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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