interviews
An Introduction to Care | Part Two
by Dr. Kali Cyrus
February 13, 2020
Dr. Kali Cyrus is our February co-editor. This is part two of our conversation.
There is a lot of off the clock work happening, and out of pocket spending. So much of the care falls on staff after hours.
I would call it the out of pocket / out of office hours commitment. In terms of the costs to me, if I happen to be a doctor who gets bothered, a doctor who works in the public system, what ends up happening is most of my time is not actually spent treating the person's mental and physical health. It's mostly spent trying to figure out case management issues.
If we know this person doesn't have any food at home and they need to be taking their meds with food, or this person doesn't actually have a primary care doctor and they're smoking half as many cigarettes, which is usually the case, or their blood pressure is 200 over 120, or they keep getting hospitalized for medical reasons, if they're in a house dealing with trapping every night, they can't get sleep, it worsens their depression, and they're in a crisis and calling the cops, I can't do my job.
It isn’t really monetary, but as a team, we spend most of our time trying to figure out how can we get this person food when they may not be eligible to get free food from the state district, how can we actually try to get this drug dealer to forgive a debt – which is like, how can we do that?
What we end up doing instead of focusing on what kind of medications can I give you, or how can I meet with you on a weekly basis and talk through what you need to change, what is a path to recovery, is trying to manage the social stressors. It more so impacts social workers or people who've gone to school who want to be therapists, they end up being case workers. They end up doing these kinds of things, you can talk to them and use your therapeutic knowledge in that way, but it's a very different job that requires a lot more patience because you're dealing with systems that are so non functioning.
It's like going to the post office every day and getting in line for eight hours.
It's essentially what that part of the job has become. I think the other end of it, if you think about teachers who end up spending their money to buy supplies, that type of stuff, I don't necessarily end up in that position because I'm the physician. That's something a lot of us have very strict boundaries about. If I have a patient asking me for food, I'm at a clinic or I'm at their house, I'm not going to. No one would expect me to go run to the grocery store. That's going to fall on my staff. If my staff goes to see them three times a week, they're the ones who are going to get asked for money three times a week.
Think about people who work in group homes, where you have mental health patients with people who have other physical or mental disabilities, staffed by people who are not necessarily nurses. One, you're not making a lot of money and you're supposed to be in house with them all day, those are the clients saying, "I need a cigarette, I need a cigarette" when they've already used up all their cigarette money. But if they're going to flip, they're going to punch you in the face because they have a psychotic illness and they don't have the insight into knowing that you can't just give them cigarettes, cigarettes, cigarettes – they'll go buy them cigarettes if that's the thing that's going to keep calm.
Thinking through the costs in that way, is something I've learned from, and the way I've tried to help my staff out is however I can apply to services for them. I have some people in D.C., once I find out that they're at an age where they could potentially qualify from a home health aid, I apply to everything. I try to get them meals on wheels. I try to get them this thing, that thing. Many of them have been denied in the past, maybe they haven't really tried, or maybe they aren't eligible, but the main way is to try to get them as many services as possible, which then leads to complicating the treatment because you have four or five different agencies involved, and you're trying to figure out who's doing what, which is a different problem, but a better problem to have.
For the most part, the out of the pocket comes from my case workers. You end up spending a lot of money to help the system function to help your patient.
What needs to happen for these systems to work more cohesively?
I think about it as large group solutions and smaller more immediate solutions. In terms of the large overall solutions, I think crisis, I think crisis settings. I really believe in the urgent care system. If you're having a crisis right now people come to the ER and there's no beds to send them to. No long term hospital spaces. Not everybody needs to be in the hospital for seven days a week, 24/7 to be monitored.
We can move them to this middle unit where they can be kept safe for a little while. Some of them just need to get through the weekend. Observation units that aren't hooked up to all the expensive hospital bays are really great places, and then a lot of people can go home after that. They might not need the five days, they just need a couple of days. And I've found that that's a good workaround of not having inpatient beds.
I've also found that outpatient urgent care settings are good. It's a nine to five clinic, with staff, social workers, usually one physician, some peers. You can walk in off the street. It's an outpatient model, imagine how much money you save in that.
You can deal with the multitude of crises by having some place where you know you can go that's not waiting in the ER for eight hours.
In terms of the large system, it's groups. If you're not going to magically be able to reimburse every psychiatrist or every outpatient, why don't you have more groups of people, who once they leave the hospital just need something from six to nine. Think about AA in terms of mental health treatment, they need other people who are going through the same things they are that are staffed by social workers or staffed by psychiatrists who can provide ongoing care for them, in a model that's in a community center somewhere. That's not expensive and something the state can pay for.
Imagine the quality of what you could have at that time. It's not one reimbursable, so it's not there. Obviously the other individual level solution, you need a meals on wheels program or functioning transportation to help people get to appointments. You could even put a psychiatrist or psychologist in primary care offices.
My simple answer is how do you incorporate mental health players in these spaces? Making sure you at least know there are places that you can go. That takes investing in social services not just mental health centers. It's investing in the community itself.
interviews
Being Not-Rich with Lauren Schandevel
by Lauren Schandevel
December 23, 2019
This interview with Lauren Schandevel, creator of Being Not-Rich at UM, was conducted and condensed by frank news. We originally published this in our May issue on The Cost of College.
Tatti: Tell me a little bit about yourself.
Lauren: I am a 4th year public policy student at the University of Michigan. Most of my work has centered around college affordability in particular. About a year ago, I crowdsourced the Being Not-Rich at UM document, which was a great resource for low income students. It was also a place to come together and realize other people were experiencing the same things, and help each other out. That's the thing that launched my career doing housing and food insecurity work on campus. I've met a lot of students on other campuses that are doing similar work. It's been really exciting.
Why did you start the doc?
The document itself is just a Google document with the sharing settings tweaked so that anyone can make suggestions or leave comments. It was crowd sourced in response to an affordability guide that our Central Student Government put out about a year ago that has some pretty tone deaf advice about budgeting – low income students were put off or offended by it. This was a response to that with substantial advice that low income students could use without the stigma or added judgment of having that advice come from an institutional figure.
Initially it was just an outline. I put the introduction in first, setting the tone for what the document would be. And then I had headings – housing, employment, on campus resources, food – people just filled in the information as they came in. Now it's grown to about a hundred pages. Before it was just a couple pages, like a skeleton outline.
What was so tone deaf on an institutional level that prompted you to start this yourself?
I think it's important to start by talking about how students perceive Central Student Government at the University of Michigan. They release reports on their demographic information each year and they're usually wealthier and less racially diverse than the rest of the student body. People already have that perception of them. When they put out the guide, the first 10 pages or so were devoted to budgeting, a lot of the advice was like, “fire your maid”, or, "stop laundry service".
That was the main issue we took with it. It wasn't like we were spending our money frivolously and that's why we were struggling. It's that we don't have a lot of money to begin with, and it's hard to live on the University of Michigan's campus.
Did you send the doc to student government or to anybody on an institutional level?
The university administration knows that it exists and certain departments like the Office of New Student Programs have collaborated with me to turn it into a more institutional thing. I chaired the Central Student Government affordability task force this year and they're going to have an affordability commission permanently from now on. So that's great.
One thing I've noticed is a lot of the time it's students taking the initiative, particularly on our campus. Students are doing most of the housing and food security work. That should not be the case. The university should take responsibility, especially in the instance of housing. They're admitting more students than they have housing for, and it's on them to build housing and make sure students have a place to live when they get to campus.
Food insecurity is the same. We just got a permanent food pantry. But a lot of that was because of student activism over the years. We shouldn't be the ones pushing the university on basic needs, particularly because low income students have a million other things to worry about.
Do you think the work is moving towards that goal?
I think it's moving in that direction, not just here but nationally. The Hope Center in Philadelphia has been at the forefront of these discussions about housing and food insecurity on college campuses. They've published a lot of reports, they hold an annual conference. People are becoming more attuned to these issues and the fact that they exist on college campuses.
How does the wealth gap you're recognizing affect students socially?
I feel like that is part of the conversation that's often ignored. Obviously there are financial barriers to being a low-income student on a college campus. But there's also, like you said, a social aspect. Students arrive on campus and feel alienated from their peers, and don't understand why. A lot of it is because of that socioeconomic disparity – but they don't realize it.
It happens frequently and it's a huge reason why those students end up dropping out – because of a lack of the sense of belonging. I myself have felt that way, and I know a lot of my peers have too. The important thing is letting those students know that it's completely out of their control. It's a structural problem, and any sort of alienation they feel from their peers as a result of those socioeconomic barriers are not because they're not good enough for a university.
How can you can mitigate the social part of the problem?
I think low income and first generation college students need more community building spaces. I know first-gen activism has taken off over the last 10 years. You have offices for first-gen programming and first-gen learning communities, which is really great. The same thing should be done for low-income students on college campus’ so they can talk to each other and share experiences and realize that they're not alone in this college experience. University administrations need to recognize they have low-income students on their campus because it's a very touchy subject for them right now.
Acknowledging that it is a socioeconomic thing is probably the first step. Particularly in America, we don't talk about class. And so when we gravitate towards certain people, we don't know that it's because they share our socioeconomic background. They don't know that diversity also includes socioeconomic diversity. I feel like naming that issue and making it clear that a lot of the decisions we make are the results of our socio economic backgrounds will make it easier for people to see the class disparities in higher education, and it will hopefully empower low income students to advocate for themselves and to feel confident enough to participate in the college experience so that they're meeting different people, people who might be wealthier than themselves.
Do you feel like this perpetuates itself into the post-collegiate professional world?
Yes. It's a combination of financial and cultural factors. Wealthy students coming in have parents who have probably gone to college, that have careers where they can get the students internships or fellowships, and pay for them to do unpaid internships. There's that aspect of it. But then there's also that cultural capital. Those students know what clubs to join, they know where to apply, and they have connections somewhere. That trajectory is already set for them. Whereas low-income students can't afford to do unpaid internships, don't know anyone in the industry, don't know how to navigate the process of applying to those internships, or even that they have to do internships in college.
When do we need to start preparing students for these realities of college campuses?
This is one of the issues I have with college affordability activism – it starts way before students enter college. The K-12 education system is so vastly unequal, that needs to be addressed in addition to how we're setting up low-income students to succeed in college. There's so many low-income students we're not capturing because our education system is so unequal. It's a rare phenomenon to even get low-income students in the door at these elite institutions.
That needs to be addressed. But that’s a combination of segregation and the way public schools are funded. There are a number of legal ways in which rich parents give their kids a leg up in the admissions process.
Does your academic focus cover these issues?
Yes, I try to make that really clear. I am also responsible for creating a minor and social class in equality studies at the university. It basically teaches about how social class influences outcomes and access to opportunity.
That's something I tried to bring into my activism around affordability because affordability is inherently political, and to talk about it you also have to talk about class and race and all that stuff.
Class is a very un-American conversation.
Exactly. People are starting to have that conversation.
Do you find it easy to explain?
Oh, it's so hard. Particularly if you're communicating it to wealthy people, which a lot of the times I'm doing because of the campus. But telling people that their success is the result of the combination of hard work and privilege is really hard, and people get defensive. You have to coddle them a little and say, "You worked really hard in high school, but have you considered that these factors may have helped you get to a place like the University of Michigan?" And then they get it, but sometimes they're still mad because the American dream tells us that if you work hard you can succeed – and it doesn't say anything about class privilege.
What do you think happens to the value of college when the reality of attendance is so tied to privilege? As an employer, what does it really mean to hire someone from Yale, if I have no context for how they got there?
People are still under the impression that if you went to one of these very elite schools, you must be very smart and that's how we maintain the system. But if people start to think that, hey, maybe this is the result of socioeconomic privilege and not necessarily merit, then the only solution to keeping people from losing faith in the education system is to admit students in a truly meritocratic way, which means admitting very smart, high performing low-income students. Hopefully the problem solves itself that way. But if not, then we're going to have this distrust of higher education.