere. It's the same way, the same numbers all across the country I could share with you, and will. But in Hawaii, we have a very small percentage of our people who are on Medicaid. 3.6% of our Medicaid population consumes 61% of our Medicaid budget. Now to put that in perspective for everyone who's listening or is in healthcare, Hawaii is a super blue state. And exactly one out of four of all of our citizens are on Medicaid because it's so expensive to live here. So of the 1.4 million, that means 352,000 people are on Medicaid. But this small sliver of people, almost a perfect overlap with those who are homeless, are forced to consume a really large part of the budget because every time there is a problem, a crisis in their life, they have nowhere to go but by ambulance to the hospital and so on.

So how does that break down? Well, 13,000 people, that's the 3.61% of the 352,000 people, consume that 61%, which is $1.2 billion of a small state's budget. And this again carries over to most states. Sometimes it's 5% of a Medicaid budget consume 50%. But it's some version of this economic challenge. That averages out to $82,000 per person per year. That's the median. Now we do have some people that consume even more. But the reason I focus on the dollar number is because when would like to solve the problem for housing purposes, through housing first, or better shelters, or you name it, and I'll go through a lot of different solutions we're entertaining, it's just impossible because you can't find the money.

The average price per person per day when they touch the healthcare system in Hawaii is $4,650. And that's because a conflict occurs. This gentleman, who there's a picture of, we're actually doing street medicine. I was just doing some bandages on his left ankle. He had terrible ulcers on his feet, serious probably resistant staph infections, if he gets picked up for wound care, it's $1250 for the ambulance, $1600 in the ER, $2000 for antibiotics and possible overnight stay, and then discharge, and that's the average bill, when we could've housed him for four months and provided social services. And many of these problems wouldn't exist. Let's go to the next slide, please.

So by the numbers, if Hawaii rights its system and provides shelter, specifically permanent supportive housing for the individuals that are homeless in our state, we will save over $300 million a year in Medicaid right away. We did one study early on, and we found that the percent saved for people who have shelter from their healthcare costs and other consumption of services dropped at least 43%. And the Department of Health didn't believe me when I said it, so they did their own study, and they showed that it saved 73%. So once again, housing is healthcare because all of a sudden, everyone's life expectancy then returned to normal. We stopped seeing people die on the streets from trauma, or terrible infections, or goodness knows, every possible disaster that can strike.

 Forgive this, but pretty much every woman under age 40 had been sexually assaulted in our streets if they were living without shelter. The number of adolescents who were homeless is surprisingly bad here and elsewhere. And check this out, guys, within the first 48 hours of being on the run or homeless for adolescents, over 70% of them were approached for sex trafficking. So this becomes a colossal ecosystem of crisis from poverty, to mental illness, to addiction, and then all the other things that come with it if you're on the street.

So when we cracked into these numbers, that's what we saw. So we started putting some solutions in place. We opened what's called a joint outreach center in Chinatown right near the epicenter of homelessness, and after starting that for nothing, it was in partnership with the police department. They gave us two rooms for free and we painted them and put free beds and things in them. The private sector saw this, was witnessing that we could do something, we started saving $100,000 a week, just because people wouldn't go to the hospital as often. They sometimes came and got their mental health drugs from us, or wound care from us, or free slippers, which is what we call flip flops out here.

So it immediately showed that you could do a lot of things. And we employed people there, paid them decent wages, and we still saved 100 grand a week. So we started raising much bigger money, raised $12 million from the private sector to start a thing called H4, which I'm going to talk about coming up. And it's one of our primary solutions for the homeless crisis here in Hawaii. Next slide, please, Ted.

So here's The Gary Challenge. I've unpacked some of the numbers for you. But Gary, who told me to share his story, Gary passed away in early 2018. But in 2017, there he is, very sweet man living over at the IHS shelter, homeless, had a little bit of mental illness, very, very solid guy though, functioned pretty well. He had a little bit of COPD, chronic lung disease. But Gary would go to the hospital every day. So in 2017, he went to Queens Hospital, our main hospital, 241 times. And his Medicaid cost was $1.229 million, him alone, to the healthcare system, paid for by taxpayers.

And I think people know me, a little bit here at least, to be a left of center guy. But even for me, that was just a little too much to bear, to spend $1.229 million dollars on a guy that wasn't even that sick when we could've provided him just some basic services. And then Gary did pass away the following year, complications from chronic disease. But Gary had fallen in love with somebody at the hospital. It was the one place he felt safe and that he got treated with respect. And so the Gary challenge that we learned was that if you provide someone with a place to be, and a respectful caregiver, or partner, or services, they don't have to go to the hospital. And it's not rocket science, I know. But it definitely underscored one of the solutions, which was we have to provide a series of services that would functionally work for someone like Gary, a high utilizing individuals that just needs a better healthcare system and a home to live in and sleep in.

Next slide, please, Ted. So here's how I break it down in a simple way, if I'm talking to people say from [inaudible 00:13:07] or something. Right? We've got homelessness and poverty, of course. And it's a calamitous problem across the country. And needless to say, when you add drug addiction, you end up in that kind of left side of that circle that's a little gray. And sometimes people don't become homeless. They may just be in poverty, and they're addicted, but it's hard to say. They may pull out of it.

And then the right side of the circle here, you see mental healthcare or mental illness. But when all three come together, deep poverty and the homeless state, plus mental health concerns, plus addiction, which often people of course are self medicating, as I would if I was living on the street and being beaten up all the time. You end up in ground zero with chronic homelessness. I describe that as over a year with mental illness and addiction. And there's just almost no way to break that cycle unless someone comes and holds your hand right through the problem and gets you not just a home, but wraparound social services like housing first, but even more flexible, because you can't simply put someone in this dire of strait into an apartment and expect their whole life to get better and kind of turn around immediately. So we challenged that paradigm, and we began to develop some other ideas.

Next slide. So here's where I talk a little bit about substance abuse in Hawaii. So of the people that are addicted or have addiction issues, and often it's been from opioids because we have problems with the opioid epidemic just like everybody else, only 4% of our individuals with addiction can get into proper services they need because people just don't commit themselves adequately in our state, or almost any state, to do comprehensive treatment. And for addiction, particular methamphetamine, the people who study the physiology of the brain, will tell you that people need at least nine months off a drug in a safe space to really recover. And in Hawaii, we have a lot of methamphetamine.

We don't have as much opioid as other people do across the country, but we have a lot of methamphetamine, so that's a huge crisis. And a lot of our homeless have suffered that drug addiction. We've got big drug and alcohol use problems in some parts of our state. 51% of all young pregnant moms on the big island, 51% were either smoking, drinking, or doing drugs during their pregnancy. And then we have generational homelessness, so all of these things continue to roil around together. And you can see someone there kind of is symbolically drowning in pills and pain and emotional suffering, so this is a huge problem for us.

And remember it's a problem for all of America because we have 4% of the world's population, yet we consume 80% of the world's opioids, so it's kind of terrible. And it's something that we have to correct. We will see a massive opioid settlement nationally in the coming months. I think it's going to be at least a $50 billion settlement in my estimation. But that's just the tip of the iceberg with the problems it's caused. Our next slide please, Ted.

So there are some things that we're starting to do. This one is relatively stupid, but we are trying it. It's called Lift Zones. And our mayor just announced that he's going to be supporting this. It's pretty expensive and I don't know if it's going to work. But it is one of the many things that have been proposed as basic solutions. These are inflatable, non permanent tents that will leave after 90 days, so they'll lift out. Homeless can transition there and get services, especially social work, which is good, and healthcare, which our nonprofit will provide for free. And this provides an opportunity for law enforcement to clear out parks and provide shelter temporarily.

The challenges with it are many. The reason we're trying it is because it was politically expedient. But it just might do a little something for a few people. It is meant mostly to give people a place to go rather than be arrested, and that's a plus. But it should not be used as an excuse to just get around the ACLU, which is what I'm afraid is going to happen. So Lift Zones are not going to be our long-term solution, and we will waste some money on this in the short-term. But there's a lot of other things that we're going to do that I'm going to tell you about next. I probably should've taken that slide out.

All right, so shelters. Obviously, we have to, like many places, be committed to shelters, and adequate shelters and good shelters. We have wonderful shelter providers here in our state. The challenge is of course: Do we have adequate beds? Well, we kind of do have adequate beds, but the challenge also exists that people don't want to go to shelters a lot of the time because, for example, the shelter may next be populated by a few people that come out of prison, who do deserve a chance to be housed again, and should be put in the permanent housing. But without that option available, suddenly a couple people that have been convicted of felonies show up at a shelter, and it creates quite a challenge for other people who are maybe have some mental illness, or maybe have young children, and they're in the shelter.

So you get the idea of why people sometimes leave shelters. Also, there's all the traditional issues. There are privacy issues. There are bed bug issues. There are issues of intimacy that people have as real life questions. And so a lot of times, people in Hawaii won't go into shelter because they can survive outside because it never gets under 72 degrees here. Sorry. We also provide social and medical services at some of our shelters, which are good. And so we're trying to make them better and we're trying to lean towards other modalities of care. And I'm going to come to that in a moment, particularly tiny home villages, which we're calling kauhale. I think that's going to be one of the most important things that we do.

So we'll go to the next slide. This is kind of our pride and joy, which is the Hawaii Homeless Healthcare Hui. A Hui is an organization of people or gathering in Hawaiian. And this is a labor of love. We started a nonprofit, like I mentioned earlier, because we saw the incredible impact of individuals who were homeless going to the emergency department at extreme costs, like Gary. So Gary probably would've been at the hospital 360 days a year, except they didn't count it on some nights when he wrapped around past midnight. So this system, this H4 that we're calling it, is meant to be 24/7. We finished already two and a half of the four floors.

They hygiene floor is set, so we see 200 to 300 people every day to provide hygiene services. None of this was necessarily some kind of stroke of genius, but it really combined a lot of the best practices that we got from across the country. So now people can go to the hygiene facility for basic staph treatment, basic care, do their laundry, food and so on, like many, many hygiene centers across the country. Seattle was influential for us when we started this, and that was part of our public private partnership because the county gave us the building. And then we just did an RFP and got to run it, and we're paying for it totally with private equity so that we have the freedom to operate.

The second floor will be a 24/7 urgent care clinic. And that means that ambulances can come and drop patients off here if they want to be seen immediately. We'll see about 75 people a day, instead of going to the emergency department for $4500. And we will see people irrespective of their ability to pay. In fact, we probably won't bill anybody because we're stressed out about taxing the insurance system. Although, they gave us $8 million to build this thing out, so indirectly, they're reimbursing upfront. We have 36 or 38 months of upfront funding to operate this facility. We'll have about 80 people hired to work there. A lot of community health workers, psychologists, psychiatrists, physicians, nurses, everyone you can imagine, nurse practitioners, PAs, plenty of security.

But providing 24/7 healthcare, because there are at least 50 unnecessary visits at our hospital every day for basic little things. And 50 people were stuck at the hospital when they should've been discharged because we were too ... We didn't want to hurt them and send them back to the street. So you can imagine what that impact was on the hospital. At about $5000 a day, those 50 people were consuming an enormous amount of money. It's a quarter of a million dollars a day that didn't need to be consumed. So we started the third floor, which is medical respite, so people can be discharged and come straight to our third floor. They'll live there temporarily until they're well, until their wounds heal, get antibiotics, get house calls from the second floor, but have medical respite out of the hospital, again, at zero cost essentially.

And then permanent housing on the fourth floor, where people will ... We'll have 21 units for people like Gary, who hopefully live there. The highest utilizer is people with significant needs that they can get wraparound social services from our social work team that's going to be employed. So this is the model. It doesn't have to be truly linear. It can be a virtual model. But by providing these services and then moving people to permanent housing in their own apartments when they're ready for it, when they've gotten stabilized on their medications, when they've had long acting antipsychotic medication, if that's what they need. All of these things are meant to kind of cut into our homeless crisis and get people to housing.

Next slide please, Ted. So Ohana Zones, we passed a bill, a $30 million appropriation when I was still in the legislature, to fund small housing. And we meant to create little housing villages. It hasn't worked out perfectly, but we're getting there. The goal is to do ultimately what we're going to call kauhale, which is tiny houses about 150 to 200 square feet each. Very simple, so people have their own little home, a part of a community, that's the critical piece.

If you want to see something exceptional, I recommend, this is one person's opinion, go look at Community First in Austin, Texas. Look at their website. We're modeling it after that, where people pay a little rent, commit to their community, forgive me, have a job, have a little work, work towards sobriety if they can. They may not be able to. Work toward good mental health, people may or may not get there. But live in a safe place. And Ohana means family in Hawaii, so Ohana Zones. So I'd like to do 12 of these across the state. And we've already broken ground on one. Next slide, please.

I mentioned earlier the Joint Outreach Centers. We've started a second one. This is where we have just basic healthcare, mostly mental healthcare and wound care, but in two spots now. We'll probably open three more, one in Chinatown, one over across the island over in Kaneohe, and then some on the neighbor islands. This is the way where you get people savings. It's not unlike an urgent care center, but it's a joint outreach center. So a couple hours of a doctor, or nurse practitioner, or PA, a couple hours of social workers overlapping, housing experts. Anyone can come and use the space with their organization for free. And the only necessary commitment from people is that they all work together and that they're compassionate.

So by targeting, we already met our target for Kaneohe, it's opened, and Kaka'ako is our next one. We can see amazing savings, which makes it a lot easier for the philanthropic community or the companies that own healthcare systems or hospitals to immediately have that savings to invest in us because they see an incredible return on investment. The H4 facility, just so everyone knows, we're projected to make a 1700% year over year return on investment, 1700% because the costs of going there are virtually nothing compared to the cost of going to the hospital. Next slide, please.

Assisted community treatment, again, we speak often about housing is healthcare. But there is some actually healthcare of course involved in helping individuals who are homeless. So aside from putting a roof over an individual's head, it's my opinion that getting medication available to them, if they will take it, and some won't. I'm going to say some controversial things here. Keeping in mind, I've spent the same amount of time with you guys in Wharton and Willits and McCabe and all over the place studying and trying to be very sensitive to our civil rights. We are focused on getting people treatment. We call it assisted community treatment, focusing on people who have passively lost their civil rights over years.

This woman named Latonya, she has a serious schizophrenia. She can't remember her name, basically. We found her ID. She had wounds that were full thickness wounds through her leg to her femur. Florid schizophrenia, like I said, and just couldn't move. She'd been in that same spot for five months soiling herself, peeing on herself, and so on. And it just breaks your heart. But we couldn't get her into care because by the definitions in our laws, she was not an imminent danger to herself or others, though I would argue that she is because the average life span's 53, and she was right at 53. Excuse me. Sorry about that.

So what we did was we began to look at our laws. This is me with a gentleman named Dr. [inaudible 00:27:00], he's a great guy who's a psychiatrist. And we would like to give her the option of care, or even get her into mandatory treatment, or she's going to die. And we didn't have adequate guardianships. We didn't have adequate working relationships with our public defenders or our judges, so we couldn't get her off the street. And one person a week was dying in Hawaii. So we amended our law to change the statute so that people who are actively decompensating with their health can now be forced into treatment. And we still will only use it for people who are in the sickest of sick states, and then frankly, drive them right back to wherever they are.

 But I do think people need long acting antipsychotic medication. It is somewhat controversial, and I would respect anyone who disagrees. But I can tell you this, as a legislator, every parent that I ever met in these hearings begged us to pass laws like this. Parents of individuals that were lost to them, that were homeless and on the streets, and many people that we've activated this law and treated are now walking around doing quite well, not suffering and struggling the way they were. And many are housed. Many are maybe still houseless, but are able to communicate and to take care of their needs. So we need an additional 240 stabilization beds to make it work in our state. And of course, the top floor of the H4 is one of those areas. Next slide, please.

We're coming down the home stretch a little bit here. Other services I think that need to contribute toward getting us into a place where we can house everyone are Treatment Today, which is a process to get people active treatment for mental illness or addiction the same day that they ask for it, or one of their family members plead that they get it. So at detox on the second floor of our H4 and expanded our services across the state, have wet beds at some of our shelters, have addictions specialists available in real time through telehealth, tele site, have rehab services and referrals and place people when they want to go into help, which a lot of people I've noticed when I'm working my ER shifts do.

But as you can imagine, if someone leaves, they may not have the same motivation to get treatment the next day, or the next day. And that's a big crisis because I tell you, I've seen many people begging for treatment. And then the next day, I find them overdosed on heroin, and sometimes not able to be resuscitated. So this is a crisis of our time, and I think that having this treatment and having some form of the [inaudible 00:29:38] treatment available for people, including those who are serious addicts, and would ask for help if they could avail themselves of it, is probably the right thing to do. But we're talking about some serious ethical problems there too. Next slide, please.

Permanent supportive housing. And I think there's a typo there, forgive me. Many years removed from our excellent education. Housing first model is a must. Everyone's clamoring for it, but we just never have enough resources. Rapid rehousing is working for us. It should work for everybody. Expand section eight, having affordable housing development by giving some tax breaks wherever you can, it will save you a fortune wherever you are. We'll get people housed, and then we're going to build a rail for $10 billion in Hawaii, which a lot of people think is insane, me included on most days. But putting in transit oriented development together is smart. So if we're going to build that rail, we should actually build housing. So this is our approach. We'll go to the next slide.

But I think we instead should be building places of social respite, and we call them kauhale. There's a picture of one. And this draft was done by a homeless community with 300 people who are homeless. And it's pretty serious approach to end homelessness in a sustainable way by building small communities. The most possible would be about 300 in Hawaii. And I think they'll be more like to be 70 to 80 people per. We build them on public lands, very low impact, very low infrastructure needs usually. It needs to come on lands that are already available, otherwise, you just can't possible afford it.

But by providing social respite in a culturally sensitive way and is permanent, you can actually get people from a place of homelessness into shelter and provide some healthcare and social services. And then you're really moving people into a place that they're much more well. And if you do this for the chronically homeless, I think you've provided healthcare by way of housing. So kauhale is a word you're going to hear out of Hawaii. I do think after traveling in California, Washington state, DC, Boston, New York, Texas, it's just everywhere that we need some form of this. And each place will be a little different. But our price point for each unit is about $18,000.

And to provide a small house, a tiny home, with something community services and support for $18,000 is something that pays for itself in many people's cases in a week or two. But certainly, with the average spend at $82,000 per person, it pays for itself many times over each year. Next slide. This is just a quick visual on how we look at things, although, absolutely the problem is not linear. But unsheltered, to lift zones, where they might get into shelter or a H4 program, and ultimately end up in permanent housing is the way we look at it. But if someone can jump over one step or another and maybe go straight to the H4, we believe in that too. Next slide.

I say we should prescribe housing. And when I do it, people think I'm insane. But look, if I can prescribe a treatment for hepatitis C, which costs $150,000, or if you or I are a healthcare provider, and we can prescribe a chemotherapy, which is $30,000 a month, which doesn't increase your lifespan, except for maybe 60 days, or if we could prescribe antibiotics to the tune of $800 a pill. Why not prescribe housing when it decreases people's healthcare costs and spend by between 43% and 73%? And also increases their lifespan by 25 to 30 years. I think it's obvious we should do this. And I've proposed this to the current administration, the HUD secretary. It would feed into the housing first, but by opening up 2% of a Medicaid budget in each state, you will see at least 8% come back. There's no way to not save that much money. And so that's the pilot I've proposed. And I think that it's a simple prescription would be vetted or authorized by a Department of Human Services or Housing, just like we do with insurance.

But you could make sure that you get people who are homeless, chronically homeless, in crisis, into a much better setting. And I think that this is an option that would be simpler than doing the waivers that we see at the federal level, or block grants, or what have you. So I would tell you that it's a good idea to do this and to prescribe housing. And I won't be shocked if this is one of the things that emerges in the future. Next slide, please.

These are ways that you can help. This is us just with families in Waianae, one of the most beautiful places in the world, but extremely poor and where the healthcare disparities are catastrophic. A lot of you know that zip code is more impactful on your health now than genetic code. We hear that a lot from people, and it's absolutely true. But if you have a joint outreach center, [inaudible 00:34:55], or support assisted community treatment up to your standard and your willingness to tread on that question about people's civil rights, but I think you restore civil rights when you get people care, or support kauhale development or an H4 program, it would go a very long way. But just support people how you can in your discipline.

You guys are the most talented people I've ever met as Swarthmore grads. And I'm still in touch with a lot of old friends, dear friends, that are doing things like this. Next slide. Just another couple pictures of things that I'm doing, which tie into this. Emergency management there on the right side because if we have a category four or five hurricane that hits the state of Hawaii, we're finished. And we're going to have a lot more than homeless challenges to deal with. We will have an economic meltdown. So we're working on some emergency management plans, so all you guys can keep visiting us and contributing to our economy in a healthy way.

And the provider shortage, we're 22% short of all healthcare providers across the state, 40% short in the neighbor islands. And so that also contributes to a lot of our healthcare disparities. And we can't help people who are homeless in that circumstance. Next slide please, Ted. Just a couple pictures from the street. On the upper left corner, that's me with children who are living homeless. I'm just putting Superman Band-Aids and such on them because just the touch of someone is helpful often. And eventually, we hope to get better care and actual housing for all of these kids.

There you see us trying to convince Latonya to accept an ... Sorry. Not immunization, a long acting antipsychotic shot. And she wouldn't. This was before the bill passed. Today she probably could. And we would get a guardian for her and make sure that we could get a sustaining order for her going forward. But it's challenging. It's even challenging now. In the lower corner, that's a gentleman with chronic liver disease, who is happy now when it's not the rainy season. But he needs a home too if he's going to get better and do well with his treatment for chronic disease. And then in the lower left corner, a gentleman named Royce, who went to our best prep school, same place Obama went. Same place that my colleague and partner, the psychiatrist, Dr. Chad [inaudible 00:37:22] went, who I showed you before.

Royce is now speaking to us and clear minded after getting medication of his own accord. They both went to Punahou, where Obama went. But then Royce, because of his schizophrenia and addiction, ended up on the street. And Chad ended up at Harvard Medical School after college. So it's just incredible the different life paths we sometimes take. So we'd want to be compassionate and help Royce, and just be part of his life in a positive way. Next slide might be the last, it think. Yeah.

So that's just our social media. And please connect because I want best ideas and best practices from all across the country. And I want to help us continue to make Swarthmore proud and come up with ideas. They won't all be good ones. I'm sure I've had many, many terrible ideas. But I hope that people think that looking at housing as healthcare is a decent idea. And I'm hoping to make this one of the principles that we would carry across the country. So sorry I went a little over. I just want to say you should all come to Hawaii and visit us and engage, and see these beautiful people and beautiful things that happen here in Hawaii. But also, if you have expertise, I'd love to hear. And I'd love to incorporate that into what we do.

Ted: Great. Thanks very much, Josh. By the way, I should tell everyone that we've been recording this. I forgot to say that at the beginning. And I think we'll be posting in on the web. Josh said that it was fine to do that, so you'll have a chance to spread the word about what Josh had to say. I'll start with just one question. If people could post questions in the chat window, that would be terrific, along with your name and your class year. One question I had was about education. At the end, you showed a picture of several kids on the street, you said giving them Superman bandages. What's provided in these sort of plans in terms of education for homeless children?

Josh Green: Great question. So all of our homeless children do go to public school. Although, there are some barriers, of course. Obviously, a lot of their parents have great challenges, and there's just not a consistent capacity to parent because they're in such desperate states. But our Department of Education, we have only one department in our whole state, makes sure everyone has access to school. We also have a lot of kids that are immigrants, for instance, from Micronesia, because we have compact with the free states of Micronesia, where kids come. But historically, there has been some drop off in attendance at schools and our rates. It's been quite difficult, so we do our best to get kids into school. But that's obviously necessary because until we provide people stable permanent housing, they're constantly uprooted, and then getting to the school is almost impossible in a consistent way.

Ted: So one question comes from Will Greenhouse, class of '70. Says, "The national statistic is about six vacant dwelling units for each homeless individual. Legal and financial barriers prevent us from making the units habitable and providing homes for everyone. Is that situation also true in your state?"

Josh Green: I think that number is probably much smaller here in Hawaii. I really appreciate that. And I'll take a good look at that. We have a severe housing shortage in Hawaii, the kind of perfect storm that you don't see in every state. Hawaii is so desirable for visitors. We have over 10 million visitors now for a population of 1.4 million people, that a huge proportion of our land, which is extremely valuable, and people can get ridiculous rates on when they put their houses into all the different ways to rent houses, like Airbnb, that we've had a crisis for rental availability. And even houses that are pretty much tear downs, people will buy, quickly renovate, and toss into the Airbnb category. So we've had to crack down on that really significantly in the last six months.

And it's beginning to show some dividends. So we're now seeing rents come down. Rents have dropped already $100 per month on average because we've increased our inventory. And for every $100 you drop rents in any region, you can see an uptick of a pretty solid percentage of people being able to afford them. So you have less people who are in poverty and just homeless because of that, and not the other considerations. I don't think we have many vacancies. For instance, our Hawaiian Homelands program, we only had 60 to 80 units or houses that could be renovated adequately to put people in. And that's been a constant challenge for us. You can't find a rental on the big island, where I used to represent as their senator. There's just nothing.

And it's pretty incredible when you can't find rentals even. I understand if people can't afford the $600,000 or $700,000 a year, which crazy numbers, to afford a house. But to have rentals be unavailable is crazy. So if there are barriers like that, this is where I think we have to be understanding as citizens and find out what our threshold is to set aside some of the regulations. It sounds crazy coming from a guy from Swat, but deregulating some of the housing market, as long as it remains safe and sanitary, is a heck of a lot better than seeing the 550,000 people who are homeless across the country. I personally would use Medicaid dollars to do it, put people in housing immediately, and watch the incredible reward and savings in Medicaid to pay for al these budgets. That's how I'd take it on right away. So that's where I'd find the renovation money in the first quarter.

Ted: The next question is from Bob Kushman, class of '71. And he asks, "Do you see differences in acceptance among the various communities in Hawaii of your holistic approach to social support, such as native versus non native communities? Or you talked about people from Micronesia."

Josh Green: Yes, absolutely. So there's definitely discrimination still. Some communities were deaf on the idea. But after I spent time sharing with them the macroeconomics of it and also the health economics. And once you really share with people that is a challenge for all of us in our backyard, no matter what backyard you have, whether it's a beautiful part of Kahala, which is a very wealthy community, or in [inaudible 00:44:10], where people are quite poor, or downtown in Chinatown, where there's a lot of mixed ethnicities, but a lot of addiction and a lot of homeless on the streets unsheltered.

Each and every community benefits similarly when you just provide some basic housing. So yes, there's been some pushback about building kauhale in different areas. I just push right back and I say, "Okay. Well, what's better? Having people on your street corner, or on your curb, or in your house desperately trying to find shelter, or stealing from you if they're addicted, or in their own tiny house or an apartment." I mean, which one do you want. And usually people say, "All right. All right. I get it." And people who are a little more hard nosed about it, they may yell at me a little bit about personal responsibility, which I get. And believe me, I want everyone to have a job and contribute. But I asked them what challenges they would face if they were schizophrenic and had been neglected for a long time, and also were substances abusers because they were suffering so badly. And then most people just shut up and try to house people.

Ted: The next question is from Freed Whitman, class of '64. How does sober housing fit into your service continuum?

Josh Green: Very, very important. We have totally inadequate access to sober housing and to rehabilitation for alcoholism. But we've partnered up with a lot of different groups. And not surprisingly, the Salvation Army has programs. A lot of the faith based programs are prominent here. Hawaii is a pretty religious state going way back. The historical nature of Hawaii was you had a lot of missionaries over here. I'm a Jewish guy married to a Mormon, so I've got issues of my own. But there's a lot of religion here, and so we do lean heavily on people that are faith based and doing sober houses, and we could use a lot more.

We need our Department of Health to add those services. And I'm with them constantly trying to ... And they're listening to incent that, but sober houses don't pay as well as a lot of the other healthcare organizations do. And sadly, it is the new crisis that we have to face. It's been going on for a long time. We're treating less heart disease and cancer. We're treating a lot more mental illness and addiction. So I think the healthcare system's got to change over.

Ted: What's striking about the numbers if you see them not just with the homeless, but if you look at these things called DALYs, which is disability adjusted life years, something like 20% to 25% of disability adjusted life years, the cost of that is from psychiatric and neurological disorders. And that's more than cancer. It's more than heart disease. And when you think about it, when I was at Swarthmore, soon after that, it was AIDS. And that's something now we have treated with very effectively now. But mental illness has remained a major, major challenge. That's absolutely true.

Josh Green: It's hard. It's the hardest. This is the doctor in me. It is the hardest [inaudible 00:47:18] of illnesses or challenges to treat. It's just so hard. And I don't know that we have yet ... We don't cure a lot of things, of course, we all know that. But the medicines are sometimes, some are better than others. But it's just really intractable illness. And the very nature as we all know of mental illness can include fear and paranoia and crisis. So therefore, even if we have good meds, the very nature of taking meds makes people afraid. So it's tough, tough stuff.

Ted: The next question is from Jimmy Gastner, class of '16. Who have some of your unusual partners been in this work, beyond the healthcare and community development sectors? And how have you engaged them? And could you talk about the private equity component that you mentioned in your P3, or public private partnership?

Josh Green: Yes, absolutely. Great question. So I don't know if it was a surprise to me or a surprise to others, but the hospital system put up about two thirds of our money because they were benefiting directly, but also compassionate. So they wrote open checks basically to us because they saved so much more. They're burning through $70 million a year of lost opportunity. So putting $2 million or $3 million a year into a program like this, which sustains them, which takes those patients into a better space so that they can actually treat billable patients has been an interesting relationship, so they've been great, the hospitals.

The health insurers, very, very supportive. Saw the wisdom in it right away. They saw that they would much prefer to not be forced to reimburse for visits, 100, 150, 200 times a year that were unnecessary when they could just get people into a stable situation. They didn't want to just write a check for housing, but the idea that they support a health institute, which was H4's pitch, worked. It happens to be heavy on housing, but it does have healthcare. And then a major hospice entity is supportive because this person's hospice program realized that they couldn't treat people on the streets. It's just too difficult.

And they wanted to give back. They made a lot of money, and so they also supported us. But I got little kids sending little checks, and parents telling us that they would gladly support this institution. And the firefighters and policemen, who spend so many hours a day trying to deal with people that are in crisis on the street, when they would rather have a place for them to go, so they come and they paint and they fix things for us and donate. I mean, it's amazing. Just people all across the spectrum. I really like it when ultra, ultra conservative tough nosed people get involved, and they see that this is something that they like because they know it's a quasi entitlement, or a social program. But they see that someone's suffering badly and it's going to be a positive change.

And so I will say that Rush Limbaugh called in one time when I was on a talk show and said he liked the show. And it freaked my mother out because she's a radical from Woodstock. But hey, you take what you can get when you can get it.

Ted: There's a couple other points that I'll just highlight. One is from Jeff Ring, that relates to what you said, that health plans across the nation are starting to think about providing housing. It's an interesting point that in fact, the healthcare system might find this a valuable investment. That's really interesting.

Josh Green: We do $3 trillion or $3.5 trillion now of healthcare expenditures. And it's estimated as much as 45% of that is waste by some pretty smart health economists. And I know that a third of it could be avoided as direct spend just because we could do a better job, as we know from other perhaps better organized industrial nations and how their healthcare systems are built. So that's where a huge part of the money is. It's tied up in our gigantic health system, so I see that as a huge part of the answer. We just have to be less uptight about how we decide to pay for healthcare. And that's why using the Medicaid model I think is one of the ways.

Ted: So there's another point from Dan Cream, who's class of 2016, who lives in Waterbury, Connecticut. And one question he had was about the weather issues, because in Hawaii, actually, you have the benefit ... You have rainy seasons, but not the cold that one has in Connecticut or in Iowa, where I am. And he told a story about someone he knows, who's in and out of rehab, but also just going to the hospital to get out of the cold. So one question is: How do you see this as applying more broadly? I guess you talked a little bit about what's happening in Seattle and in Boston. Do you see this as really something that could apply in the sort of broader Northeast, for example, in New York, or Boston, or Connecticut?

Josh Green: Absolutely. So each region will be a little different. But if you think of it, we all have the same physical and physiologic challenges, the health problems, the addiction, and the mental illness in each of our societies. So each state has to wrestle with this. In each state, you can do the following. You certainly should have institutions like the H4, which are built to be completely accessible programs. You just say, "Yes, we'll help," period to get people out of the weather, temporary housing, longer term housing, and so on. And you can use social impact bonds or whatever to pay for them, or just build them with private equity investment.

People can choose how they want to do it. They're going to make a lot of money if they do it privately because it pays for itself fast. But you do that, and you have to have some permanent housing solutions, low cost. And that's why tiny home villages, the one, I'm serious, the one in Austin, Texas is really brilliant because it took the challenge of their regional people, they only treat people from their region. They do it for those who are chronically homeless, so they were the high impact users of the healthcare system. They simply gave them a home. Their rate of retention was 80%. People paid about $200 to $375 or so of rent, depending on how big their unit was. Cost almost nothing to build these things.

And I tell you, we're going to need them in a lot of different regions, not just for people who are chronically homeless, but also when you have people who are simply impoverished. They may not have mental illness or addiction, but they're elderly. They don't have a support system. Elderly people, the numbers are growing all across the country for that part of the homeless challenge. We have teachers that can't afford housing early in their careers in some cases. Smaller houses in communities that are going to be for teachers, for instance, could work. Nobody can live outdoors. And being in a van is no way to live. So this is a solution that I expect could be used and should be used in every region of the country, with of course, different permutations.

But a small house, the ones in Austin were more like 225 to 250 square feet, have a little bathroom, a little bedroom space, and not a lot else. But there are shared services. There's shared social services and treatment. And I would say this would be great for New York. It would be great for the Northeast. You can apply heating. Everything else is more expensive. And everything else is a heartbreak. So it's a good way to go. I think it will happen. And then you can also get people access to healthcare because you know where they are, rather than trying to find people hiding out in far away places out of a sense of shame or catastrophic loss of sense of self.

Ted: So one last question from Layla Bengali, class of 2011. And she asks, "My impression is that there are two populations of homeless individuals that are made homeless in different ways, those that have just become homeless, perhaps because of an economic or health emergency or shock, and those who are currently homeless and have been for many years. Could you talk about how or whether government should prioritize aid to one of these groups over the other in terms of costs and benefits?"

Josh Green: Yeah. Boy, that's a great way to end. So my personal feeling is those who are chronically homeless with comorbidities of addiction and mental illness should be treated first. They're the most vulnerable. They cost the most to the system. By helping on individual, and decreasing their healthcare costs by 70%, we may save $800,000 in a year, for which you can then build regular sustainable housing, low income housing, subsidized housing, section eight housing, for all those individuals that have recently fallen into an economic crisis because of say, bankruptcy through healthcare costs, or the provider in the family, he or she gets cancer, and then they can't make their payments.

So by targeting the highest utilizers, you will solve the largest breadth of the problem. The inclination, of course, is to immediately help any families with children. And of course, we do try to do that, or veterans, that's another large impact group that people go for right off the bat because we feel a sense of debt to veterans, and we can't stand the idea of kids being on the street. But if you really want to help kids and veterans, help the mentally ill and addicted individuals because immediately by helping them, you reduce the chaos that comes with that lifestyle. You reduce the cost, which is catastrophic to the healthcare system. And you restore your capacity to actually afford all of the other good solutions and quickly, for all of the other populations that are actually a little less vulnerable, but will benefit very quickly when you put in some decent affordable housing.

So you've got to flip the model. And I don't really care how we do it. I mean, I would of course be happy to work on any of these groups and try to compassionately help them. But if you look at the Gary Grinkers of the world, and you get him into care, if I help 10 Garys, I can fund my program for another five years. So that means I can help another 300 or 400 people each day. So you see how quickly you can help by weighting at the right spot of the problem.

Ted: Terrific. Josh, thank you so much for a terrific talk. And thanks for all that you do. It's great to see us Swatties making a difference in the world. Thanks very much.

Josh Green: Take care.

Ted: Bye.