In a time of competing narratives and virtually unprecedented levels of polarization, there is one sad truth that Americans can readily agree on: our mental-health system is broken.
Specifically, the U.S. has long faced a critical shortage of inpatient psychiatric-treatment beds, with devastating societal consequences. From its historic peak in 1955 to 2016, the number of state psychiatric-hospital beds in the United States plummeted almost 97 percent, in a trend known as “deinstitutionalization.” There are now fewer beds per capita in the United States than there were in 1850. An analysis of the broader system of both inpatient and other 24-hour residential-treatment beds similarly found a 77.4 percent decrease from 1970 to 2014.
While inpatient treatment beds represent only one aspect of a functioning mental-health system, they are a vital one. Without access to a bed, acutely ill individuals are left to wait for the proper treatment, forcing mental-health professionals to triage the most severely ill in hopes of short-circuiting the next awful, unnecessary massacre. At the same time, families are caught in their own nightmare, watching helplessly as their loved ones deteriorate in the absence of the right care. With nowhere else to turn, those in need end up in the only remaining systems that cannot say no: emergency rooms, homeless shelters and, too often, jails and prisons.
Without treatment beds, the criminal-justice system has become our de facto mental-health system. By 2014, ten times the number of people with serious mental illness were in prisons and jails as in state mental hospitals. Astoundingly, the largest mental-health facilities in the nation are now the Cook County and Los Angeles County jails.
In Florida, where the national spotlight is now focused, law enforcement spends inordinate amounts of time responding to mental-health concerns. In 2013, Florida law enforcement initiated 85,276 involuntary mental-illness exams — almost three times the number of aggravated-assault arrests and double the number of arrests for driving under the influence in the same period. Meanwhile, a Pulitzer Prize–winning series by the Tampa Bay Times and Sarasota Herald-Tribune noted that “years of neglect and $100 million in budget cuts” had turned state-run mental-health hospitals into “treacherous warehouses where violence is out of control and patients can’t get the care they need.”
More than a half century after deinstitutionalization began, restoring needed treatment beds will not be simple, but it is necessary. A concrete first step would be for President Trump to publicly support the repeal of Medicaid’s discriminatory Institutions for Mental Diseases (IMD) exclusion. Borne of an age that saw promise in medications that would supposedly end the need for inpatient psychiatric care, the IMD exclusion prohibits Medicaid “payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases.” This somewhat opaque language effectively bars Medicaid reimbursement for adults’ mental-health or substance-abuse care in facilities with more than 16 beds, simply because of the nature of their illness.
Without treatment beds, the criminal-justice system has become our de facto mental-health system.
Without such reimbursements, the financial burden for both inpatient substance-abuse and psychiatric care is shifted entirely to the states. Adding insult to these many injuries, data show that purported cost savings from restricting inpatient care are largely illusory. States with shorter median psychiatric-hospital stays have significantly higher readmission rates than states that provide for longer stays. In fact, a federal study found that, for Medicaid patients, mental-illness conditions were two of the top three causes of 30-day inpatient readmissions. Along with diabetes, these conditions resulted in approximately $839 million in hospital costs in a single year.
Meanwhile, states across the country face lawsuits and constitutional challenges owing to the glut of mentally ill prisoners awaiting transfer to a state hospital bed. Three-quarters of the states surveyed by our organization, the Treatment Advocacy Center, maintained such waiting lists. Maryland and Michigan have even seen state officials threatened with contempt of court for their delays, while Washington officials faced contempt warnings over similarly long waiting lists for admission to their emergency rooms.
If there is a silver lining, it is that these devastating consequences seem to be finally encouraging bipartisan support for reform.
During a listening session in the wake of last week’s Parkland, Fla., school shooting, President Trump himself seemed to acknowledge the problem. “You know, years ago, we had mental hospitals . . . a lot of them, and a lot of them have closed,” he said.
Former New Jersey governor Chris Christie, the chair of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, has called the IMD exclusion “old-fashioned, antiquated and ridiculous.” The commission has recommended eliminating the exclusion, as has the recently established federal Interdepartmental Severe Mental Illness Coordinating Committee. A provision scrapping the policy was even included in Senate Republican plans to repeal and replace Obamacare.
We are pleased to see so many national leaders recognizing the serious problems that deinstitutionalization has caused and the urgent need for reform. As lawmakers struggle to achieve consensus on a host of issues after the stunning tragedy in Parkland, ending the IMD exclusion represents a bipartisan opportunity to right a longstanding wrong and help those most in need.
We all agree that the mental-health system is broken; now we must come together to do something to fix it.
— John Snook is the executive director of the Treatment Advocacy Center (TAC), a national nonprofit that works to eliminate barriers to treatment for people with severe mental illness. E. Fuller Torrey is TAC’s founder.