In 1963, JFK signed the Community Mental Health Act. Its order to close the state psychiatric hospitals was followed, and hundreds were shuttered; the community mental health centers that were meant to replace them were never built. With far fewer beds for a growing patient population it should not have surprised anyone that the streets gradually filled with the severely ill. But somehow, we were surprised. The state governments were mostly just grateful to save money that had once gone to mental healthcare. The passage of Medicaid two years later deepened the problem. Medicaid’s funding structure presented states with an opportunity to further offload costs, this time onto the federal government. Unfortunately, the private institutions that filled with Medicaid patients were no better than the state facilities that had been closed; often they were worse. And maintaining access to Medicaid funding for such care, in practice, was more complicated and less certain than staying in a state institution. In 1975, the Supreme Court’s O’Connor v. Donaldson decision established a national standard that the mentally ill could only be involuntarily treated if they represented an immediate threat to themselves or others. This completely removed actual medical necessity from the equation, and the standard directly incentivized hospitals to discharge very ill patients, many of whom leave these useless emergency room visits and immediately abuse drugs, self-harm, commit crimes, attack others, or commit suicide. In 1990 the passage of the Americans with Disabilities Act further empowered treatment-resistant patients and created legal incentives that led hospitals to release severely ill people rather than face the burden of litigation. Various state reforms in recent decades have almost uniformly pushed the severely ill out of treatment rather than into it, under the banner of “autonomy”. For sixty years we’ve done everything in our power to make it harder to treat people who badly need care. And here we are.
Freddie deBoer, “We Closed the Institutions That Housed the Severely Mentally Ill and We Made It Dramatically Harder to Compel Them to Receive Care”, Freddie deBoer, 2024-05-14.
