Dr. E. Fuller Torrey on the Unintended Consequences of Emptying out Mental Hospitals

The president’s budget proposal includes the repeal of Medicaid’s IMD (Institutes for Medical Diseases) exclusion, a Johnson-era policy that withholds federal Medicaid monies from residential adult psychiatric facilities with 16 or more beds. In 1965, Congress incorporated the exclusion in the seminal Medicaid statute for two distinct purposes: first, to honor the spirit of the late John Kennedy’s 1963 Community Mental Health Act, which called for the large-scale depopulation of American asylums, and second, to ensure that states retained a role in funding those state mental hospitals, whose maintenance had been a state responsibility for more than a century. The results of this and other deinstitutionalization policies are no doubt familiar to readers here: the explosion of homelessness, the surging incidence of mental illness in jails and prisons, sporadic cases of mass violence. But other outcomes, such as the “psychiatric boarding” crisis of psychiatric patients languishing in emergency rooms, or the takeover of state hospitals by the criminally insane, are less obvious to a disinterested observer.

Support for the proposed repeal of the IMD exclusion runs the gamut from contributors to the Wall Street Journal through the New York Daily News editorial board, but critics have crawled out of the woodwork to defend the exclusion as the only thing standing between the mentally ill and the “snake pit” asylums of old. With the homelessness crisis at a fever pitch and mental-health policy very much in the news, I asked Dr. E. Fuller Torrey, the founder of the Treatment Advocacy Center and the author of four books about psychiatry and mental-health policy in the United States, to discuss the state of our national mental-health system in light of the president’s proposal. Remarks are edited for clarity.

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The president’s budget proposal includes the repeal of Medicaid’s IMD (Institutes for Medical Diseases) exclusion, a Johnson-era policy that withholds federal Medicaid monies from residential adult psychiatric facilities with 16 or more beds. In 1965, Congress incorporated the exclusion in the seminal Medicaid statute for two distinct purposes: first, to honor the spirit of the late John Kennedy’s 1963 Community Mental Health Act, which called for the large-scale depopulation of American asylums, and second, to ensure that states retained a role in funding those state mental hospitals, whose maintenance had been a state responsibility for more than a century. The results of this and other deinstitutionalization policies are no doubt familiar to readers here: the explosion of homelessness, the surging incidence of mental illness in jails and prisons, sporadic cases of mass violence. But other outcomes, such as the “psychiatric boarding” crisis of psychiatric patients languishing in emergency rooms, or the takeover of state hospitals by the criminally insane, are less obvious to a disinterested observer.

Support for the proposed repeal of the IMD exclusion runs the gamut from contributors to the Wall Street Journal through the New York Daily News editorial board, but critics have crawled out of the woodwork to defend the exclusion as the only thing standing between the mentally ill and the “snake pit” asylums of old. With the homelessness crisis at a fever pitch and mental-health policy very much in the news, I asked Dr. E. Fuller Torrey, the founder of the Treatment Advocacy Center and the author of four books about psychiatry and mental-health policy in the United States, to discuss the state of our national mental-health system in light of the president’s proposal. Remarks are edited for clarity.