COVID response, Mental Illness, Housing & Homelessness | Dean of Public Policy, New York University, Sherry Glied

Recorded February 1,, 2023

Evan Meyer welcomes the Dean of Public Policy at New York University, Sherry Glied on this episode of Meyerside Chats. 

Meyerside Chats seeks to eliminate the "us and them" narrative and toxic polarization by striving to create virtuous community leadership and authentic conversation.  The intent is to showcase the humanity in those that take on the often thankless jobs of public service through civil discourse, and honoring differing points of view.

About Sherry Glied

In 2013, Sherry Glied was named Dean of New York University’s Robert F. Wagner Graduate School of Public Service. From 1989-2013, she was Professor of Health Policy and Management at Columbia University’s Mailman School of Public Health. She was Chair of the Department of Health Policy and Management from 1998-2009. On June 22, 2010, Glied was confirmed by the U.S. Senate as Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services, and served in that capacity from July 2010 through August 2012. She had previously served as Senior Economist for health care and labor market policy on the President’s Council of Economic Advisers in 1992-1993, under Presidents Bush and Clinton, and participated in the Clinton Health Care Task Force. She has been elected to the National Academy of Medicine, the National Academy of Social Insurance, and served as a member of the Commission on Evidence-Based Policymaking. In 2021, the Association of University Programs in Health Administration selected her as the recipient of the William B. Graham Prize for Health Services Research. The following year, the American Academy of Arts and Sciences elected her as a 2022 Fellow.

Glied’s principal areas of research are in health policy reform and mental health care policy. Her book on health care reform, Chronic Condition, was published by Harvard University Press in January 1998. Her book with Richard Frank, Better But Not Well: Mental Health Policy in the U.S. since 1950, was published by The Johns Hopkins University Press in 2006. She is co-editor, with Peter C. Smith, of The Oxford Handbook of Health Economics, which was published by the Oxford University Press in 2011.

Glied holds a B.A. in economics from Yale University, an M.A. in economics from the University of Toronto, and a Ph.D. in economics from Harvard University.

Podcast Summary

1. Introduction to Sherry Glede |

Transcript

SUMMARY KEYWORDS

people, problem, housing, masks, mental health, cage, pandemic, world, psychiatrists, therapy, happen, policy, hard, sleep, humility, money, anxious, economics, bad, manage

SPEAKERS

Evan Meyer, Sherry Glied

Evan Meyer  00:00

Hi, everyone. Thank you for joining us today. Today with me I have Sherry GLEDE, Jerry was named Dean of New York University's Robert F. Wagner Graduate School of Public Service in 2013. From 1989 to 2013. She was the Professor of Health Policy and Management at Columbia University's Mailman School of Public Health. She was the chair of the Department of Health Policy and Management from 1998 to 2009. On June 2 2010, she was confirmed by the US Senate as Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services, and served in that capacity from July 2010 through August 2012. She had previously served as Senior Economist for healthcare and labor market policy on the President's Council of Economic Advisers in 1992, and nine to 1993, under President Bush and Clinton, and participated in the Clinton Health Care Task Force. She has been elected to the National Academy of Medicine, the National Academy of Social Insurance, and served as a member of the Commission on evidence based policymaking. In 2021, the Association of University Programs and Health Administration selected her as the recipient of the William V Grand Prize for health services research. following year the American Academy of Arts and Sciences elected her as a 2022 Fellow, she's wrote multiple books, one on health care reform, chronic condition was published by Harvard University Press in 98. One with Richard Frank better, but not well, mental health policy in the US since 1950, was published by John Hopkins University Press in 2006. Co editor with Peter C. Smith of the Oxford Handbook of health economics, which was published by the Oxford University Press in 2011. And he holds a BA in economics from Yale, an MA in Economics from University of Toronto, and a PhD in economics from Harvard, that is pretty good,

Sherry Glied  01:53

I'm old, you should say.

Evan Meyer  01:57

You've done a lot. And I think you're the perfect person to speak to on what we're talking about today, which is destroying this toxic polarity that plagues us from local state federal levels and make solutions difficult to arrive at takes a long time for more people to get what they want, because people can't get along. And part of what we do here is explore how to stop that. So people can get along and respect each other for their beliefs, their values, and realize we're all just people. So thanks for being here. Audible. Yes. Thank you. Thank you. So to start off, and I think I've explained who you are. But tell me what you see, as the problem with politics today.

02:49

So I I thought you might ask that. So I'm trying to think about an answer. And I think one answer is, you know, politics is always about ends and means like, what is it we're trying to achieve? And how are we going to try and get there. And I think one of the things that has happened is that we've kind of lost sight of where we're trying to go. And we're all fussing about how we're going to get there. We don't have, you know, I think a lot of people are quite agreed about where we want to go. Like, even think about something crazy, like COVID, right, where there's just incredible polarization. But can there really be a lot of disagreement about what the goal here is? Now the goal here is to have people be as healthy as they possibly can to keep things going as much as we possibly can. If we would all sort of sit down and say, that's what we want to get to and then do we have some trust in whether in the way we might get there. So what we've lost is like, we've we've gotten into this thing where we're we have no trust in, in how we actually will get to someplace, and we can't have a conversation about where it is we want to go. So instead of saying, Well, you know, there's kind of a middle ground here, we need to try and keep people safe. And we also want to go about our lives. And what's the best way to do that. Instead we get into like, you know, Dr. Fauci is terrible person or Dr. Fauci is walks on water or whatever. Or masks are bad or good? How can that What do you mean masks are bad or good masks are not bad or good masks are just pieces of fabric, right? What?

Evan Meyer  04:26

I love that that's a little bit like the, in a sense, it reminds me that like all events are neutral kind of thing and how you interpret life, right? There's a little bit of that, like, can't get mad at masks.

04:38

We've all been used to masks. We've all been to hospitals before COVID where somebody was wearing a mask. We recognize that in certain circumstances. It was the right thing to do. No one ever got mad at their dental hygienist for putting a mask on before their teeth were cleaned. Right. That never happened. And we all accepted the idea that there was a reason that dental hygienist was doing it and it was reasonable Now we've gotten into this world where like, whether you wear a mask or not is a sign of your, your ethical beliefs. And that's ridiculous.

Evan Meyer  05:09

It is interesting that you would judge a person of whether they wear a mask or not. And then insinuate much of this is about insinuation of how people categorize other people when they see one decision that they make. Right?

05:26

Right. And you don't know you don't know why I'm, if I'm wearing a mask today, you don't know why I'm doing that. You don't know. But it's just silly. It doesn't affect you. Why are you even getting upset about it, but we've allow these things to be completely loaded up with meaning. And we've forgotten about where we're trying to get to in the end.

Evan Meyer  05:46

Yeah, that's, that's true. We, and I see that a lot of this is just to make people feel better about their own beliefs. Yeah, right. Whether you're like,

05:56

maybe things are just too good, and we don't we just have too much time to waste on like, getting upset about oh, I think

Evan Meyer  06:02

that's definitely I think that's definitely true. First world problems, champagne problems, as we call them, like we get, we get hung up on this stuff, and we lose a sense of gratitude. And we start hating people on things that don't matter. The majority of people are not to blame for any of this stuff. Anyway. So it's usually extremists that are pushing out these types of messages. Right.

06:25

Absolutely. And in fact, you know, most people behave in reasonable ways around all of these issues. And it's, it's the, but you know, they're not very interesting. There's also, you know, there's a huge entertainment value of crazy people. And so

Evan Meyer  06:38

we go through political Why did it why did this get so political? And how? And, yeah, let's start with that. Why? Why did COVID gets so political? Do you think?

06:49

It's interesting, right? Because Trump, who's actually its President Trump is trying to walk it back right now trying to figure out what to do was always in favor of, you know, he funded the vaccines, right. And, and it was under his leadership that Fauci got into his position and, and now, he's trying to figure out where the party's at, because people got so upset about it. One of the things that happened is that power balances changed, right? So all of a sudden, all these folks who were in public health, who were sort of nobodies, that nobody cared about, or ever listened to, suddenly got to be the most important people. And that created two problems. One is, you know, absolute power corrupts absolutely. And and they may have overstepped, they certainly overstepped in terms of their confidence and what they were saying early on, which they shouldn't have done, but comes from, I don't know, a belief that people won't listen otherwise or something I don't know. And then the opposition to them because because when somebody's power goes up, somebody else's power goes down. That's kind of power is sort of a zero sum thing. And so you know, people were resentful Wait a minute, what why can't I do this thing? I used to be I have that have the power and now you've taken the power away. So, but then it sort of then it just got into the drinking water. And now when nobody cares, and there were no mandates and nobody's requiring anything. People are still up in arms. If somebody's when they're doing it completely voluntarily. No one is telling them to

Evan Meyer  08:24

Yep. Yeah. Hey, Sherry, give me favorite sit back, like one foot. Yeah. So I can see your whole face. There we go. Okay. So I think, you know, you said something really important, which was that it's the the overconfidence, right? In whatever we're working on. Right? It could have been COVID. Right, that we have, we've nailed the perfect solution, and everyone should listen. And we shouldn't take this with any bit of humility, right? We should all just right. Like, like, it's the first time we're dealing with something like, specifically like this, we've had other pandemics but like, you know, this is a new type of vaccine. Right? There's, there's lots that have gone into this, that people we all could have a little humility about, especially. And one of the things I talked about on a lot of these shows is is is media headlines and people reading one piece of information without understanding the entire picture. They write they read one one thing, whether it's CNN or Fox, and then they go well, these are this is all the truth. CNN said it, it must be 100% True, there's no error. If CNN said it, I should go forward with full fervor and staunch belief that, that that and argue with my family and friends

09:40

and we, you know, we've got these debates in terms of these magic words like truth and science and like follow the science. What the heck does that mean? Um, when people say follow the science, science is a thing that that is a science is an activity. It's not a conclusion. So I'm like, follow the Bible. Follow the science the If statements, so why can't we? I mean, at the same time, if somebody if the same person, so what's really interesting to me, if somebody got COVID, and they were hospitalized, and the doctor said, I'm putting you on a ventilator, or I'm gonna give you oxygen, they wouldn't at that point say, Well, wait a minute, how do you know? Are you sure? Follow the science. I saw some article that says ventilators don't know people actually trust medicine most of the time. We we, there's, there's not because you believe that they absolutely know. But because you believe that that's their best judgment at this point in time. And so how do we have a conversation where we say, given what we know, right now, this is what our best judgment is? Right? That could change because we always are learning things. We used to think, you know, cigarettes were good for you. Doctors used to recommend them, and then we learn things. That's okay. Like, that's, that's what happens in the world.

Evan Meyer  10:55

That's an incredible point. You, you blew my mind for a second because it's something that and I've mentioned before, I believe it was in the Pete Peterson interview, where we talked about science being a there's a misunderstanding of what science is. Science is a methodology. Right? It's not a conclusion, like you said, it's how you approach things. And it often, it's had a million benefits. And I believe, I mean, you know, my background is, couldn't be any more in the belief of science, like that's what I do. But then you have to understand what science is, in order to say something like follow the science. Science allows for error,

11:40

especially in a pandemic situation, early in a pandemic. There are a lot of ideas floating around, we don't know what the right thing to do is it takes some time to get there, I think a little bit of leveling with people and saying, you know, right now, this is what we think we should do. This is our best guess of what we should do. We're actually playing it really conservative right now, because we we don't know very much. And we think that's wisest in a situation where we don't know very much. But as soon as we know more, we're going to tell you more, right? We're going to keep informing you we're going to keep updating, we're going to tell you what we learn, we're going to go down some right correct paths and some incorrect paths. Because that's the way of these things as you learn about stuff. You think it was presented that way smarter, maybe treating people as a little more intelligent might actually help reduce polarization? Yeah, maybe.

Evan Meyer  12:30

But I asked Do you think if if that it was presented that way that people would do that, because it didn't feel to me like it was presented, everything was presented with your like, this is going to solve the problems, this vaccine is going to save everyone?

12:48

Let me let me give you an example. I just looked this up, because I'm interested in this exact problem. But the sales of hand sanitizer today in the world are at least triple maybe more than they were before the evidence, the pandemic. And yet, I think most scientific organizations are now quite clear, although they never say it, that there's virtually no transmission of COVID from surfaces. But everybody was very happy to start using hand sanitizer, and nobody came back and said, You know what? Hand Sanitizer, that's probably not the thing that's gonna save you. Um,

Evan Meyer  13:27

there have been this is interesting. There have been and correct my knowledge if I'm wrong, but a handful of things that have come back due to isolation. Over sanitizing Hand, Foot Mouth Disease, is one of them that came back two

13:43

adults, all kinds of stuff happens. But like if we would have just said, Listen, it's March of 2020. We don't know anything this new virus has come along. Okay. take every precaution you can stay at home as much as you possibly can. If you got outside, try not to breed stuff in because we don't know, right, wash your hands, and stay home and we're in and then two weeks later, you could say, You know what, you probably are okay, going outside. But that's not how we did it. Like,

Evan Meyer  14:11

yeah, the approach was off. And well, and, you know, do you think this had to do with getting elected? Like it?

14:19

Were? I mean, I think some people did it much better than others. There were some governors. Even Governor Cuomo before he did his, you know, craziness. But I think there was actually the governor of Ohio I think a couple of others who would do these nightly broadcasts and say, This is what we know. This is what's happening. We are aware of it. We understand we're trying to put our best foot forward we're doing the most we can and we'll tell you tomorrow how things are going right um, that but it requires a kind of humility, hard to think of Andrew Cuomo in humility in the same sentence, but, um, but not making confident as assertions about when this is all going to be over when we're going to be done not forecasting the future when you don't know it. I'm not looking for the sensational headline recognizing that people have lives. That's a really challenging thing that you know, people people are gonna go out they are they're not going to sit, you can keep people at home for a couple of weeks. You can't keep people at home for six months. That's not a reasonable answer. What are we going to do?

Evan Meyer  15:25

They close the beaches here in Santa Monica. Yeah.

15:30

Think a little bit if you close the beaches, what is going to happen? People are going to visit each other in their homes or in their backyards. That's probably worse. Right. So you're gonna stay home?

Evan Meyer  15:40

Yeah. But California, New York, which we're both in where the strictness in this type of behavior.

15:47

Much better than Florida in terms of mortality, right? We did. Okay, California, and New York got hit really hard. Early before anybody knew anything. We went back to school, New York City school kids went back September 2020. So we did not close the schools. We were less bad. Not bad. We were less, you know, restrictive than California, in New York. So which is interesting. But we didn't, you know, it's a disappointing story. I think it's a disappointing story everywhere in the whole world. I don't think it's just a disappointing story in the United States. I don't think anybody really handled this very well. And that's, I think, a caution for all of us going forward.

Evan Meyer  16:33

Yeah, and one of the things, you know, it depends on where you get your data from to right, like getting the data, the right data, that's not intended to mislead or from a source that's reliable, and then doesn't have some conflicting report a week later, that with a different confounding variable that was taken into consideration. Like I really

16:53

hard, really hard. You know, there are 40,000 articles in Google Scholar right now that have the words facemask and COVID in them. But here's a thought for you. I can't find anyone who can tell you by how much your risk of getting COVID declines wearing a face mask, everybody agrees that it declines. I totally agree that it declines. Here's my face mask, right. But does it declined by 20%? Or 60%? Or 80%? We have no idea.

Evan Meyer  17:21

Yeah, common sense. Would says say if you breathe into someone's mouth, you're gonna have a better chance of getting COVID Anything? Most things most things, right. Maybe not a rash. But,

17:34

you know, but But should we be mandating it? If we're mandating it, you would like to know whether it's 10% or 90%?

Evan Meyer  17:42

Well, that was the issue. I don't think people had it. And I think that was a I don't think that was a fair, politicized issue. I didn't see people upset that other people are wearing masks, I saw that the mandate of mask wearing or the mandate of taking a vaccine is the problem. Not that there's a problem. If you want to take your whatever you want to do with your body, do whatever you want to do with your face. But

18:10

like if somebody would have said, This is why we're doing it. Right. And this is what we've learned. And this is what what we're finding out, right. And you could have gotten, if you could have said, if even if they had backtracked at any point and said, We thought this, we learned this, this is why we no longer think this, we've changed our mind. And now you can do X, I actually think that would have built credibility.

Evan Meyer  18:33

Oh, totally. Because it shows that you're learning like a regular

18:36

person of saying, you know, instead of everything, just loading things on you, it said Purell isn't really what you need here. Don't Don't wipe down your groceries, that's not important. Like, at least you would have said, Hey, these people are not like just loading stuff on and they knew that, or, you know, you your friends outside. It's okay.

Evan Meyer  18:59

How? How do you feel mental health? Well, we know it was affected. To what degree do you understand mental health to have been affected during this period? And how are we doing now? And where are we going?

19:13

So, um, mental health was definitely affected during this period. And I think it was a long period. So I think at the beginning, of course, people were very anxious about what was happening totally understandably, I don't actually know whether we should call that a mental health problem. You know, when a truck is coming at you and your blood pressure spikes, like, is that a mental health problem? Or is it just you know, when the world was in a catastrophe, and people were anxious, that was the reasonable response to the catastrophe? I don't think mental health treatment was going to keep you from being anxious over time. You know, I think we conflate mental health with a lot of stuff and like it's a real thing and it doesn't help us when we say everything is mental health, but over time, we saw a couple of things. One is some people who had mental health problems had trouble accessing proper therapy because things were shut down or because they were overloaded or right in New York City, one of the problems we have is that hospitals closed all their site beds and converted them to COVID. Wards. Not brilliant, right? Probably happened. Other places, too, segments don't pay very well. So there's a great opportunity for hospitals anyway. So there's, you know, kind of systemic things that happen like that. The isolation was really bad for a lot of people. It was also not really bad for a lot of people with a bunch of kids. There's a bunch of interesting studies about like, school bullying went way down, because we're not, we're in remote school. And so you know, nothing is clear, nothing is 100%. Clear. But we are now post COVID. I actually said it, I shouldn't say that. I don't know whether we're post COVID, who, whatever. But we're all out there doing things. We're back in the world. And I think the behavioral health problems that we are seeing now are mostly not because of COVID. It's because we've actually seen an increase in anxiety and suicidality over the last 15 or something years. That COVID was a blip in it. But I think we're kind of back to where we were, which is, which is difficult.

Evan Meyer  21:15

Yeah. Where's that? Where's that coming from? Do you think?

21:20

I don't know, I think the most convincing things I've seen have been about social media. I'm not, because I think social media is so bad. But actually, you know, when you look at trends changing, you want to think about, like what has changed in the world. And that's probably the biggest thing that has changed in the world,

Evan Meyer  21:38

particularly for teens, particularly for people, I think, bleep believe. 11, between 11 to 15. Now,

21:47

generally, I mean, I just watch the pace of emotional engagement, when you can be texting people all the time, like, think back to like, when long story I know, doesn't matter. But for various reasons, I have been writing letters to somebody. And I realized that when you write letters, you know, you write something down, by the time they get the letter, the thing is done. And when they write back, it was it was a week ago, right? Even however good the mail might be. And you know that as you're writing the letter, and you think about your life in a way, because you know that the person isn't going to get this for three days. Right now. My kids texted me, it's like, you know, something happened four seconds ago. And and it's all everything is really important all the time. We live at just a higher urgency, higher urgency, and that's probably not good. I mean, it's probably physiologically not good. But I'm not a psychiatrist or a psychologist. So I don't know, I just say there's nothing else that has changed as dramatically in the world as social media. And and that seems to be the most likely the most plausible explanation of a phenomenon that is being seen not only in the United States, but in other countries as well. Yeah.

Evan Meyer  23:01

It's, yeah, and I guess, that we can separate the way that affects children in the way it affects adults. Yeah. Because that the way it affects children means you're now going to be you're going to develop into a personality or a lifestyle. Right?

23:17

Yeah. You're you don't have that base of like, we all have, you know, older people detox, right. Or people have had the experience of not living at that pace, at that emotional pace.

Evan Meyer  23:29

Right. Yeah. And some people now when you, you know, it's, you always live like that. Right, man? Well, it's a little scary. It's a little scary. So what degree do you think that? You know, there's a lot of mental there other than social media, there's plenty of mental health issues in the country? Yes. Right. Whether COVID helps meet some of that. I like you said it conflates what mental health really is, you know, basic anxiety to schizophrenia. Right? There's a continuum of

24:05

right problem. I don't know what it can be. I mean, there is there is anxiety that is pathological. I don't mean to suggest otherwise. But there's also situational anxiety. And situational anxiety is not pathological. Right? So the same thing can be pathological or non pathological depending on how it arises. If you're anxious in ordinary circumstances, all of the time, you should see you should get help for that. If you're anxious, because if you're sad, because some somebody died, that that's different from being sad for no particular reason,

Evan Meyer  24:36

are also clinically anxious versus general anxiety, which is probably standard for most people. Right. So but mental illness is a big issue in the country right now. It sure many levels. Yes. And one of the things I've heard you speak on is about how we don't have the right people treating the right Patients, right? Like there's a gap and tell me if I'm misunderstanding this. But there is a gap in the right there's a gap in the professional. Who's who's treating who and shouldn't the best psychiatrists be treating the most difficult patients? And if that's not happening, how are we aligning? How are we making the matchmaker?

25:18

Yes, so very subtle point. Okay. So, mental health is really interesting. Because, well, for many, many reasons, but one of them is in in medicine. Pretty much until very recently, the only people who treated you were doctors, and now we have nurse practitioners. And so we have doctors and nurse practitioners. And that's pretty much the whole world of it. In mental health, we have lots and lots of different kinds of people who provide treatment. And there are actually no studies zero, that show that there are real differences in the quality of treatment provided by these different kinds of people. So there are a psychiatrist, and there are psychologists, and there are social workers, and there are counselors, and there are pure workers. And there are religious people who have training and like just a whole array of people. Of course, they cost very different amounts, and they have different amounts of education, and only some of them can prescribe meds. That's an important distinction. Although primary care doctors can also prescribe psychiatric meds and do a lot of it. This really complicated system is a lot harder to think about how to manage effect efficiently than other systems. And one of the things that makes it complicated is that there is still, and I don't want to say this in a bad way, I'm trying to think about how to say it in a way that is not bad. There was a long tradition of analytic psychotherapy, psychoanalysis, Sigmund Freud, all that good stuff, right? That is about self exploration and about deep seated ways of engaging with the world and may do a lot of good for for people, but is incredibly costly from a time and professionalism kind of world, right going, being Woody Allen or whoever it is, and going to go to see your shrink four times a week for an hour lying on a couch. That's not something that most people can possibly do in their lives, even if they had the money, right. But psychiatrists, and psychologists can provide treatment to can provide care to people who are like that, who want that kind of care, and those people are willing to pay large amounts of money out of pocket for that care. So what you have is a situation where unusual among all physicians, psychiatrists are the group who are least likely to participate in any kind of insurance, they are the most likely to be getting a lot of their customers who are self paid. Now, the self pay patients, I assure you are not the homeless people who are wandering around Santa Monica, you know, spouting things, they are prosperous people who would like to have analysis, and that's wonderful. But what happens to the people who need complicated medications that psychiatrists can prescribe or complicated therapies? We don't, we're not, we're not matching that very well at all. And at the same time, we have all these different kinds of providers, we have lots of people who have different kinds of problems, how do we think about the best way to make sure everybody gets care, and the most serious cases are treated most efficiently, but you know, by the people who really need it. And one of our problems is because we have so many different kinds of demand for mental health services, we don't do this very well. And that's going to be a hard problem that's going to take us some time to solve.

Evan Meyer  28:40

What are the solutions that are being put forth right now that can begin to even solve this? And, and to keep with the theme? Is it politicized?

28:51

So this one I think, is not terribly politicized, this is so wonky and wonky problems sometimes don't get politicized. So the place that it's politicized is around what to do with the severely mentally ill who are on the streets? And to what extent should they have civil liberties? This is a long standing argument. It doesn't bring completely on traditional party lines, but it is a long standing argument. It's a little different than what kind of therapy should be going to which people and how can we make sure that the right people are getting the right therapy, which is actually a problem that actually say this? There is alignment among people in a bad direction, which is that that nobody should tell you what kind of therapy you should get your insurance should pay for everything, and they should pay more money for it. It's probably not the right answer here. Because it takes an awfully long time to train a psychiatrist or a PhD psychologist, we don't have enough of them, right? We're not going to get enough of them between now and 10 years from now because it just takes such a long time to train them. And we don't really want to think doesn't make sense to be spending that kind of money unless we have some proof that they are actually going to help people with moderate anxiety disorders better than social workers are or counselors are. So you probably do want managed care or some other nasty person to say, at least start off seeing somebody who's not the most expensive kind of therapy. And let's see how that goes. Let's work with your primary care doctor or your primary care nurse practitioner to get you on some treatment. And let's see how it's happening. And then if we have to escalate, we escalate. But let's, let's save the precious resources for the kid who has their first psychotic break, or, you know, somebody who's suicidal. And how do we do that? So that's not going to make me any friends?

Evan Meyer  30:46

Well, I don't I don't know if good leadership is equates with friend making.

30:52

I'm a dean, tell me about it. Yeah.

Evan Meyer  30:58

So I mean, when it's hard, so it's hard to say if and when this something like this can even be fixed. If we, we know what the problem is, but we don't have real,

31:11

we have some things we can do. And one of them is, one of the things that kind of is positive that came out of the pandemic is that we realized we could do a lot of therapy online. And maybe that just opens up some of the possibilities and kill telehealth and get so telebehavioral health has actually been pretty successful. And so maybe that's a way of expanding people's access to care and triaging people more effectively. Because they're coming in in a new way, you can sort of hear a little theme here on me, which is that technological developments give us a policy opening sometimes to organize things in new ways, because we have new opportunities that are available to us.

Evan Meyer  31:50

Sure. Sure. So do you see that there is a an element of, like timeliness, that this is being pushed forth? Or people?

32:04

We do need to? I mean, the challenge here, and the reason that I think this is like old style politics, it's difficult, right? The psychiatrists and psychologists do not want people from other states competing with them and paying lower prices, right. So just old fashioned lobbying, Politics isn't very good here. Patients generally would like to see whoever they want to see, I get that, I totally understand that. But that might not be good policy. So this is one of those difficult policy problems, were doing the right thing annoys everybody.

Evan Meyer  32:38

Do you think there's an element of or the models of administrative costs? Take, make it difficult to where the allocation of costs in hospitals or in facilities make it difficult to hire the right people to do you know, under these, sort of the idea that this is the job requirements, and then they go and market for that? For those issues?

33:05

Oh, I don't know. I mean, there's not. Mental health is really hard. It's, it's really, it's a very hard field. It's hard because, um, so as I was telling my students, it's hard, partly because it's not really unpleasant. I mean, mental health issues are terrible, but mental health treatment is not that unpleasant. And so we don't worry that much about people. If I said you can get you can have 10 free counseling visits, I'm gonna give you 10 free counseling visits aren't bad, I don't know anything about you. I've only talked to you on this thing, you probably would use them at some point. By told you, you can have 10 Free angiograms. You know, anytime, or colonoscopies, you'd never go, you don't want them. So it's much harder to manage behavioral health, mental health, just because it's not oral, um, if it was really painful and miserable, would actually be an easier problem to solve.

Evan Meyer  34:02

But people don't do it. Maybe, you know, you know, I know a lot of people who can't seem to want to get into therapy. There's a fear of getting into therapy period, even for moms,

34:12

some people are afraid of getting into therapy, but there's still what we call an economics a high price elasticity. So if I make it cheap, people will go more, they'll go for more visits, if I say you get 10 visits, and then I say you get 20. And I extend it, probably the extra visits will be used. PT is that too?

Evan Meyer  34:29

Do you think there's an issue of getting people to realize that wow, there may be I'm just a human that has issues like every other human

34:37

might be a good thing for everybody. So here's another thing about behavioral health really hard. Lots and lots of people go for one therapy visit and then never go back. And some of those people might really benefit from going back. But they're not the ones who do so it's just it's very the allocation of stuff here is really is really challenging. There's a lot of

Evan Meyer  34:57

measurable outcomes either. What Does better mean right? You You know, there's no measurable outcomes. So if you go like, okay.

35:04

My colleague Richard Frank and I wrote about have written a lot about mental health, and we're like, it's all the problems of the healthcare system, only every one of them is worse. Just really hard, policy wise is really hard. So, you know, people who need care don't want it. external effects on other people, which we don't see that much people have someone has something else wrong with them, it doesn't usually affect us. Somebody has behavioral health problems that affects their friends, their family, strangers.

Evan Meyer  35:33

But everyone's got something no one gets out of life completely, you know, free of some sort of something that bothers them more than it probably should, that affects the way that they may do things. We all struggle with something.

35:47

Absolutely. So but you know, if we, if this is the challenge here, how do we think about how you serve how what services are useful in that circumstance? What the most efficient way of doing it is? How to kind of make sure that the right people are doing it. These are are not? Nobody again, this is, you know, I look at problems and say, Has any country solve this problem? This is not one that anyone solved, either.

Evan Meyer  36:11

Yeah. Well, it's also like, I know going to school. I'm not sure how teachers deal with emotional well being, I don't believe they're in curriculums. From from what I've seen, but at an very early age learning to manage emotions, things like art and music get taken out first, right? This is a classic problem that everyone talks about. And, you know, we physical and mental acuity, these things come first, but emotional health doesn't. And I can make the argument, I think

36:45

we should teach everybody cognitive behavioral therapy by the time they're in seventh grade. So they understand the difference between thoughts and feelings. And they can think about how to I mean, there's lots of evidence that that's really good for lots of problems. And I don't see why we don't do it. But I'm not at neither an educator nor a psychologist. I'm just an economist. So what why now is obvious

Evan Meyer  37:03

that you would have one, if mental health was such a big problem. And that's usually comes down to how people internalize and think about the world and themselves and manage their emotional. Self. They're the white why would that not be? It seems too obvious?

37:24

I don't know what that is. I don't know. I don't know. I mean, when kids do get be able to help in school, it's usually like, what this disease is about and what that disease is about. That is not what you need to know. Like, you don't need to know the difference between anorexia and bulimia. What you need to know is like, when I feel this way, this is what I should do.

Evan Meyer  37:44

Yeah, and I wonder if doing it, you know, there's a lot of support in the idea that doing it in group settings, and being vulnerable, some level of vulnerability and in a group setting can make you feel comfortable with expressing yourself.

37:57

This is like COVID, and face masks, we should know the answer. And we don't know the answer.

38:04

Oh, no. I think you're

38:08

right, well, the answer to these things, we don't have the answers. We're messing up. We should figure this out.

Evan Meyer  38:13

Why don't we work on if these if these things are obvious? Why don't we work on them? Is there is this something that gets what's in the way? What's standing in the way

38:23

away? real solution? We actually should do much more of this somebody? Should I think foundations should do it. For example, maybe it's hard for the government to say, this is a big question. Can you answer this question for us? Whoever's got the best answer. We're gonna, we'll give you a grant to figure out the answer. And then we'll give a prize to whoever got gets the best answer. I mean, there should be ways to do

38:44

this. No one's taken it on, though.

38:47

So far as I know, no one has taken it on. But we should do this because we like there are real questions we would like to know the answers to

Evan Meyer  38:53

Yeah. All right. So we got some real solutions. Here. We've got we need some mental health training, and emotional intelligence training at a very early age in curriculums around the country and around the world. We've got some, we need more humility, about when we come out with new solutions to big problems, like pandemics that maybe we don't have all the answers and stop pretending like we do.

39:18

Yes.

Evan Meyer  39:20

That's too. So for everyone listening. Take that into consideration.

39:26

We need to be more serious about trying to answer questions. It'll like have a little, you know, let's see whether we can answer some of these things or just move on make a little progress. Yeah, I mean, my big thing is like, I don't I don't think I'm going to solve answer any of these questions. No one's going to answer any of these questions. Could we get 20%? Closer to the right answer?

Evan Meyer  39:45

Yeah. Well, hopefully this encourages somebody to take on that, that problem and work on their big problems to solve. How about the mental health as the versus housing argument that comes out where houses a lot of people believe housing is the this the panacea for, for the problem with homelessness? And then there's a lot of people who believe that well, so many of these people are mentally ill, they're not going to stay in housing, it's not a good use of funds. Some people don't want them in their neighborhood. Why should they be in my neighborhood? What is your take on this argument? And how are we doing?

40:26

So there's a lot of aspects of this as well. And I have to say that it is a different, it is a completely different problem, where I'm sitting and where you're sitting. Okay, so I'm sitting in New York City, and there are an estimated 2500 street homeless people in New York City, which is a tiny number, there are no tents, there are people who sleep on the sidewalk, but if you sleep on the sidewalk in New York City in January or February, it's a mental health problem, right? That's not there's no other story, you have to have, you have to be a certain kind of person to live in to sleep on a on the on the street, in New York City in February. Now, I'm moving those people into housing can definitely be done. But it isn't enough to build an apartment and say, here's an apartment for you. Like that isn't going to work for somebody who's been sleeping on the street corner. They almost certainly have more needs than that. So you have to do so there's this term called supported housing, I'm sure you've heard it, right, you have to provide people with a lot with support, you probably have to provide people with a lot of support, what much more support than traditional supported housing does, because these people are very troubled, Otherwise, they wouldn't be there. And even when you do that, some of them are going to wind up back on the street. Because, as one of my colleagues said, if you've been living on the corner of you know, Houston Street and Lafayette for 30 years sleeping on the subway, great, that is your home, right, and we move you to some nice apartment somewhere. But your friends and all the people you see and the hotdog stand where you used to buy your coffee, it's that house did in Lafayette and you find out wind up going back there. So people have will they have they are human beings, they have preferences, and it's hard to fight that. So but but when you're talking about New York City, you're talking about 2500 people. And that's possibly a manageable thing with a lot huge amount of investment in highly supported housing. What you've got in California is the sun. So you could be a little you don't have to be quite as strung out as you are in New York to be willing to sleep on the beach in Santa Monica.

42:41

Southern California,

42:42

Southern California or even in San Francisco. I mean, San Francisco is not you know it's not sunny but it's not you know, it's going to be nine degrees here tomorrow.

Evan Meyer  42:53

But it's manageable not seen maybe not Seattle Seattle's got a

42:57

pretty bad either, like, it's you look at places like Chicago, Chicago does not have the kind of homelessness that Seattle does. There's a reason right. It's a scale. It's not there are people who sleep on the street in Chicago. I don't know how they live, but they do.

Evan Meyer  43:13

It's not rain. It's temperature. Janna, its general temperature.

43:17

I think rain can be managed, I think. And this is not to say, you know, it's not this is not it's not like it's something like you were I would like to sleep on the street or on the beach in Santa Monica. No, that is not the case. It's just a question of on a scale how badly ill do you have to be to put up with

43:36

nine frigid temperatures,

43:37

fine. I don't want to, I don't want to suggest that people are not troubled or whatever. Um, housing costs definitely matter. Because if you can't afford an apartment and you're sleeping in your car, you these things feed on themselves, you it's gonna be very hard to get to stay sane. When you're sleeping on the beach, and you can't write it all of these things are they they feed on to each other. A lot of the things that we have done in cities to try and improve the quality of housing have actually made it much harder for people at the very bottom of the income distribution. So we used to have I live my office is block away from the Bowery. Barry used to be where all the drunks and severely mentally ill people hung out. And for a while they had a thing called cage hotels, which is exactly what it sounds like. You know, for a few bucks, you could rent a car in what was effectively a cage that we don't let people do that anymore. And that's probably humane and good that we don't budge at all. But like those people don't have any more bucks just because we ruled out those cages. Like we haven't given the people any more money and we took away that thing. Something happens they gotta go somewhere.

Evan Meyer  44:53

Wait, let me let me let me let me try to but there was a time where you were putting people on cots essentially in constant cage. It's not again their own,

45:00

not against their own well, they're their own Well, right. They, they, they they collected $10, from bottle caps or whatever it was. And they went into one of these places, and you could stay in a cot in a cage for two bucks. And then you're out of the rain.

Evan Meyer  45:15

That was and that was determined to be a bad thing

45:18

over the last 75 years, we have said, You can't do that, right? You can't do this. And you can't do that an apartment has to have a bathroom. And

Evan Meyer  45:26

lots of why is that? Why, though? Why? I'm curious to know what

45:30

caught in the cage. And they say this is terrible. How can you let somebody live in this way? We can't allow that to happen. So we get rid of it, which is totally understandable. But the guy who used to sleep there doesn't have any more money just because I got rid of it.

Evan Meyer  45:44

It also gives him something better than where he's at? No, no, if

45:47

we give him something better. If we gave him something better, everything would be fine. But that's not what we did. We just said that can't happen anymore.

Evan Meyer  45:55

Oh, I say Right. So you went from cotton, you removed the cotton cage. Yeah. And then nothing instead and then gave

46:00

nothing. That's basically what happened. Everything went

Evan Meyer  46:02

better. Better for $2 a night or whatever.

46:08

Night, but there's nowhere for you to take $2 A night. So you can sleep on the beach in Santa Monica. Right? Right. This is it. You know, that's an extreme example. But in general, housing has become better and more expensive. everywhere in the country, we have gotten rid of the really crappy, horrible housing stock that we used to have. That's probably a good thing. But we haven't given people any more money to find anything better. So why are we surprised if they can't find any place to live?

Evan Meyer  46:37

How do you determine the standard of someone who's say 10 years living on the street? has, you know completely nothing at all? And then you say, well, here's a cot in a cage. We could do that. That's that's your first step. And then if you

46:51

think we should do that, right, I'm not I want to be very clear. I'm not saying we should do that. I'm saying, right, I'm just saying, it isn't surprising that if there is anything you can buy, you wind up not being anywhere, right. And we have made for many reasons, including not building housing, and all sorts of, you know, the EMB stuff, lots of things, but also a lot of zoning and a lot of improvements in the quality of housing, watch old movies, right? We housing used to be really awful. We've we've gotten rid of a lot of that. So we ever

Evan Meyer  47:21

asked, and I don't want I don't want to get like kind of hung up on the cotton cage. And I don't it doesn't matter if it's a cognitive cage or anything better in any solution that was just a little bit better than an experience right now. Did we ever do any surveys to the people, they're saying, Wow, this is way better than where I was. Thank you for the $2 and $2 a night I'll pick up cans. That's a service to the community, I guess. And I'm happy to sleep here. Because it's better.

47:47

Because, well, the question is better than what so so I think the people who were reformers because I think they were good. They thought what we were going to do is get rid of the cots in cages and build nice little apartment studio apartments for people. And that was what was gonna happen. But of course, that's not what happened. And if we had built little studio apartments, we couldn't necessarily have kept them for only the people who used to be in cages, right, we would have given them to whoever showed up, and then people would have showed up, and there would have been a big demand for them because they were nice. So this again, reminds

Evan Meyer  48:19

me a little bit of the new Batman movie, the latest Batman movie the Reformation. Okay, okay. Well, it's about reformation or think that was the word and it didn't happen. Millions and millions of dollars promised didn't happen. Anyway, different things.

48:35

The problem is, you can't have you can, you can give a lot of money to low income people, you have to be very careful, because a lot of that money is gonna get swept up in rent increases, because there's more people wanting apartments. You could build a bunch of housing, right? But there's a balance here, there's there's going to be one problem is a lot of people cannot actually earn enough money in the modern economy to be able to pay for an apartment, even if it cost $800 A month. Right, as opposed to $2,000 a month.

Evan Meyer  49:14

Do you think you'd think that the the level, the way that we're putting forth housing in the country is we're doing it in the right way that we are going to be able to manage this better because we're doing it.

49:28

So this is not a country problem. This is a city by city problem. It exists in some places much more than in other places. I was recently in Detroit, apparently there was no homeless problem in Detroit.

49:40

Yeah. That was

49:44

an interesting thing. Like why is that there's lots of empty abandoned housing, terrible housing. I don't know why that is. No, no, because because the city is there's a lot of housing stock relative to people. So because they're all these apparent places that are bad. Then it's cold. Right? I think Houston does not have a huge street homelessness problem. I mean, it's not

Evan Meyer  50:08

isn't something recently without, there's some stuff going around about the housing they put out they had some policy that they improved it a lot, I forget exactly what it was, but there

50:17

was an issue. So I think there's one piece of it that I think is very important, which is people with serious mental illness need supportive housing, they need services, they need all of that together. And that's going to be a chunk of the people. There are also a lot of people who are, who are somewhat mentally ill. And in part, it's because they are living in horrible circumstances, they would do better if they were living in housing. And it's challenging to figure out how to balance the amount of money they could possibly burn, how much housing will cost where that housing will be. We definitely need more housing and cities, for sure. But these are but you know, which housing how you build the housing, one of my I don't work on this, but some of my colleagues would say, if you build high income housing, you still free up housing for poor people, rich people right into the new units. And the and the old units remain. So I don't know. I'm not Yeah, it's not my thing. It's

Evan Meyer  51:18

another one of those things where it's not the intent. It's not the idea of having more housing, it's the approach and is or their, you know, the NIMBY attitude where they don't want it next to them? Or, you know, there's, it's, it's, and to some degree, that's understandable, not everyone, some people pay to live in a certain environment. They don't want to they pay to be surrounded by a certain type of people.

51:39

Of course, it's understandable. Oh, you know, I mean, when, but this is one where I think we, I think this is one where it's not even a partisan thing. It's like a, just recognize all of the values that are on the table here and think about what the best compromise is not that you're going to get to perfection. But But how much better can you do? And that probably means putting some limits on where on on people and putting some limits on zoning and putting some right and putting some more money in it. And it's going to be a combination of stuff. And I think you probably can do a lot better and make most people happy if you did a combination of stuff, but I have to go in a minute.

Evan Meyer  52:22

Oh, you do? Yeah. I think we're almost at an hour. Yes. I had one more question for you, but I'm gonna save it for next time.

52:28

Okay, pleasure talking to you. All right. Yes.

Evan Meyer  52:31

It was great talking to you. Thank you for your time and

52:33

bye. Bye bye.