Evidence is mounting that America’s community mental health system is just a passing phase. The system is under-designed for the task it faces, under-funded for the mission it is permitted to address, administratively fragile, locally corrupt, and too deeply connected with stigma to justify sustaining as anything other than a transitional phase in the evolution of American health care.
Under-designed. State asylums addressed both housing and health care for the populations they served. De-institutionalized system are treatment-only, and further limited because they only address the mental health component of a person’s overall health. Consequently, people with mental illness experience more homelessness and poorer overall health than other Americans, even those with other chronic health conditions.
Under-funded. Over time, managed care practices and funding decisions have resulted in a system where care is both rationed based on clinical need or other factors, and stretched out through technology. Insurance companies have focused almost exclusively on medication for outpatient care, rarely make psychotherapy available, and restrict access to family therapy and other more intensive treatments. In many areas of the country, patients wait for months to access psychotherapy delivered through a video system. This does not meet anyone's "best practice" standard.
Administratively fragile. Mental health providers are often fully-funded by Medicaid and other public dollars, and prepaid for services they contract to perform. Meanwhile, the people to be served are assigned to treatment agencies, denied the opportunity to choose their own provider. When regulators reclaim misspent funds, the result is service cutbacks that leave captive constituencies with zero recourse.
Locally corrupt. In many states, publicly-funded mental health services are no-bid contracts with no limits on executive compensation or administrative costs. This leaves new providers without opportunity to compete, as entrenched systems become self-reinforcing if not pay-to-play.
Deeply connected with stigma. In many places, mental health treatment providers continue to regard the people they serve as defective, perpetually dependent, discredited, and deserving of inherently coercive, degrading treatment approaches.
The bottom line: If what we have now is just a system of de-institutionalized asylums, we must redesign the whole thing.
Readers, what do you think? Is the community mental health system worth preserving, or should we just move on to something that's different and better? What do you think that might look like?
By the way, for some of my ideas on what it will take to fix mental health, start here.
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