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Comment by silvestrov | Hacker News Reader

> 2) People are severely disabled by mental illness or addiction, and simply can't manage a household by themselves

This is reduced a lot by early intervention, i.e. always provide housing and always provide free healthcare.

It is so much easier to handle being "slightly mentally ill" when you can trust 100% that you will always have housing, healthcare and enough money for food, clothes and other necessities.

If you can do 90%, then government can provide you with last 10% by paying rent automatically and having a social worker visit once a week. This fixes problems early compared to you becoming homeless.

There is a lot of steps between "fully functional middle class person" and "mental institution".

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Some mental illnesses are naturally resistant to treatment. They lead to paranoia and mistrust. Attempts to treat sufferers are likely to fail, with the patient responding negatively and potentially viewing the doctor (or anyone else trying to help) as an adversary.

You might respond that such folks be involuntarily committed to a mental hospital. That step has become taboo in the U.S.

Involuntary commitment to mental hospital has to be one of the tools. Its far better for everyone that the extreme cases be committed than left out on the streets.

Only if person is violent and has caused actual harm and only through the court. North America has a history for putting people in jail / special treatment institution for fucking nothing. How about woman of improper moral character sounds.

The sketchy history of institutionalizing people shouldn't stand in the way of genuine medical treatment. Yes, putting women into counseling for 'hysteria' was ridiculous, but so is thinking someone with schizophrenia living on the streets has made a lifestyle choice.

From the research I've seen the rate of severe, not mild, mental illness among the homeless population is estimated to be as high as one third. These are not people who are making choices in any sound state of mind, they actually need to be put in medical care, not because they're dangerous but for their own sake.

> The sketchy history of institutionalizing people shouldn't stand in the way of genuine medical treatment.

It seems like it should in some way. For example, required ethics classes for the practitioners would limit who is allowed to apply such treatments. A bad history should at least prevent further bad history.

Also, in the US a lot of people with mental problems end up in prison eventually. So I think it’s a bit foolish to pretend that it’s ethical to not institutionalize in mental health facilities only to put them a few months later into a prison.

At least in Germany the treatment by itself is also not mandatory in a psychiatric clinic, but one can be held there for example in order to prevent suicide. Then it’s up to staff to convince patients of a treatment plan, they have to agree to that for the hospital to start treating. Until then the hospital is pretty limited in administering anything.

But befor the conversation details into ethics questions of forced institutionalizations. I think it’s worthwhile to point out that easy access to mental health is for everyone in society is of utmost importance. I can only assume but I think a lot of people on the street wouldn’t be there if they had seen a psychologist earlier on, if they had not started to self-medicate with alcohol and drugs. It’s beyond me why rich nations in the west don’t promote early intervention much more

>"The sketchy history of institutionalizing people shouldn't stand in the way of genuine medical treatment."

Yes it should. It shows how fucked up we humans are. Given a chance we will abuse things again and again.

Let's be real here, some people can't even do 10% let alone 90%. And than some people are severely mentally ill or addicted, not "slightly".

I don't think GP is saying they're not doing a good job, but that "ending homelessness" sounds like a euphemism.

If you can "fix" 95% of people by providing housing, then handling the remaining 5% is much easier.

These problems do not scale linearly.

It is also surprising how much drug addicts and mentally ill can do when the basics has been taken care of.

First, it may not be 95 and 5 percent. Second, thats not whats asserted by “Finland ends homelessness.” The assertion is that homelessness doesn’t exist there. So it seems like these cases are unaccounted for.

I feel it’s like how employment statistics don’t include people not looking for work… if all the people who want housing get it, then homelessness has been eliminated. Someone who has a house but chooses not to live in it isn’t homeless.

I always encourage people who have this viewpoint to go and talk with your local homeless community.

Bring some food and small bills with you as basically bribes and just talk with some folks. Ask them how they came to be homeless, what they do in their day, what they want to do.

Give them your idea, ask them if they think it's a good idea.

The 5% - 10% is the bulk of the problem. The other 90% are living in cars or couches but aren’t causing wide spread damage

Full employment is 3% unemployed. In Finland if you want off the streets it will happen in tractable time.

The key point is early intervention, particularly in adolescents and young adults. Severe mental illness doesn't suddenly emerge out of nowhere - there is an identifiable process through which people decline from "struggling" to "completely unable to function". We know that the longer mental health problems go untreated, the harder they are to treat. Likewise, the longer someone stays on the streets, the harder they become to re-integrate into society.

Housing is only half the equation. For housing-first policies to work (and they can work very successfully), they need to be accompanied by comprehensive psychosocial support to address the issues that cause and perpetuate homelessness. That support is obviously expensive, but it works out much cheaper in the long run.

America has an unusually severe homelessness problem. It is often presupposed that this problem is caused by factors which are unique to America and essentially intractable, which leads to proposed solutions like mass institutionalisation. I believe that this is fundamentally false; the key factor is a lack of political will to invest in the social infrastructure which prevents people from becoming homeless and prevents homelessness from becoming entrenched. This is ultimately a false economy, because the unavoidable costs of having a permanent dysfunctional underclass vastly outweigh the costs of proactively supporting people at the earliest opportunity.

"Ending homelessness" in an absolute sense is a fantasy, but the vast majority of homelessness is avoidable.

> America has an unusually severe homelessness problem.

Maybe.

Over 580,000 Americans are experiencing homelessness. That is a rate of ~0.18%, if my calculations are correct (600k / 332m).

Contrast to Sweden (population 10m) which had an estimated 33,000 homeless people in 2020, yielding a rate of 0.33%. [1]

Contrast to Japan, which has an estimated effective homelessness rate of 0%.

So Sweden has a worse homelessness rate than the US but we all suck compared to Japan and Finland!

1. https://www.homelessworldcup.org/sweden#:~:text=Country%20st....

Japan has homeless people. Not to the same degree as USA but they exist.

In the US, a lot of homeless people are likely in prison. There is also a second class of people who live on the streets during thr week(San Francisco), but then travel back to their home for the weekend

The Japanese do have homelessness problem, they are just not recorded. Knowing Japan, it is something bureaucratic. Unless you register yourself as living in the street, it is assumed you live on your last known adress. And you likely can't register yourself as living on the street as that is illegal.

https://www.theguardian.com/world/2003/dec/19/japan.justinmc...

A lot of people lose their support network in prison (or lose it before going in) and are released to the streets. They just get an open bus ticket courtesy of the state, go where it’s possible to live as homeless, and that’s it. A lot of the bussing we hear about is simply these open bus tickets prisons (especially Texan prisons) give out to people with no one picking them up.

As well the negative feedback loop of how hard it is to get good employment after going to prison.

Correspondingly, I understood Japan's covid numbers were so low during the early stages of the pandemic due to the fact that you could only get officially counted covid tests with great difficulty and discouragement.

Definitions of homelessness and data collection methodologies vary to such a degree that it is difficult to make direct comparisons between countries. The term "homeless" includes a broad range of conditions, from sleeping on the streets to living in temporary accommodation. Japan's purported homelessness rate is transparently false to anyone who has spent time in the less salubrious parts of Tokyo.

What is clear is that homelessness in the US is very unequally distributed geographically and has become associated with increasingly severe social problems. The level of homelessness might not be exceptionally high, but there's a prima facie case that the severity of homelessness has. Being inadequately or insecurely housed is undoubtedly bad, but it's a heck of a lot better than living indefinitely in a tent underneath a freeway overpass.

The last time I looked into these numbers, the definition of "homeless" between the countries was so wildly different that the numbers were impossible to compare

Note that Finland isn’t doing that in this article. They probably do intervene on problems before they become chronic, but most of those housed in assistive housing require some supervision, are not cured of their addictions or mental illness, and are not expected to ever be independent or productive ever again.

However, by providing some housing and supervision to these people, they wind up saving money because on the streets they would be using way more social resources at a far higher cost.

Exactly. You don't even need to care about the people you are helping because, in the long run, it is cheaper to help. This isn't about money. It's largely about having someone to look down on.

Ya, I think America is mostly losing because they feel like these people need to be cured into productive members of society. They don’t need to be cured, they just need to be taken care of somehow that doesn’t involve the constant calls to the police and fire department. However, given the lethality of fentanyl, many will die quickly without some kind of rehab.

The other issue is that Finland can manage this nationally, while Americans expect the richest cities with the highest property costs to shoulder the burden locally, how many free flats could be provided in SF?

American does not have the structure in place to take care of people in this way. The cost of “housing” a single homes person that easily top 50k a year or more due to high administrative costs and medical costs. It cost more in Seattle to run a RV parking lot per spot than to does to rent a nice 2br apt.

> The key point is early intervention, particularly in adolescents and young adults.

That is entirely false. Full blown paranoid delusion or schizophrenia is not "depression but extra bad".

> Severe mental illness doesn't suddenly emerge out of nowhere

It basically does? I mean it's a cross of genetics and in-vitro development factors with some real life trigger at times, but outside of robust genetic engineering it might as well be from "nowhere".

Early intervention is vital in psychotic illness. Single episodes of psychosis can in many cases be prevented from developing into schizophrenia; even if schizophrenia does develop, outcomes are far better for people who receive early and effective treatment.

https://www.nimh.nih.gov/research/research-funded-by-nimh/re...

> Single episodes of psychosis can in many cases be prevented from developing into schizophrenia

Your source does not say that.

> Some people who receive early treatment never have another psychotic episode.

That actual number of some (and not "many", "most" or even "meaningful proportion") is not defined in the page or underlying study.

Broader studies seem to suggest some people regardless of treatment only have an isolated episode. It is not clear the RAISE intervention itself changes that proportion.

Let's be real here, if only those were the majority of the homeless in the US, and other such places.

Instead, they are used as an excuse not to do anything for the homeless masses.

You're suggesting that the government pay the rent for all 90% functional adults? How are you going to vet who qualifies for this? "Mild" mental illness when the incentive is totally free rent seems like an attractive proposition for to encourage a deluge of incredibly hard to falsify applicants.

What I'm hearing is "just implement UBI so we don't have to worry about fraud and waste time and money on administration"

From my experience, free Healthcare has extremely long wait lines, and bad quality of service, unless it is an urgent matter. I would guess if the mental illness is not severe, not an urget matter, it will not be treated well.

This feels like a political statement and not from knowledge of Finland.

Finland: "The time within which you must get access to non-urgent care and treatment is laid down in law."

source, which has list of waiting times: https://www.hel.fi/en/health-and-social-services/data-and-th...

You can’t legislate a waiting time! Laws act on people, not reality. What if it takes the doctors longer to work on the people in front of you? What if more urgent cases arrive and goes to the front of the line?

Yeah, for urgent care that can happen wether it's free or not.

I’d suggest reading the link the person you’re replying to posted.

You can legislate it because it puts the government in breach of law if they don't provide sufficient funding to ensure sufficient excess capacity to meet the criteria. Governments legislate standards of care all the time.

Imagine this take on something like an enterprise SLA, that helps me reason about how at an individual level it feels nonsensical but at the parent level there are a bunch of upstream levers available to meet those SLAs.

And the law is frequently violated.

Nowadays more than 50% of Finnish newborns are covered by voluntary private health insurance, although all of them are covered already by public health care. I think that tells very much how much people still trust in the public health system.

...or it tells how easy it is to sell insurance to the parents of newborns

Partly. But if you have queued for Finnish healthcare you know that the problem is real.

There are practically no consequences for breaking these laws. It is a fact that these time requirements are not met by public healthcare in areas like Helsinki [1] [2].

[1] https://www.laakarilehti.fi/terveydenhuolto/hoitotakuu-pitaa...

[2] https://www.iltalehti.fi/politiikka/a/f3392e98-c524-4c22-a53...

Your experience isn't from Scandinavia I take it?

Free, universal health care works extremely well in Australia, New Zealand and the Nordics (as noted).

Not in Finland I can tell you from living there after having lived in several other countries. A significant part is private, paid "voluntarily". Why would anybody pay voluntarily to avoid "extremely good" service they are entitled too?

For the same reason some people wont be caught dead in a 3 star hotel, and would rather only stay on 5 star hotels.

Meanwhile, for millions who would otherwise stretch to afford the latter or skip it altogether, it works extremely well, as it does anytime you just want a bed for the night (the 95% of basic medical treatments), and not jakuzi and 3 restaurant choices.

You don't get "extremely good" (as the GP wrote) service at a 3 star hotel. Less than 1% of the population uses 5 star hotels. In Finland over 50% of the population use private health care (either directly or via their work contract).

Edit: As a commenter pointed out it's 50% that use private health care, too. Very few people would exclusively use private health care.

If you can afford it (or your employer pays for it), you get to use whatever. It helps cut some queue times, and gives you more choice and convenience.

Doesn't mean the free one can't still be "extremely good". I might pay for IntelliJ, even though a free IDE or even editor like Emacs is still extremely good.

And 40% of the population is still a huge number of people, who would otherwise had trouble affording private health care or get the shitty low tier and/or hella expensive private care afforded by the poorer in the US.

It's also not exactly like "50% of the population use private health care". It's more like "50% of the population ALSO use private health care", in addition to the provided free health care.

> your employer pays for it

Well, in the end the employer has reduced your salary by that amount, employers are not known for welfare. Every employee is already entitled for full public health care. Something must be wrong with it if 90% of the employers offer double insurance in away. It's a public secret or gentlemen's agreement that employed people are not supposed to use the public health sector they are entitled to before they need specialist or hospital treatment. The gentlemen's agreement would stop working if basic public healthcare were reasonably good.

> Why would anybody pay voluntarily to avoid "extremely good" service they are entitled too?

Maybe because expectations rise with the availability of other options? Why would one pay for a Porsche when they could drive a Prius?

I live in Germany. Our healthcare system struggles a lot (mostly by design, thanks to incompetent/hostile politicians). I'd still bet the average citizen in Germany has better availability for treatments than the average American.

Yes, and the average German gets much better health care than the average Finn (which still gets better health care than the average American).

Most of the basic health care is Germany is not publicly organized, but private. The health insurance system is heavily publicly regulated.

I live in Finland and all of my relatives in Germany, so I see the differences very often.

> Most of the basic health care is Germany is not publicly organized, but private. The health insurance system is heavily publicly regulated.

This is a pseudo-distinction imho. Yes, the doctor's offices and clinics are private institutions and not organized under a single umbrella like in the UK the NHS would represent. However, the vast majority take appointments from publicly insured patients and are in compliance with the guidelines setup by the public health insurances. Also, in most cases publicly insured patients make up the majority of appointments.

Moreover, there isn't really a competition between public health insurance providers. The price difference between providers is negligible and so are the services covered (most providers cover the minimum as outlined by the law plus a few extra things you usually don't ever need).

TL;DR: the German healthcare system is public

I have regular insights to both systems.

In Germany the risk of unnecessary treatment is higher, doctors earn money that way.

In Finland being denied treatment is higher, especially for people not good at negotiating. On the appointment line they will just tell you we have no free times. Only insisting and quoting the law might help. And lying about your symptoms. Waiting for surgery typically lasts many months.

Germany spends around 30% more in health expenses than Finland.

Neither of them is perfect. But when I am really ill, the German system feels easier to work with.

The US of course spends even more in health expenses. But only a limited group benefits from most of it.

Why would anyone pay for business/first class when the plane lands safely and at the same time for economy?

I pay for private insurance in one of the countries I mentioned to have choice of doctor and nicer hospital rooms and meant that my (non-urgent) knee reconstruction got done in 6 weeks instead of the 6 months I would have needed to wait for the same surgeon.

Finland is not "economy class". Taxes are rather high, the fees in the public health care system are high in European scale, too. But the standards are not. So you pay parts of your mandatory "economy class ticket", but you throw it away unused to get a more expensive one.

Your comparison does not work.

I moved to Finland and have found the public health-care good. However I also get some medical stuff provided as part of my employment.

I wanted to have a particular operation and was told I could have it carried out almost for free if I waited for "about a year". Alternatively I could pay for it myself and have it in "a few weeks".

In that kinda situation, a procedure I wanted for myself, I figured I'd just pay. Certainly there wouldn't have been a problem waiting for it, voluntarily. But given the opportunity it seemed like a good decision to make.

In the past I've had work-related healthcare covering me when I had some forearm injuries, caused by climbing, which directly impacted my keyboard usage. My usage of public healthcare involved having brainscans, and other tests before deciding that I was fine. Both cases were nice and straightforward, even without adequate Finnish language skills on my part.

So I think I've had a decent interaction with all three of the systems - paid stuff, which I managed myself, public system, and private healthcare provided by my employer.

I’ve lived in Australia. The quality of care is so much lower that it’s hard to imagine. This is true across GP, specialist, and emergency visits.

… compared to?

Compared to the private healthcare systems in other countries I’ve lived in?

Which is super insightful when you failed to mention… any of them.

When you remove lack of funds as a reason to stay out of the queues, you do indeed tend to end up with demand more accurately reflecting need, and sometimes that leads to queues.

When you also have private care available, as you do in almost every country with universal healthcare, the proportion who opts to go private is a good reflection of whether people consider the public care sufficient. I don't know about Finland, but e.g. in the UK only about 10% opts for private insurance - most of it as incidental employment perks in higher paying jobs rather than an explicit choice -, despite private insurance here being far cheaper than the US (in part because the NHS offsets some of their costs by renting out excess capacity, and insurers mostly offer "top up" services - e.g. faster access to specialists etc).

The low level of private healthcare spend in countries with universal healthcare - especially in those, like the UK, where taxpayers pay less in tax per capita for public healthcare than in the US (NHS costs less per capita across the whole population, not just users, than Medicare and Medicaid) - to me is a fairly strong indication that most people don't consider them to provide bad quality of service or too long waits.

I am British but live in Finland. The Finnish health service is a lot more complex. I'm not really able to make a distinction on better or worse because thankfully my exposure to both has been pretty minimal, although, I'll end with an anecodote that illustrates that it's not easy to compare.

The private sector in Finland is, compartively, huge. Like, imagine a normal shopping centre and two of the bigger units are private, nationwide doctors surgeries. This is pretty much any larger shopping centre in a reasonably sized town here. The reason is that employers are mandated to provide some kind of health insurance to employees. It is this health insurance that is then responsible for giving you a sick note or ensuring that workplace injuries are taken care of - not the public service. The legal minimum is pretty low, so you can't go to them like a GP in the UK and be guaranteed that they'll do anything if it's not covered by the contract with your employer. Now, employers are free to top this up, so 'yeah the pay's comparable but the healthcare is much better' is a common point of disussion in social groups. In my personal case, which is not that special, it's great! I can book an appointment for basically _now_ (Sunday afternoon) online and go get whatever I want looked at. If I was dependent on the public system, lol no - just like home pretty much.

Anyway, I guess what I'm saying is that it's very much a two tier system, and I think it was long ago realised that a way for working people to 'skip the queue' was becoming needed, as if these people became ill and stopped working then they wouldn't be paying for the public system (through taxes).

> The reason is that employers are mandated to provide some kind of health insurance to employees

Even many Finns don't understand that this is not correct. Employers are not mandated to provide any kind of general health care. They must take precautions to protect you from work-related health risks. So for IT workers a physiotherapist checking that your are sitting in a good position would probably be enough. In a mine or steel work it would be a bit more. When you get sick and go to your company health care doctor, that is a voluntary part of your employment contract, in no way mandated by law. One explanation given in the public uses to be: Employers don't want to wait for employees to queue in public health care forever, they want then to return to work soon. Even that explanation does not sound very convincing to me. After all the average flu is over in a week if see a doctor and in seven days if you don't. As an employer I would not voluntarily pay significant money for it if I hadn't to for one reason or another.

See also my comment https://news.ycombinator.com/item?id=37199110 , it's a really weird, historically grown cost-sharing model that cannot be explained by legal obligations.

Fair enough I have learned something. I just remember the concept being introduced in the onboarding and me and the other foreigners finding it a totally, ahem, foreign concept.

I’m not complaining and I’m certain that I wouldn’t see the full cost in my take home pay should the employer remove it, there must be some kind of tax benefits to them, negotiations, etc.

In my experience its a lot faster to get into a specialist too in the US than the UK for example. A matter of weeks compared to years. When it takes years you effectively cant get treatment for some acute issues which last for a few months at a time and then go dormant for a while, such as some serious sinus problems.

That's the experience of people who live in places with shitty free healthcare options and can afford top tier healtcare on demand.

Difference to the experience of millions who'd rather skip treatments for even basic stuff like dentals than bear the costs...

Japan has universal health care and it has the opposite problem - it's great for anything that is not urgent (more MRI units per capita than anywhere else) but there are horror stories about people stuck in ambulances riding around looking for emergency care.

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