Taking a Look at the Costs of Health Care for the Homeless

A True Accounting: Taking a Look at the Costs of Health Care for the Homeless

by Joe Dennis
Originally published in Flagpole (cover story)  on Feb. 28, 2007

Athens hospitals – and in effect hospital consumers – spent more than $12 million in 2005 providing care to area homeless people.

“A lot of people don’t realize the serious homeless problem we have in Athens,” says Evan Mills, community development specialist with the Athens-Clarke County Department of Human and Economic Development. “The economic costs of homelessness are very high, and when it comes to health care, the hospitals have to make up that cost somewhere. The expense trickles down to those who pay for their hospital care.” Mills, who conducts the county’s annual homeless census, got the idea for a study of those costs based on similar studies done in Asheville, NC and San Francisco, CA. He collected 891 Social Security numbers obtained from area homeless providers – such as the Athens Area Homeless Shelter, the Salvation Army and the Homeless Day Service Center – and submitted them to Athens Regional Medical Center (ARMC) and St. Mary’s Health Care System to compare with their service records for the year 2005. What Mills found over the three-month study shocked him: 576 area homeless people accounted for 7,000 total hospital visits. Including emergency room, inpatient and outpatient services, and ambulance rides, the total cost absorbed by hospitals in providing care to homeless patients was $12.38 million.

According to the study, repeat visits account for a large part of the hospital bill, with 234 homeless individuals visiting the hospital more than eight times during the year for a cost of $4.2 million, or approximately $19,950 per individual. The preferred entry point for homeless patients is the emergency room, with 4,687 ER visits during the year costing more than $3.23 million. Nearly half of the homeless individuals who visited one of the hospitals were also identified as clients who have been diagnosed as having a mental health and/ or addictive disorder by Advantage Behavioral Health Systems, a state-funded agency that provides mental health care services to the uninsured.

No Surprises

The high use of the hospital by homeless individuals with mental health or addictive disorders doesn’t surprise Laurie Wilburn, adult mental health services coordinator for the Athens office of Advantage.

“It’s really difficult if you’re sleeping out on the streets or living from shelter to shelter to consistently take your medications and manage your symptoms,” she says. “What happens is many of these people end up in a crisis and head to the emergency room.” Who pays the bill? The $12 million spent on homeless individuals is part of a combined $47.5 million the two Athens hospitals spent in uncompensated care in 2005. “A homeless person is no different than someone in the working poor who is getting paid minimum wage and has no insurance,” says John Drew, President and CEO of ARMC. “It becomes a cost that the hospital, and the doctor, has to absorb in its cost structure.” The expense is made up through higher costs for hospital procedures, personal care, equipment and supplies. Since most paying customers of the hospital have health insurance, these higher costs are billed to insurance companies who eventually pass on the additional expense to the consumer and employer providing the insurance. “It’s truly a hidden tax to those who are paying for private insurance,” Drew says. “In essence, everyone in this country is helping bear the load for the uninsured, and at nearly 50 million people, that number is increasingly growing.” For uninsured people, the emergency room has become the destination of choice for health care needs. Under federal law, emergency departments are required to provide lifesaving care to those who need it, regardless of their ability to pay. However, Drew says hospitals have traditionally provided much more than lifesaving care in the ER, taking care of all patients who walk through the doors. “It’s the charitable mission of the hospital,” he says.

It’s also the most expensive form of care. In a July 2006 letter to Judge Steve Jones, chairman of Partners for a Prosperous Athens, Drew and St. Mary’s President and CEO Thomas Fitz expressed concern about the increasing use of their emergency rooms. “At both of our hospitals we see excessive use of emergency services by patients who have no other access to health care,” they wrote.

While the hospitals provide care to all who walk through the doors, it’s up to hospital administrators to determine how to make up the expense of treating the uninsured. “We have to be around for tomorrow,” Drew says. “We can have small aberrations, but what we’re going through now is really stretching us to the limit. The system is in a bad need of an overhaul.” A cheaper alternative? The community has a number of places that offer some form of health services to the uninsured, such as Advantage, the Athens Neighborhood Health Center, the county Health Department, the Athens Nurses Clinic and Mercy Clinic. In their letter to Judge Jones, Drew and Fitz said such programs offer much-needed primary care that can be provided at significantly lower costs than in the hospital emergency room. However, Mills points out that those programs are grossly underfunded. “Our current delivery system doesn’t have the capacity and the resources to meet the needs of patients,” he says. “And when clinics aren’t open or can’t provide the care, people go to the emergency room.” In providing health care for the homeless, Mills says the solution lies in shelter-based care. One such program already in place is the Shelter-Plus Care program run by Advantage. Funded in part by a federal grant from the Department of Housing and Urban Development, the program is part of the Assertive Community Treatment (ACT) program run by Advantage (which was described in more detail in a Flagpole article of Nov. 8, 2006). Through the

program, homeless individuals are provided an apartment in the community. Advantage staff work closely with the individuals, monitoring the clients’ mental health and/ or substance abuse issues, and linking them to available resources in the community.

“Once you get into the program, you have to do one of three things: either find a job, volunteer in the community or complete your education,” says Michael Dock, residential services coordinator with Advantage. Although the client initially doesn’t have to pay for rent, as they earn income, 30 percent of it must go towards their housing costs. As the client proceeds through the program, social workers with Advantage continue to work with the client on everything from ensuring they take their medication to providing budgeting advice.

The program works because it provides the two aspects critical in treating the homeless: shelter and care. “Housing is not enough, and providing care is not enough,” Wilburn says. “People who have a mental illness or an addictive disease don’t have the ability to maintain housing, and a homeless person with a mental illness will definitely not be able to consistently care for themselves.” The Shelter-Plus Care program currently has 21 apartments in Athens and 28 in the greater Athens area. At an annual cost of $110,000, the program spends roughly $4,000 annually for each resident, or the cost of roughly six emergency room visits. “What can cost the hospital up to $500 a day runs about $30 with one of our clients,” Wilburn says. More importantly, as clients transition out of the Shelter-Plus Care program – with the average stay at between two and three years – they become self-sufficient, Dock points out.

Forward Thinking

An easy solution? Mills says programs like the Shelter-Plus Care program are examples of how forward thinking can help alleviate a long-term problem at a much cheaper cost. “The hospitals are spending more than $12 million to provide health care to the homeless,” he says. “We can eradicate homelessness with just half that amount.” Mills backs up his statement using the following logic: taking the estimated 475 homeless people in Athens according to the 2006 homeless count, and multiplying that by the Athens fair market rent of a one-bedroom apartment at $500 a month ($6,000 a year) results in a total cost of $2.85 million. That would leave more than $3 million for area health care clinics, job training programs, childcare programs and other homeless services.

Furthermore, Mills says this would put the person in a stable environment, and as they transition into work would convert them from being a strain on the system to being a contributing taxpayer. They would rely less – if at all – on charitable care as they begin to join the ranks of the insured.

Unfortunately, because that $12 million expense is money that doesn’t exist in one place – instead spread out through thousands of insured employees and employers – it’s not that simple to obtain that money. However, Mills hopes that future efforts by the city and local organizations – including the collaboration of Partners for a Prosperous Athens – will consider such sweeping solutions.

“We can really wrap our hands around the homeless problem in Athens,” Mills says, contrasting the relatively small homeless population of Athens to the large populations cities like Atlanta and Augusta. “We’ve got enough folks in Athens that care a lot about this issue. We just don’t have the resources we need. If we had the resources, we could really make a dent.”


2016 Oscar predictions

One conclusion can be made from the 2016 crop of Oscar nominees: 2014 was an incredible year for movies. The Oscar nominee class from last year featured several stellar films with unique filmmaking techniques (Boyhood, Birdman, The Grand Budapest Hotel), a behind-the-scenes look at American heroes (Selma, American Sniper), and inspirational stories that focused on previously untold aspects of the lives of internationally acclaimed geniuses (The Theory of Everything The Imitation Game). This year’s class — movies released in 2015 — is underwhelming. Almost all nominated movies last year could take the top Oscar from any of the nominees for best picture … well except for one.

Following is a short review of each movie, in order from the most deserving of an Oscar to least deserving of an Oscar.

the-revenant-2015.39576Perhaps better than any movie ever released, The Revenant showcases the innate human desire to survive. Leonardo DiCaprio beautifully plays the role of frontiersman Hugh Glass, who has to fight to grasp on to every piece of life that is left in him. DiCaprio excels at showing us not only the physical pain, but the mental anguish suffered by his character.  His performance is so powerful that at times we become so distraught at his pain that we want to check out of the movie, just like his character must have wanted to check out of life. But his incredible performance, and the beautiful imagery ordered by director Alejandro G. Inarritu, makes The Revenant by far the Best Picture of 2015.

I’ve always thought that the hardest acting gigs were ones in which the actor largely acted alone in the movie (like Tom Hanks in Castaway and Sandra Bullock in Gravity). It’s easy to be a good actor when surrounded by other good acting performances. In The Revenant, DiCaprio is mostly on screen alone, and furthermore has no dialogue throughout much of the movie (unlike the narration of Matt Damon in The Martian). Yet he still displays a powerful performance, well deserving of the Best Actor award. Furthermore, Inarritu has cemented himself as one of the greatest filmmakers of this generation with The Revenant, which is drastically different from his previous award-winner, Birdman. While Birdman made us laugh with its clever dialogue and filmmaking technique, The Revenant made us cry with its raw emotion and imagery so powerful we felt the chill. For the second year in a row, Inarritu deserves the Best Director award. And in 20 years, he’ll be collecting  his lifetime achievement award.

The last time I was uncontrollably crying in a movie was in 2004 Oscar winner Crash. (If you didn’t weep when the little girl jumped in front of a bullet to save her father, then check your heart, because it’s probably not beating.) That changed when I watched Room. The story has two equally inspiring chapters: the first shows us how a kidnapped mom tries to paint an imaginary world for her growing boy, and the second shows us how the pair adapt to a brand new world once they escape. Admittedly, I never read the book. But the movie is very good. It’s a shame Jacob Tremblay wasn’t nominated for supporting actor for playing the 5-year-old Jack, because his performance was the most memorable aspect of a terrific film.

I saved Brooklyn for last on my Oscar movie binge. I had no doubt it would be a goodbrooklyn movie, but the storyline wasn’t my style: an Irish woman in the 1950s who immigrates to Brooklyn and later goes back to Ireland must choose between the two lives. To my surprise, I really enjoyed the movie. It was carried by a phenomenal performance by Saoirse Roman, who plays the socially awkward Ellis who finds herself adapting to the American way. Her character is not all that charming, but Roman makes us like her, especially when she is faced with her own moral dilemma. She is deserving of the Best Actress award.

Movies are often based on real-life events. But turning the 2008 financial crisis into a movie would seem to be a difficult task. A story about bankers and investors? A comedy about the big shortsecond biggest financial collapse in the world economy? That’s exactly what The Big Short is, and it’s very successful at it. Based on the Michael Lewis book of the same name, the film tells a highly complicated story about the housing market, default credit swaps and credit ratings in a unique way — for instance Selena Gomez explaining the intricacies of synthetic collateralized debt obligations — that makes what could’ve been a boring movie highly entertaining. While the cast is strong, it’s the writing that makes The Big Short shine, and is why director and co-writer Adam McKay deserves the Writing-Adapted Screenplay award.

As a journalist, there was no movie I was more excited to see than Spotlight. But where The Big Short succeeded, Spotlight failed. I wasn’t expecting Spotlight to make light of the story of Boston Globe reporters uncovering the Catholic Church molestation scandal, but the movie came off as more of a documentary than an entertaining movie. It will take its spot right next to All the President’s Men as one of the best investigative journalism movies ever, but not as one of the best movies ever.

The Martian is the lone science fiction picture among the nominees. Matt Damon plays an astronaut stranded on Mars, and like every movie Matt Damon stars in, we root for him. The movie is very entertaining, with its depictions of Mars and space and the always lovable Matt Damon. For the time-committed, it’s not nearly as gut-wrenching as another movie that clocks in at more than 130 minutes — The Revenant. Entertaining? Yes.  Award-winning? No.

With Tom Hanks star power, Steven Spielberg at the helm and an age-old rivalry of America vs. Russia, Bridge of Spies was destined to succeed. The movie is just OK, at times really slow. While the action and dialogue were just OK, the imagery was the star of the movie. Seeing the Berlin Wall being erected, watching a U-2 pilot being shot down, viewing a captive release at Checkpoint Charlie was all fascinating … but I can get that on The History Channel. I was hoping for more.

For the life of me, I cannot understand how Mad Max: Fury Road was included on the nominee list. I love action movies. And I can even handle brutal action if it has a riveting storyline (The Hateful Eight, Django Unchained … come to think of it, any Quentin Tarantino movie). But Mad Max sucks. The storyline is too simple. The acting is over the top. And the violence is too much. This was actually one of the worst movies I’ve ever seen, and the fact that Academy voters put this on the list over films like Straight Outta Compton, Chi-raq and The Hateful Eight just gives fuel to the argument that voters are prejudiced.


2015 Oscar Movie Reviews & Predictions

by Joe Dennis

Reviews published individually on Internet Movie Database.

My Oscars go to …

Best Picture: American Sniper
Best Director: Richard Linklater, Boyhood
Best Actor: Bradley Cooper, American Sniper
Best Actress: Felicity Jones, The Theory of Everything
Best Supporting Actor: J.K. Simmons, Whiplash
Best Supporting Actress: Patricia Arquette, Boyhood
Best Animated Picture: The Boxtrolls (not reviewed here)

The following reviews are in order of “should definitely win” to “why was this even nominated”?


Like 2010 Best Picture winner The Hurt Locker, American Sniper provides insight into how war impacts the psyche of soldiers. Although Navy SEAL Chris Kyle is celebrated among fellow soldiers, director Clint Eastwood lends as much time portraying the strain the war had on Kyle’s personal life, specifically his wife. Bradley Cooper (who trained for three months to gain 40 pounds of muscle) should win the Best Actor Award for playing the conflicted Kyle, who forces himself to develop a hatred of the enemy, referring to Iraqis as “savages,” so he can justify killing them. The action scenes provide an adrenaline rush, but it’s the intentional moments of silence — such as when Kyle, with finger on the trigger, is deciding whether to kill a child who is holding what appears to be a bomb — that make American Sniper the best picture of the year.

SelmaThere have been many films that rightly glorify Martin Luther King and the Civil Rights Movement, but Selma is the first movie to showcase the internal battles within the movement. Director Ava Duvernay places the focus on King’s struggles — not just with the people against him but also with the people on his side. David Oyelowo plays a King who remained determined in his battles with President Lyndon Johnson, his right-hand man Andrew Young and Malcom X. In the penultimate moment of the Selma march, we find King not engaged in a fight against segregationists, but in a struggle to save his marriage. Selma humanizes King, which strengthens his legacy.

theory_of_everything_ver2The Theory of Everything is the ultimate love story. Eddie Redmayne does a phenomenal job portraying physicist Stephen Hawking physically self-destructing as ALS cripples everything but his mind. Redmayne showcases the pain Hawking must have felt at each new struggle he faces — such as his inability to crawl upstairs as his baby curiously stares down at his daddy through the baby gate. But the heart of the film is Felicity Jones, who should win a Best Actress award for her portrayal of Jane, Hawking’s determined wife. Jane refuses to let Stephen feel victimized, struggling to maintain a normal family life despite his crippling disease. Jane is the poster-child for the feminist wife: intelligent, determined and totally in control of her family.

WHIPLASH1The dark-horse of the best picture nominees, Whiplash poses the ethical question, “how much is too much?” J.K. Simmons plays tough college music teacher Fletcher, whose mission is to find the next great jazz musician. In his efforts to get the best out of his musicians, he verbally, and at times, physically abuses his students. Simmons should win the Best Supporting Actor Award for playing the character we should hate, but for some reason have an affection for. The movie is accompanied by an outstanding soundtrack and the best ending of the year, however is cluttered with an unnecessary plot line involving the main character and a girlfriend.

BoyhoodThe idea of Boyhood is groundbreaking — tracking a family over 12 years. It’s very neat watching a family evolve before your eyes. Director Richard Linklater should win the Best Directing Award for piecing together such a complicated puzzle. The movie promotes the growth of the boy, but it’s the development of Patricia Arquette as the mom that is most interesting. Arquette should win the Best Supporting Actress Award for showcasing a mom who is doing all she can to provide the best foundation for her children. While her kids are growing, the aging mother encounters homelessness, an abusive partner, and an absentee partner while she works her way through college to eventually provide the family with a firm — but still shaky — foundation. Although the premise of Boyhood is groundbreaking, the story — which is simply working class life — begins to lose its luster.

BirdmanHollywood is full of itself, and no movie is as self-serving as Birdman or The Unexpected Virtue of Ignorance This film is one big who trip, and its mere premise fails to make the audience feel sorry for main character Riggan, played by Michael Keaton. The disappointing ending adds to the viewer’s anger with the selfish Riggan. With that said, the movie has entertainment value. Tremendous acting jobs by Keaton, Edward Norton and Emma Stone (all deservingly nominated for Academy Awards) and the illusion of the movie being filmed in one continuous take make Birdman worth viewing, and makes director Alejandro Inarritu deserving of his Best Director nomination.

ImitationGameThe Imitation Game tells the true story of Alan Turig, a World War II British mathematician who develops a monstrous machine (now known as the computer) that ultimately helps defeat Germany. Benedict Cumberbatch is outstanding in his portrayal of Turing, whose life story has two major facets: the development of the machine and being charged for the crime of being gay. The fault in The Imitation Game is director Morten Tyldum’s attempts to tell both stories. Ultimately, the story of Turig’s inhumane sentence — undergo painful hormonal treatment to reverse his libido — was seemingly crammed into the movie, not giving it enough justice.

grandbudapestThe Grand Budapest Hotel is just plain weird. It’s the kind of humor director Wes Anderson is known for — think stupid humor for intelligent people. However, unlike his other films like Rushmore and The Royal Tenenbaums, The Grand Budapest Hotel storyline feels disjointed, and the main characters gets so wrapped up in hijinks that it’s difficult to remember just why they are in a given situation.

Best day of the year arrives

Best day of the year arrives
Another Look by Joe Dennis
Originally published in The Walton Tribune
Dec. 25, 2002

As a child, Christmas was the best day of the year, and it started as soon as the clock turned to midnight.

Growing up in a Catholic household, midnight mass was the cornerstone of any Christmas celebration. Admittedly, I never looked forward to the extended service, but what kept me from drifting off in church was the hope that something would be waiting for me under the tree as soon as we arrived back home.

Surely Santa wouldn’t let me down. I would help my father make his specialty — molasses cookies — for the special event, and my mother would help me fill up a glass of milk and we’d leave it right next to a couple of cookies on a table in front of the tree. Every year, my mother assured me that even though we didn’t have a fireplace and a real chimney, Santa would find a way to get into the house. I wasn’t really sure how, because even though I insisted, my parents would not leave the door unlocked for Saint Nick. My biggest fear was that he would be making his stops on the south side of Chicago, and would not be able to get into the Dennis home.

But I was a lucky kid; Santa never failed to hit our house very early in the morning. We would stroll in from midnight mass around 1:30 a.m. — well beyond my bedtime — and I would scamper to the tree as soon as my father pushed open the back door. The milk glass was only half full, and the cookies were half-eaten; Bingo! Now, where are the gifts?

They were always there. Whether it be a Dukes of Hazard car, Star Wars action figure or Dennis the Menace books, Santa managed to come through. My euphoria would be short-lived though, as my young brain would catch up with the rest of my body and inform me it was bedtime. I would be back to the toys in the morning.

When I would wake up late Christmas morning, I would look out our front window for any signs of Santa’s visit. Since there was usually snow on the ground, this was pretty easy to do, and sure enough, I always saw reindeer tracks across the front lawn (though I failed to realize animal tracks were almost always visible on our front-lawn snow).

I would then retreat to the tree, putting my new toys to work, reveling in the best day of the year.


How Literary Magazine Changed My Life

The Weekly Wednesday: Literary Magazine Changed My Life

The Weekly Wednesday is a column written for members of the Georgia Scholastic Press Association, mostly comprised of high school journalism teachers.

by Joe Dennis

As I was shuffling through boxes at my mom’s house, I came across a folder packed with random pieces of paper filled with forgotten poetry, half-written short stories and attempted drawings from my high school days.

Most memorable was a stack of song lyrics I wrote. It was the early 1990s and I was going to be a rock star! My best friend played guitar and I would take my folder of poems and we would jam. He would play riffs as I shuffled through the papers finding a set of lyrics that best fit with the jam. Once I found a fit, I adjusted the lyrics as he strummed some different chords and we would develop a chorus and intro for the song. We ended up writing almost 20 songs that way.

Each song was deeply personal to me. “Change in the Weather” was about Ivey — the girl I so desperately wanted to be my girlfriend, but I didn’t quite know how to make that happen. “Dial the Devil” was about my inner demons that wanted to come out every time I lost my temper. “Confusion” was about my battle with depression (although I didn’t know it at the time). As I read through each lyric sheet — with the chords scribbled above them — the emotions of that teenage boy 25 years ago took over me.

I was very guarded with my lyrics — they were deeply personal and I feared letting others read them would leave me vulnerable. It’s why it was such a difficult decision for me whether I should submit a poem to my high school’s literary magazine. I was pretty successful at staying under the radar in high school. An all-boys Catholic school with a proud tradition of state championships in football, basketball and hockey, one had to either be an athlete or an Ivy-league bound genius to get recognized. I was neither. So I made a conscious decision to stay invisible. But my English teacher (and literary magazine adviser), presumably being impressed with some of my poetry written for class assignments, encouraged me to submit something.

So I transformed my darkest and most personal lyric into a poem and submitted it to the literary magazine (here’s a segment):

Sadness. Happiness. They battle for my mind.

My sense of self is impossible to find.

Confusion. It’s taking me over again.

I don’t know what message to send.

In my sorrow you get amused.

I’m angry and confused.

When I learned it would be published, I experienced the full gamut of emotions, from pride that my work would be published to fear that my true self would be exposed. Weeks later when the issue came out, I grabbed my copy, proudly looked at my name in the table of contents and flipped to page 16 to see my words. Almost immediately, a sense of accomplishment — one that I haven’t felt in high school — took over me. That sense of pride grew when teachers complimented my poem, when other students in the literary magazine befriended me and when I was actually approached to join the drama club. After three years, I was finally visible in my high school.

Being published in the literary magazine was the start of my journalistic career, and more importantly the evolution of my public self. It’s scary to think my life may have been completely different if Mr. Taylor didn’t give me that extra push to submit my work to the magazine. Because of that seemingly uneventful, but truly fateful moment in my life, I try to look out for those students flying under the radar, and give them that vote of confidence and extra push when appropriate. They don’t know it yet, but It just might change their life.