In the United States, treatment for the mentally ill is underfunded and resources are poorly allocated. Misguided policies at the state and national level result in tremendous human suffering and increased homelessness at a high cost to society. As a result, undue and unnecessary burdens are being placed upon law enforcement, the judicial and prison system, and hospital emergency departments.

Far too many of our mentally ill, particularly those with concurrent substance abuse, are caught in an endless cycle of incarceration, homelessness and emergency medical care. According to a recent article in the Economist, Lamp Community, a nonprofit organization working for the mentally ill in Los Angeles, calculates that those caught in this cycle can cost society $100,000 per year.

In a recent meeting I had with the Straub Emergency Department, physicians expressed concern over the growing trend of mentally ill homeless people being brought to the ER for treatment.

During the past legislative session, lawmakers voted to fund Hawaii’s ability to fly homeless people from the mainland back to the mainland. A modest $100,000 was appropriated for the Department of Human Services to run a three-year pilot. However, the DHS recently announced that it would not be implementing the program because of costly and burdensome requirements.

Considering Lamp Community’s estimate of annual costs to manage this population, if the Hawaii pilot prevents one tough case from living on the islands for one year, it should pay for itself. Given the exorbitant costs for health care and law enforcement, the price of a plane ticket may seem well worth it for one overburdened institution to export their problem to another city. However, that is no solution for these suffering souls or for American society.

Their numbers are great. According to Bernard Harcourt, until the 1960s, hospitalized mental health patients outnumbered prison inmates in the United States by approximately 5-to-1. Today it is the inverse. The shift occurred in the 1960s, when the Kennedy administration shifted a great deal of the responsibility to care for the mentally ill to the community but the promised community resources never fully materialized. I recall my father, as a young psychiatrist, giving lectures about the problem. Later, he served at the Napa State Hospital, and as a medical student I spent some time with him seeing patients. Those few who were deemed sick enough to remain there for the long term were unspeakably, unimaginably ill.

Hawaii is no different. The vast majority of mentally ill patients referred to inpatient mental health facilities are discharged within days, regardless of their severity, if they are not considered an active danger to self or others. As a primary care physician in Hawaii for more than 20 years, I have referred many patients to these facilities and been amazed at how quickly they are again discharged, often without a solid plan for follow-up despite severe, ongoing mental illness and inability to care for themselves.

I recall one patient who I referred to an inpatient facility on Oahu. He was discharged two days later and made a suicide attempt the following week. Only after the suicide attempt did I receive a call from the psychiatrist saying that he had been discharged. It was too late.

Enhanced incentives to solve this problem are now afoot. The Hawaii medical community is now forming between two and five competing accountable care organizations of community providers, specialists and hospitals that will pool their patients into an at-risk population and, in theory, earn incentives for improved clinical outcomes. Never before has the risk been so fully shifted to the providers for patients who live at the fringe of society. Inappropriate emergency visits and hospital readmissions will now need to be tackled head-on. A great deal of this work will involve finding sustainable solutions for the mentally ill, particularly those with the dual diagnosis of substance abuse.

At Manakai o Malama, we have found that for primary care and the management of chronic pain, a robust department of mental health providers closely integrated with medical providers is highly effective. However, throughout the community, more resources must be made available for caseworkers, care coordinators and social workers to assist those who cannot care for themselves. Prevention is also indispensable. There is no replacement for a supportive ohana, quality education, a drug-free environment and opportunities for meaningful employment.

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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.