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Story: The Homeless Triangle: San Francisco, Los Angeles and Prison

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This is a three part series that was also republished by The Daily Casserole. See Part I and Part II previously published. Part III is below. It has also been republished by SF Gate's City Bright's blog Pary I.

Homeless Triangle - Part I

If you work as a doctor in a clinic for the homeless, you see all kinds of simmering panic. There’s the “God, someone’s got to help me” panic of the person who lost their house to foreclosure. There’s the fatalistic panic of a street person with a hard, bone-rattling cough who senses, deep inside, that this might be the infection that kills her.

But this time, when the man stopped me in the hallway between exam rooms, grabbing my upper arm a little too tightly, there was a different kind of panic in his eyes.   “I don’t know how to find the bathroom,” the man said, terror-stricken. “Curtis,” with salt and pepper hair, was in his late 50s.   “It’s just around the corner - through those doors and to the right.” I hoped to speed-walk past him, but his grip on my arm only tightened.   “I can’t do that,” he said, his voice rising to a near-shout.   His upper lip was shaky with emotion. The only clue that his problem wasn’t some type of unusual neurological defect was the fact that he had way more muscles than you’d expect to see on a man his age. “Just got out of prison?” I said.  

He gave a sharp nod. “Twenty years in a cell. I walked down one corridor. That’s all. For over 20 years.” He said it again, this time shouting it: “I can’t find the bathroom.”  

My mind struggled to grasp his last 20 years. All the changes in the world. All the ways in which we maneuver through our lives – simple things that he’d never done. He’d become a man no longer able to even follow an easy task like going through the doors and turning right. At his age, to have been so restricted for so long in prison, he’d undoubtedly committed a truly vile and violent act against another person.  

But now he is, as we say in the healthcare business, ours.   He is a man who is unemployable, with multiple chronic health problems, and most likely – even without being confronted with all he cannot do - with serious anger management and impulse-control issues. He is in our town with nowhere to stay, nowhere to go and no ability to get there.  

“I’ll walk you there,” I said, and wondered, as we walked the few feet to the bathroom doors, which way he would go when he left the clinic.  

He wasn’t mentally ill. He didn’t have HIV. He had high blood pressure and diabetes and high cholesterol and prostate problems that might turn out to be prostate cancer. He had no idea what tests had been done in prison, or what pills or doses he’d taken for the last many years. After 20 years in a prison with years of treatment for chronic health problems, he had no summary -- not even a health card or a discharge print-out.  

We did what we could. We picked random pills and doses to start him on, since he’d been without medicines for several days already. He had no money for a co-pay so we gave him what we could out of our medicine closet. We told him to come back in two days so we could check how he was doing.  

But as he left to sleep on a sidewalk in San Francisco, we all – myself, the nurse, the staff – wondered the same thing. He had no food, no place, no ties to anyone, no way to get money. At all. So how long would it be before he hurt someone, just so he could get back to prison?   Because, odds are, he will.

Prison Churn and Homeless Churn  

California incarcerates more of its population than any other state, with roughly one in 1,000 Californians sent to prison each year. As of August 2009, there were 166,569 Californians in prison. And these numbers exclude jail. Prison is very different from jail. Jail is local, for smaller offenses, or as a holding place until verdicts are handed out. Prison is for felons, more serious offenses, and, generally, for much longer sentences. But our state’s prison system is far from static.

Except for a very tiny minority, every single prisoner eventually will come back to our neighborhoods. Generally speaking, more than 100,000 people are released, and more than 100,000 people are incarcerated every single year. Our prison system released in excess of 130,000 people into our neighborhoods in 2009 alone.  

The logistics represented by those numbers is mind-boggling. That’s basically the same number of people as the entire population of Humboldt County, or the entire city of Concord. Here’s what getting out is like. You’re not told exactly when you’ll be able to leave. Your family – if you still have any relationships left – can’t know either. No one can know. For security reasons, no one is told, ever, an exact date of release.  

One day, the door is unlocked. Only if you have certain designated types of mental illness, or have HIV that’s being treated, are you given any pills when you leave. And even then you’re only given a 30-day supply as you go. The California prison system is now the largest provider of mental health care in the state. Despite that, most studies show that a large number of seriously mentally ill prisoners are not diagnosed and treated while incarcerated. But the prisoners who are being treated for mental illness are now mandated to be given a case management assessment and an appointment for follow-up prior to release. The prison system’s own study shows that just one visit from a case manager prior to release is highly effective at reducing recidivism and increasing compliance with follow-up appointments. But the very same study also showed that no visits at all are being done in almost 50 percent of cases, even though staff were hired to perform them, and it’s mandated by state law. No one knows why they’re not being done. 

The California prison population has aged, with four out of 10 age 40 or over, with one in seven prisoners 50 or older. Many have multiple health problems. As the healthcare costs for prisoners have soared, there have been reports of expedited releases for prisoners with complex medical problems.  

But no matter what your age, even if you’re a person with diabetes requiring insulin, or if you usually take many pills, or recently had surgery, or are being treated for an infection - you’re not given even one dose when you leave. You’re not given any appointments, or even any chance to make an appointment. Even if you’re a diabetic, you may not be allowed to eat breakfast.

Despite prison health services, collectively, commanding a $2 billion annual budget, no one, not even the people with mental illness or HIV, is given even a piece of paper on release with any medical information on it. And, of course, when you leave prison, you don’t have health insurance.  

After release, all your health issues will be, without a doubt, sooner or later the problem of whatever county you’re headed toward. Why the county? Even if you had a permanent disability, and federally paid or subsidized Medi-Cal or Medicare coverage for reasons of poverty or disability, when you are imprisoned, all your coverage is automatically canceled. Clearly, no one thinks a prisoner should be drawing benefits while behind bars.

The problem, however, comes when a person is released. There is no automatic restoration of that same coverage, even for permanent disability. The county alone will bear the burden of your medical care upon your release. And, often the county may wind up paying for it forever more. Having your coverage re-instated is almost always a long and complex process, requiring multiple visits, and a high level of literacy and persistence. And the reinstatement process, it goes without saying, requires an address.

There is no reason why the prison system cannot be as efficient at reinstating coverage as it is at canceling that same coverage. If there are doubts about whether qualifying conditions still exist, there is also no reason why coverage could not be reinstated upon release for a probationary period of, say, six months. It would then lapse unless the released prisoner was seen and assessed by an outside provider. Such a process would be a powerful incentive for released prisoners to maintain preventive care. And for counties to be able to provide care instead of post-release crisis-level, unreimbursed emergency room visits.   ***  

PART II: Get on the bus

Each year, for 130,000 Californians, the prison door is unlocked one day and the question now becomes - where do you go? And how do you get there? Do you get any money? If so, how much? It is remarkably hard to find an answer to those basic questions, even if you’re a concerned family member trying to find out.

Nowhere on the California Department of Corrections and Rehabilitation’s (CDCR) website could I find a description of the release process, or how a destination is chosen, or how much (or little) financial aid or transportation help a prisoner might get upon release. If you are the mother of a son with disabilities, impulse control disorders, and mental illness and you’re trying to find out exactly when he’ll be released – you can’t know. And if you’re trying to find out where he might be headed, or how much money the prison system might give him – you can’t know.  

Recently released prisoners often tell me in clinic that they got “nothing.” After 10, or two, or 15 years, the door is unlocked and they take a bus somewhere with no medicine, no appointments, no place to stay and not a penny to their name. After being unable to verify this process on the CDCR website, but finding references in news articles to “$200 and a bus pass,” I decided to call CDCR and find out what was true.

Eventually, I spoke to the highly professional and extremely helpful officer Joanne Duroncelet. She was a bit surprised that she couldn’t find the information on the website either. But she proceeded to explain that decisions about what you’re given, and where you can go on release can be highly variable. The maximum someone can get on release is indeed $200 – but you’re not guaranteed it. And there is no adjustment for length of time behind bars. And, if you need a bus ticket, and/or clothes, those come out of that same amount.  

But you may indeed arrive in a neighborhood without a penny. There is something called a “parole hold,” which is when a parole officer decides to keep whatever is left of your potential after-bus-ticket-and-clothes money. A parole officer may choose to do that to encourage you to comply with the conditions of your parole (such as checking in). How does a parole hold decision get made? It depends on the parole officer, I was told.   Officer Duroncelet also later sent me the link to the written policy, which is here: http://www.cdcr.ca.gov/Regulations/Adult_Operations/docs/DOM/Ch_8_Printed_Final_DOM.pdf  

When it comes to the choice of destination, many prisoners may have contraindications that prevent them from returning to within 35 miles of the place they previously lived. Reasons can include a stay-away order, history of domestic violence, restraining orders or sometimes as a condition of parole. No data exists on where those people go, or how many of them become homeless in a different community’s neighborhoods. But generally speaking, most prisoners are expected to return to their county of incarceration. If you have relationships to rely on, that’s where you are expected to go. Back where it all began.  

Set up to fail

So you’ve got no food, no place to stay, no money, no pills, no appointment, no health insurance. But you can still work, right?   Unfortunately, many prisoners are released without at least one ingredient crucial to getting hired: an I.D. Forget about skills, or education, or the depressed economy. If you’ve got no driver’s license, no passport and no social security card, you can’t get a job. At least not a legal one.   And if you have nothing to prove who you are, how do you prove who you are?   

The bottom-line step that is required to cut through the circular bureaucracy is to obtain a notarized birth certificate. Just being able to figure that out is quite complex – even if you have no issues with literacy, access to technology or a disabling mental illness.

Unfortunately, you must go to your county of birth to obtain it. Even after you’ve figured out what is required, without an address, a vehicle, or money, how are you going to achieve that step, the first one required just to be able to start the process of obtaining I.D.?  

At Project Homeless Connect in San Francisco, the line in front of the booth for assistance obtaining an I.D. is consistently huge. Lack of identification is a large barrier that many, many people cannot overcome without assistance – particularly for those living on the street.  

If there is any division in the entire state that is in an excellent position to certify a prisoner’s identification, it would be the Department of Corrections. They, more than any other, should be able to issue the same state identification to any and all people being released from prison.

Not a correctional I.D. – that is a form of identification that would not be acceptable for employment for many reasons - but the very same state identification that the DMV issues. It’s hard to imagine why this isn’t done prior to release, even if you may not be out for long.  

The news is full of the overwhelming difficulty finding a job in our current economy. Even for people with highly marketable skills and extensive contacts, unemployment can be prolonged – and can become a semi-permanent state. Add to that backdrop the reality of a felony conviction. Felony convictions render applicants not only undesirable, but also bar them from many types of work, such as getting a contractor’s license.   Added to that is the well-documented fact that felony convictions don’t occur evenly across populations. If you grew up in an environment with poor educational and employment levels, your chances of being incarcerated are higher. Your chances of being employed at any job, once released, without marketable skills or education, are quite small. How do you even look for a job without an address, money, a phone, a change of clothes or transportation? And what are you going to do for food during the time you’re looking for a job?   

The brutal fact is, once you’re sent to prison and released, the majority of people don’t stay out of prison. California also has the highest recidivism rate in the nation – 70 percent. Only 25 percent of prison admissions are actually a new prisoner. By far the largest majority of admissions are people sent back to prison for parole violations. And among the group of people returned to prison for what might be called a “fresh felony,” important differences emerge. The types of crimes committed differ between those who are sent to prison for the first time, versus those who were in prison before, and are now being incarcerated for a new felony court commitment.  

In 2009, of the more than 63,000 first time prisoners sent to prison, about a third committed crimes against people, about a third committed property crimes, and about a third committed drug-related offenses. But of the 18,000-plus former prisoners who were sent to prison for a new court commitment, only 18 percent committed crimes against people. About 30 percent again were committed for drug offenses. Property crimes rose to approximately 40 percent - of which the largest sub-groups were second-degree burglary and petty theft with a prior.

The remaining crimes fell into the category of “other” (12 percent), of which possession of a weapon was by far the highest subgroup. What do these changing numbers tell us? In a best-case scenario, these numbers might imply that prisoners learn something from their imprisonment – and are much less likely afterward to commit violent crimes against people.  

A more cynical view might be that, as a group, after release, as time passes, even if they don’t want to re-commit a violent crime, ex-offenders become increasingly economically desperate.  

Although a different state, data from Massachusetts supports that interpretation. Researchers did a random-sample survey of 17,565 prisoners to determine their rates of homelessness in the year prior to incarceration. They found that 9 percent of inmates had been homeless – a rate 4 to 6 times the rate in a comparably matched adult population (matched for age, race/ethnicity and gender). They also found that “In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income.”  

*** Carried across state lines  

Prison erodes and eventually can destroy even the strongest of relationships. Those effects can occur in a relatively short time, but are more likely the longer the term of incarceration. Our recent attempt at cost-cutting the $49,000 per year that California spends on our lowest-level inmates has led to shipping prisoners out of state to private facilities.

Given the fact that people who are incarcerated disproportionately come from economically deprived communities, sending prisoners out of state will most often mean that families, even if they wished to, cannot afford to travel to see inmates. Extended time apart, and extensive geographic distances, fracture already strained relationships. California may be saving money in the short run, but sending prisoners out of state may mean we are sentencing a higher number of released prisoners to homelessness when they are returned to us after release.

***

PART III: Sentenced to indefinite homelessness

It is universally acknowledged that the first wave of homelessness occurred when the mental health system was abolished. Many would argue that a second wave of homelessness occurred when vast amounts of affordable housing were eliminated. I would argue that a third wave of a more desperate, intractable, and frequently violent phase of homelessness has been created by our vast prison system.  

How many people enter the prison system homeless? How many leave our prison system with no fixed destination? What subset of the 70 percent of ex-felons who return to prison are homeless?  

Just for public safety reasons, you might assume the correctional system would want to know those numbers. A homeless person, by definition, is a wild card. You cannot know where they are at any point in time – much less immediately after a crime has occurred in the vicinity.  

Surprisingly, according to both California Department of Corrections and Rehabilitation’s (CDCR) research division and the voluminous reports on its website, the prison system does not explicitly track that information. A well-funded assessment tool (COMPAS), which has the goal of predicting the inmates likely to become higher-risk parolees, was begun in 2008. A preliminary assessment of its data shows that 39% of inmates are at high risk of “residential instability.”   The research branch of the CDCR also provided a summary list of the total number of parolees at one point in time, and the numbers among those whose address is listed as either “transient” or “homeless.” This is a very narrow definition of homelessness, since even listing a shelter’s street address, or your mother’s address (despite the fact that she won’t let you stay there), would remove you from the homeless category.  

Even within this relatively narrow definition of homelessness, the figures provided by CDCR show that 1,193 released prisoners are homeless in Los Angeles County with no identifiable address. Using their own provided denominator of the total point-in-time parolees in Los Angeles County, that translates into approximately one in 25 parolees in Los Angeles County being homeless. Looked at another way, using instead as the denominator the total number of people homeless in L.A. (from L.A.'s 2009 point-in-time Annual Homeless Count), one in 50 homeless people in L.A. is a released prisoner.   San Francisco has similar numbers. Although only 199 felons are listed as homeless, that represents 13 percent, or nearly one in seven released inmates. Using San Francisco’s 2009 point-in-time Homeless Count, those numbers mean that one in 33 homeless persons on the sidewalk is a parolee.  

In the 2009 San Francisco Homeless Count survey, 4.5 percent of street-living respondents stated that they were homeless because of incarceration, and that same number (4.5 percent) reported their criminal record as the reason why they could not obtain permanent housing. Those survey numbers translate into roughly that one in 20 of San Francisco’s street-living homeless became homeless, and stay homeless, due to their incarceration.  

A felony conviction will ban you from almost all forms of transitional, subsidized or supportive housing; sex-offender status restricts options even further, with service providers reporting that more and more sex offenders are living on the streets.  

For the Bay Area as a whole, although the numbers are small, Napa County has by far the highest percentage of listed homeless parolees (17 percent, or roughly one in six). Conversely, San Mateo and Solano counties were tied for the highest estimate proportion of released felons in their homeless counts (6 percent, or roughly one in 17 homeless being a parolee). And, state-wide, 388 released inmates on active parole had “blank” listed as their county.   From the relatively small numbers of studies done on this subject, and from reports from people working in this field, the CDCR numbers – as high as they are – likely represent not an over-estimate, but, instead, an extreme undercount. A cross-sectional survey of 360 California prisoners in 2004 all aged over 55 and within two years of release from prison found that the “Mean age was 61 years; 93.8 percent were men and 56.5 percent were white. Nearly 40 percent were veterans, of whom 77.2 percent reported likely VA service eligibility…Overall, 79.1 percent reported a medical condition and 13.6 percent reported a serious mental illness.”

In our California prisons in 2004, older inmates (who make up nearly one in seven inmates) soon to be released had extremely high rates of health problems, and 1 in 12 reported a risk factor for homelessness.   And even those high rates of homeless risk, given our markedly depressed current economy, have likely only worsened.  

Sick and on the streets

Inmates released from California prisons often have no food, no place to go, no money, no change of clothes, no pills, no identification, no phone, no strong family ties, and little to no hope of employment. One third were originally incarcerated for drug-related reasons. They’re older, and frequently ill. They’ve been stripped of qualified coverage and have no appointments or ongoing care. Without an address or a phone, obtaining those is nearly impossible for many. Even if a parolee had a sound education, and is extremely motivated to change, with no history of mental illness, impulse control, or disabilities of any kind, our current release-process from prison is a perfect storm of conditions to create and perpetuate homelessness, even among the most motivated and self-disciplined. And 130,000 Californians a year are experiencing this. What’s remarkable is that even more of them are not on our sidewalks.  

But is this a public health problem?  

Once a person loses their home, their life expectancy plunges. People on the streets die at rate four to 32 times that of people living behind a wall. Additionally, people struggling without a home often churn between states of street-living (called “sleeping rough”), transitional or sheltered living, and stints in marginal transient housing often called SROs (single room occupancy hotels). The reality of the homeless churn again points to the likely extreme undercounting of the true numbers of homeless released prisoners.  

Once a person is living homeless, people often become trapped in a complex web of violence, mental illness and substance abuse. Starvation is not unusual, and homeless people increasingly learn to ignore physiologic signals that something is wrong. Head trauma is shockingly common (with reported rates of more than 70 percent), severe, and often results, short and long-term, in a loss of “executive functioning.” Executive functioning encompasses such abstract abilities as long-range planning, and goal-setting, and the loss can result in impulse control problems, depression and rage disorders.  

Those struggling on the street often die of preventable and treatable illnesses. And when the health hit of living on the streets begins to take its toll, homeless people tend to access our safety-net public health systems in sporadic, ineffective and very expensive ways. All of these factors together converge into a profile of early mortality, immense suffering and high cost.  

Changing the prison-homeless churn  

There are many simple, relatively cheap institutional changes that can dramatically alter the barriers facing Californians released from prison, and decreasing their risks of homelessness. They include:       

Prior to release, automatically re-enrolling inmates who were stripped of their Medi-Cal and Medicare coverage at the time of incarceration, at least on a probationary basis

  • Providing a California identification card to each released inmate who does not have one
  • Printing for each inmate a one-page summary of their medical history and medications
  • Creating and implementing sanctions and penalties for whenever the prison system fails to perform mandated case-management visits prior to the release of mentally ill inmates
  • Collecting, tracking and analyzing homeless rates (based on any widely acceptable definition among the many that exist) of admitted, released, and reincarcerated prisoners
  • Either reducing out-of-state prison transfers, or, at minimum, being highly selective about which prisoners are chosen for out-of-state incarceration based on the vulnerability of their relationship ties
  • Arranging an identified post-release medical home and appointment for inmates with recent surgeries, on-going treatment for infections and a selected list of chronic conditions requiring uninterrupted medication compliance – not just mental illness and HIV.

There are more complex and highly effective ways to address the link between incarceration and homelessness. The good news is that the CDCR as a whole seems to be moving toward a much more rehabilitation focused approach. Models that have been developed for jail inmates could serve as a useful template for dealing with some of the most high risk and mentally ill inmates where appropriate.

Mental health courts have been implemented in a number of cities, including San Francisco. Results of their effectiveness, from the CDCR website, include: “prior to program enrollment, a total of 887 bookings for new offenses were reported; post-program, only 126 bookings - an 86 percent reduction. With the exception of two counties, it appears programs are having a positive effect on reducing the severity of new offenses by 5 percent.  

The number of days in jail also decreased significantly; there were 45,611 jail days pre-enrollment but only 2,320 jail days post-enrollment, a 95 percent decrease. Note: clients participating in programs with a mental health court spent less time in jail post-enrollment than clients not participating in a mental health court.  

The number of individuals homeless for any amount of time decreased by only 65 percent although the number of days these individuals have been homeless post-enrollment has decreased significantly; 212 participants previously reported being homeless for an average of 72 days - these same individuals have now reported being homeless an average of less than seven days, a 97 percent decrease.  

Those are impressive results.  

So is it worth investing the kind of multi-system effort that creating, legalizing and setting up a mental health court for prison-level parole violations and convictions would require?  

Recognizing the role that the prison system plays in creating, concentrating and condemning ex-offenders to a lifetime of homelessness may allow us to create effective interventions and change the culture on our streets. It might also buffer the long-term public health costs and consequences we all must bear from the complicated mix of homelessness, violence, substance abuse and mental illness. Prison churn certainly can explain at least in part the frustrations cities and communities feel of never making a dent in homelessness despite devoting large amounts of efforts to do so.

Prisons will continue to release people at higher rates than they can be rapidly housed and reintegrated. Even if you ignore the toll in terms of human suffering, the economics cannot be sustained. Devoting $10 billion a year of our state’s dollars to incarcerate one in 1,000 people when a significant proportion will inevitably end up on our sidewalks dying premature, preventable deaths at additional exorbitant cost – that is a price too high to bear.

External Links

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Discussion

  • Thank you for all your support - the story wouldn't have happened without you. Best regards, Jan

  • Thank you so much for your excellent reporting!! This is one of the best in-depth, comprehensive analysis of an overwhelming, complex, and mostly ignored situation that I have read. It isa tragic problem to which most people seem blind. The simple, but critical, solutions presented - which would not be difficult to implement if CDCR would have some willingness - would make a huge difference, would save taxpayers millions, and add a little humanity to our system and our society. Thank you again for your excellent work

  • Your story showed up on one of our activist elists, and it fascinated me. I linked out to see some of your sources, and found the article on nutrition/homelessness in SF very informative. Yes, I can certainly see how peeing in downtown SF is a major problem. I used to work at the AAA building at the corner of Van Ness and Market, and talked to homeless all the time while walking in between the Civic Center Bart station and my job. I currently webmaster a site for the Valley State Prison for Women Inmate Family Council, and I've been told that we're easier to navigate for basic family/prison information than CDCR. You might want to check it to see if it's helpful....www.vspw-ifc.com.

  • Thanks so much for sharing your thoughts and this great resource, Best, Jan

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