Recovery From Schizophrenia: Psychiatry And Political Economy

262 WORKoriented clubhouse, while these costs remained constant in a matched group ofnon-clubhouse members. The treatment cost reduction for club-house memberswas restricted to those who were placed in work, suggesting that the savings maywell have been a result of employment. 55 Similarly the treatment costs for clientsadmitted to Thresholds, the well-known psycho-social clubhouse in Chicago,which has a rehabilitation program with a strong vocational component, were lessthan three-quarters of the costs for those admitted to a social club with novocational component. 56 In another study, mentally ill clients randomly selectedfor a program of accelerated entry into supported employment generatedtreatment costs that were less than three-quarters of those for similar clients placedin a gradual work entry program; the decreased costs of mental health care for theclients who were rapidly employed more than offset the increased costs of theaccelerated work pro gram. 57 Not all studies of this type show decreasedtreatment costs when people with mental illness obtain employment 58 but themajority do. Placing mentally ill people in work can save money. To realize costbenefits from a wage subsidy it would be important to track costs carefully overtime and to ensure that the subsidy was only made available to the most severelydisabled patients.WELFARE REFORMDisincentives to work for people with mental illness are part of a broader problem.In recent years, political attention in the US has been focused on finding solutionsto work disincentives and welfare dependency for all recipients of public support.In the run-up to the 1992 presidential election, candidate Clinton endorsed manyof the proposals of Harvard economist David Ellwood. Ellwood emphasizes thatthe primary problem underlying welfare dependency is not a lack of trainingprograms or tough work requirements but the fact that welfare recipients cannotearn enough to make work a viable economic choice. He proposes that welfarebe time-limited and that government ensure that welfare recipients be providedwith work that pays enough to prevent poverty. The minimum wage should beincreased, he suggests, and public jobs provided for those who cannot find workin the private sector. 59 Writer Mickey Kaus, in a similar vein, argues foreliminating cash assistance altogether and replacing it with a program ofguaranteed jobs, like the Depression-era Works Progress Administration (WPA),that would pay a little less than the minimum wage. 60 In the event, the legislationpassed by Congress in the boom years of the Clinton administration in the early1990s embodied some of these recommendations and not others. It establishedtime-limited welfare, and a small increase in the minimum wage, but it did notlegislate a wage that pays enough to prevent poverty nor did it establish aguaranteed jobs program. We should consider, however, whether these last twosocial policy initiatives would create economic incentives and a steeper incomegradient for mentally ill people entering the labor force. In the case of mentallydisabled people we would need to: