As the executive orders pile up and President Biden seeks to distance his administration from President Trump’s, he should be careful to preserve and learn from the things Trump got right.
One such positive legacy is the work of Dr. Elinore McCance-Katz on improving services for people with serious mental illnesses. McCance-Katz resigned in early January after almost four years as the first assistant secretary for mental health and substance use and the director of the Substance Abuse and Mental Health Services Administration (SAMHSA), which runs point on federal mental-health policy.
As the first psychiatrist to lead SAMHSA since its establishment in 1992, McCance-Katz greatly improved the agency, which had a woeful track record of discounting the needs of those with serious mental illnesses such as psychotic disorders and severe depression before she took over. President Biden and his nominee to lead the Department of Health and Human Services, Xavier Becerra, should select a successor who will maintain and build on her commitment to the most severely mentally ill.
McCance-Katz walked into an agency whose philosophy and practices championed the rights of the most helpless mental-illness sufferers to refuse care — and thus to remain in the grips of their illnesses. An annual SAMHSA-funded “Alternatives Conference” featured speakers who voiced anti-psychiatry views, discouraging patients from taking medication.
From her first day on the job, McCance-Katz, who’d earlier served as chief medical officer of the Rhode Island Department of Behavioral Healthcare, set out to re-balance the agency’s priorities, placing a much-needed emphasis on the treatment of serious mental illnesses.
High on her agenda was increasing the availability of psychiatric beds. She secured Medicaid-waiver authority to allow states to modify the so-called IMD (Institutions for Mental Disease) exclusion, which had forbidden payment for patients between ages 21 and 64 to obtain care in facilities that primarily provided mental-health care and contained more than 16 beds.
To keep fragile patients from slipping between the cracks after hospital discharge, she had SAMHSA fund 37 Assisted Outpatient Treatment (AOT) demonstration projects across the country. Under AOT, courts can order into community-based treatment individuals with an established history of ceasing to take their medication and becoming a danger to themselves or others. When faithfully implemented, AOT programs dramatically decrease psychiatric hospitalizations, emergency-room visits, incarceration rates, and homelessness.
To expand outpatient-treatment slots, McCance-Katz increased funding for Certified Community Behavioral Health Clinics from $100 million to $450 million and required the clinics to provide 24/7 crisis services as an alternative to costly emergency-room visits.
McCance-Katz aided another invisible population — the approximately 20 percent of jail inmates and 15 percent of state-prison inmates with severe mental illnesses — by revising federal guidelines to allow Mental Health Block Grants to be spent on their treatment. And she had SAMHSA begin filling gaps in what experts know about the broader spectrum of severely mentally ill Americans through a new $30 million Mental and Substance Use Disorders Prevalence Study — the first such federal study in 40 years.
In naming the next SAMHSA head, Biden and Becerra must resist calls to reverse some of McCance-Katz’s initiatives and return to the old regime, under which people with severe mental illnesses were regarded as second-class constituents. The new administration should instead look for a leader who will build on McCance-Katz’s groundbreaking work in caring for those with the most devastating diseases of the mind and brain.
— Dr. E. Fuller Torrey is the associate director of research at the Stanley Medical Research Institute. Dr. Sally Satel is a visiting professor of psychiatry at Columbia University’s Vagelos College of Physicians and Surgeons and a resident scholar at the American Enterprise Institute.