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Trump Supports Helping the Mentally Ill
We have failed the mentally ill of this country. In trying to save government money, we have watched them become subject to increasing job loss, homelessness, imprisonment, emergency room treatment, substance abuse, or vulnerable to violence. How did this happen and what is being done?
The Institutes for Mental Disease (IMD) exclusion began in 1965 as part of the Social Security Amendments Act of 1965, which created Medicaid and Medicare. Here are the basics of the exclusion:
The IMD exclusion prohibits the use of federal monies through Medicaid for any care (including non-mental health services) provided to patients from 21 to 65 years old, in mental health or substance abuse residential treatment facilities with more than 16 beds. A facility is determined to be an IMD based on its ‘overall character,’ or the totality of whether the facility is a licensed psychiatric facility, is under the state’s mental health authority’s jurisdiction, specializes in providing psychiatric care or treatment (based on the proportion of staff trained in psychiatric care), or whether more than 50 percent of patients are admitted to the facility for mental health care.
It’s no surprise that the states figured out how to manipulate the system:
Before Medicaid was enacted, states paid for psychiatric hospitalization, and it was readily available. But states soon realized that if they kicked patients out of hospitals, Medicaid would kick in and pay half the cost of care. This “deinstitutionalization” continues. The country has lost more than 450,000 mental-hospital beds since the 1950s, 12,000 of them since 2005.
For people who are seriously ill, receiving treatment is difficult and expensive. Few hospitals have psychiatric wards and, in some cases, mental health professionals may not be available to provide services. And due to the IMD exclusion, facilities are “incentivized to keep their bed count below 16 to preserve their Medicaid payment eligibility.”
What are the impacts of mental illness in this country?
- Mental illness and substance use disorders are involved in 1 out of every 8 emergency department visits by a U.S. adult (estimated 12 million visits).
- Mood disorders are the most common cause of hospitalization for all people in the U.S. under age 45 (after excluding hospitalization relating to pregnancy and birth)
- Across the U.S. economy, serious mental illness causes $193.2 billion in lost earnings each year
- 20.1% of people experiencing homelessness in the U.S. have a serious mental health condition
- 37%of adults incarcerated in the state and federal prison system have a diagnosed mental illness
- 70.4% of youth in the juvenile justice system have a diagnosed mental illness
- 41% of Veteran’s Health Administration patients have a diagnosed mental illness or substance use disorder
Meanwhile, Rep. Eddie Bernice Johnson, D-TX, a former psychiatric nurse, has introduced legislation to abolish the exclusion. President Trump supports the legislation, and even Amy Klobuchar and Pete Buttigieg back these bills. A number of ways to deal with this change have been suggested in the past. There are those who are arguing against the legislation, including civil libertarians and mental health advisors; others mistakenly believe that treatment can be successful by providing drugs and “wellness initiatives.”
At this point, I’m not informed enough to debate how to replace or modify the exclusion. The big question for me is: do we have a responsibility to those who are mentally ill, and to those families and communities who are subject to the burdens of their conditions, to help these folks, or not?
Published in Healthcare
Thank you Susan. You shed light on this problem and gave me a new insight. I’ve been under the impression that new medications had been created allowing states to close the institutions that formerly housed the mentally ill. Here all along it was another government fubar.
I’m from the government and I’m here to help.
I agree that there is a problem. I’m not convinced that “we” have “failed” anyone. Dealing with mental illness is extremely difficult, and generally speaking, people don’t seem to want the help.
I’m skeptical of any suggestion that a federal government program will be helpful.
Nope. It wasn’t.
A nasty combination of naive? mendacious? “civil-rights” folks, inspired by “One Flew Over the Cuckoos’ Nest” (“they’re not sick! Society is sick!”) and governments hoping to shed the financial burden of providing asylum to very ill people.
And yes—this is something the government has to help with. Mentally ill adults often can’t manage their own care, and their illnesses often prevent them from forming or maintaining family relationships. Even patients with loving, devoted families are too ill to be cared for at home by family members. It isn’t safe, and it isn’t effective.
Long-term supportive care can make the difference between a short, painful, harm-filled life…and a decent, meaningful, useful one.
Good for Trump. And Pete and Amy too. It’s a start.
@GrannyDude, you are right! First, the exclusion has to actually be rescinded. Then we have to decide how it will be replaced, what the requirements will be, how results will be monitored, how the private sector can respond as well as the public sector. Mental hospitals or mental illness wings will not be built overnight. Deciding benefits from facilities, what kinds of facilities and how they will be monitored is another concern. In some ways, the problem seems intractable. But it is a start. Let’s hope some of those foolish cities with huge numbers of homeless people actually recognize how these changes could benefit them (the cities, the homeless and their constituents) and how they might proceed in a helpful way. It will be hard. But so many people are suffering.
Having worked in several homeless clinics, 20% sounds REALLY low to me…
I had a friend growing up who’s mother had severe problems stemming actually from his childbirth. She had to be institutionalized. She spent 30 years in a state hospital. Suddenly I was told that a new medication was found that allowed her to be released. My friend took her into his home. She was very mentally stable but unfortunately she developed cancer and only lived a short time. The institution she was in closed a short time later. My friend implied that most of the patients were cured and no longer needed help. Little did I know it was Fubar.
I’m not surprised. I don’t know how they come up with those numbers, and I don’t know how “serious mental health condition” is defined.
If you’re sleeping in a dumpster, whatever mental illness you have could probably be described as “serious.”
yes!
This is something the government has to do. If the private sector could manage it, it already would have.
Mental Illness is not easy to manage in a society which values executive functioning above all else. The 16 bed limit is real, and I worked someplace where we did not have more bed because of that limit. It should go.
And Medicaid rates should be taken over by the feds and raised. The States set the rates, and most medicaid rates are such that doctors won’t take patients on medicaid. Sorry, guys, but these are people who need the dollars.
I included this link in the post for the American Action Forum, and they had some intriguing suggestions for replacing the exclusion. Look under the section, Reforming the IMD Exclusion.
Thanks, Bryan. I know you are very familiar with this topic and am glad you weighed in.
The problem is how “homeless” is defined. Living in your mom’s basement?
And anyone who does that long-term has a serious problem!
Eugene, where I live, has what are referred to as “street people” in far greater number that would be expected for a city of this size. The great majority of these folks simply spend their days wandering about or hanging out downtown. I have never seen a panhandler or an aggressive person. If you can get them to talk to you, it becomes very clear that many, many have serious mental issues — either drug-induced or medical.
They are the victims of someone’s “generous spirit” in freeing them from being institutionalized.
According to the federal government, homeless is not couch surfing. Homeless means you are in a shelter or on the streets. It is a huge problem, and most of the of chronic homeless (90 days or more) are on drugs, mentally ill, or most likely, both. easy to work the other way. Easy for us in homes to ignore. I think this is an area where the GOP could clean up and show some compassion. Have to stop listening to libertarians though. They want the homeless to be ignored by government and taken care of by charity. Cause as we know, charity right now is doing such a great job.
The problem with throwing money at the problem is that the mental health industrial complex will become a black hole of infinite spending. We need to stick with market solutions like copayments and using charities. Caution, non-profits can be just as bad as for-profits.
FYI, I just saw an add for Sheriff election. The incumbent was bragging about her doggie therapy for inmates. Yeah!
The statistics you cited are almost certainly skewed – but I have no idea in which direction.
I wouldn’t say I’m a proponent of doggie therapy, but many prisoners either start out with, or develop, a shortage of empathy – so there may be something to this animal business. California has at least one animal shelter that uses female prisoners as workers – but I can’t vouch for its effectiveness.
And there’s nothing new about the situation though the numbers ebb and flow over time since the institutions started closing in the 70s. Anyone who has family members who’ve gone through this (I have) know that most of those on the street are severely mentally ill and/or have drug or alcohol problems.
This has also been framed falsely as just a binary solution of government intervention or letting people live on the street. What happened starting in the 70s is that laws began to take family members out of the equation, limiting our ability to obtain medical information and our ability to intervene to help those close to us. Instead, courts appointed “public interest” representatives to defend the interests of the mentally ill, often people ideologically committed to the idea that mental illness really doesn’t exist and that family members should not be involved in treatment decisions. I’d like to see a rethinking of those laws, though it is too late for what we had to deal with.
I was under the impression that the more of the problem stemmed from the civil rights movement and detaining people against their will, no matter how much better off they’d be – that “One Flew Over the Cuckoos Nest” that was mentioned.
I’m open to the proposed changes but think that in addition to those reforms, involuntary confinement and treatment will have to be part of that mix.
Right. Because we were all about enriching ourselves. 25 years at it mad eme such a rich man.
They are not.
We have seen some devastating and painful stories right here on Ricochet, about how families are not permitted to intervene, thus having to watch their mentally ill family members encounter suffering and violence.
As I said in an earlier comment, this will be a complicated endeavor. I hope, as a society, that we are up to it and will use pragmatism, wisdom and compassion in dealing with it.
No.
Living in a tent in the woods? Yes.
I hate homelessness, but I am worried about the idea behind this legislation. The fact that it is based on the idea that we need bigger institutions makes me question the thinking and how well it might work, and frankly, who will get hurt by it.
A sixteen-bed hospital or assisted living facility is actually a pretty good size that has a good shot at remaining focused on rehabilitation and helping patients live the fullest life they can. Much bigger than that and conditions can deteriorate.
What you want most of all in a housing facility is a place where outsiders feel comfortable and want to visit. Smaller is better to achieve that end.
I have a concern too that a lot of Alzheimer’s and dementia patients and the frail elderly will end up in whatever we build. Large institutions have a build-it-and-they-will-come aspect to them. One positive outcome of the deinstitutionalization movement in health care was that states discovered many people who were confined in these places were actually just handicapped physically but not mentally–they had simply become too difficult for their families to care for (or their families had died). Many were what we now call “developmentally disabled.” Deinstitutionalization forced the states to come up with better alternatives.
This is not a federal issue. It is a local issue. There’s no federal fairy godmother that is going to fix this for cities and towns. And that’s a good thing because at the federal level and even at the state level, you get some bureaucrat who sees a captive population who cannot advocate for themselves, and you will see the quality of the facility, the food, and the staff degenerate. There’s an obvious reason for this, and that is economies-of-scale thinking. But what sounds cheaper in Washington is often unusable at the local level. And there’s nowhere for the staff to turn. Just answering machines in Washington.
I truly wish the America Psychiatric Association would become the advocates they can be and should be for mentally ill people. The nation needs to hear from them directly.
We need rehabilitation facilities all across the country.
Mentally ill people need what we all need: to belong somewhere. They need friendship more than anything else.
The test for nursing homes, rehabilitation facilities, and other housing situations should be to ask, “Would I want to live there?”
If this bill passes, every city and town in the country should immediately form a citizens’ committee whose sole purpose is to supervise the local facility.
Declaring someone mentally ill and taking away their agency thereby is a tool that is easily abused. We now have so many safeguards against that happening that the mentally ill are no longer safe.
There was also a movement against forced institutionalization under the guise of violation of civil rights of the mentally ill. Granted, many state institutions were cesspools, but the inmates were freed from the asylum with no place to go but the streets.
And of course people thought if you just gave medication to people who needed it, everything would be fine. The problem was that many didn’t stay on the meds for many reasons: disliking the side effects, lack of discipline to monitor meds, and other issues. Now they live in homeless camps.
All of the above is true. But first there must be a change in law to allow for involuntary commitment of those who are unable to care for themselves. We have lots of volunteer programs, including shelters, warming rooms, food, etc., in Eugene; but there are many, many on the streets who refuse to make use of them. I know, I’ve tried.