Role of Federal Government’s Attempts
to Improve Services
for Individuals with Serious Mental
Illness
E. Fuller Torrey, MD
(Note: The following shows how various federal funding streams for mental "health" fail to reach people with mental "illness")
1963,
Community Mental Health Centers (CMHC) Act: The passage of
this legislation effectively shifted responsibility for funding public mental
illness services from the states to the federal government, thus reversing a
policy that had existed for more than a century. NIMH paid the new federal
funds directly to local Community Mental Health Centers, thus bypassing state
governments. Prior to 1963 states were held responsible for the quality of
those services; since 1963 nobody claims responsibility. The CMHC Act shifted
the main focus of treatment from the state mental hospitals to the new CMHCs,
but almost no planning took place regarding follow-up care for the seriously
mentally ill patients being discharged from the state hospitals. The 1963 CMHC
Act was the beginning of the increase of mentally ill persons becoming
homeless, incarcerated in jails and prisons, etc.
1965,
Institutions for Mental Diseases Medicaid exclusion: When Medicaid was enacted in 1965 the
federal government was afraid that states would use it to cover the costs of
mentally ill individuals in state mental hospitals so these hospitals were
excluded from Medicaid coverage. This was the Institutions for Mental Diseases
(IMD) exclusion. However, since Medicaid did cover these same patients if they
were hospitalized on the psychiatric ward of a general hospital or living in
nursing homes or group homes, the IMD exclusion created a major incentive for
states to empty the state hospitals, thus shifting most state costs to federal
Medicaid. States had, and still have little incentive to place patients in
appropriate community settings or to follow-up and insure that they receive
continuing care; the fiscal reward comes simply from emptying the state
hospitals. The IMD exclusion has been the single largest reason why
deinstitutionalization has failed so abysmally.
Reference: Geller, J.L. Excluding institutions
for mental disease from federal reimbursement for services: strategy or
tragedy? Psychiatric Services 2000; 51: 1397-1403.
1986,
Protection and Advocacy for Individuals with Mental Illness Act: Under Senator Lowell Weicker’s
sponsorship, this legislation set up a federal program to fund independent
state agencies to investigate allegations of abuse or neglect of mentally ill
or disabled persons residing in mental institutions. Widely referred to as the
Protection and Advocacy (P&A) program, it has been administered by the
Substance Abuse and Mental Health Services Administration (SAMHSA) under the
Department of Health and Human Services. As soon as the P&A program was
enacted it was taken over by civil rights ideologues who believed that no
mentally ill person, no matter how disabled or psychotic, should even be
involuntarily hospitalized or medicated. Thus P&A programs in many states
have assumed a function of protecting patients from treatment, rather than insuring that
they receive
appropriate treatment. The federal government has made no efforts to correct
this well-intentioned-program-gone-astray, and in fact SAMHSA has encouraged
it. The tragic consequences of the P&A program were highlighted by the Wall
Street Journal on August
16, 2008, describing how P&A workers in Maine insisted on the discharge of
a psychotic young man from the state hospital despite the objections of the
treating physicians and his family; he went home and killed his mother with an
axe. Others have described how P&A programs, in clear violation of the law,
“have engaged in federally prohibited lobby efforts and how they have tried to
defeat proposed legislation, some of which would actually benefit their
clients.”
Reference: Peters, AJ. Lawyers who break the
law: What Congress can do to prevent mental health patient advocates from
violating federal legislation. Oregon Law Review 2010; 89: 133-173.
1990,
American with Disabilities Act:
Another well-meaning federal program, the American with Disabilities Act (ADA)
was an attempt to prohibit discrimination based on disability, which was
officially defined as “a physical or mental impairment that substantially
limits a major life activity.” Thus under the ADA disabled people could not be
discriminated against, for example, in hiring, promotion or termination, and
employers were expected to make “reasonable accommodation” for disabled
employees. The consequences of the ADA have been exactly the opposite of what
was intended. Employers, fearful of endless litigation, simply stopped hiring
disabled workers. In recent years the ADA has also been used by the Department
of Justice to demand that state psychiatric hospitals discharge patients to
live in “the least restrictive alternative” in the community. For example, in
April 2011, the Department of Justice sued New Hampshire. In many cases moving
patients from a state hospital to a nursing home or a group home in a
crime-ridden neighborhood is just as or more restrictive as a state hospital,
but the former is regarded as more acceptable to the federal government because
the patients are “in the community.”
Reference: Olson, W. Under the ADA, we may all
be disabled. Wall Street Journal, May 17, 1999.
1996, Health
Insurance Portability and Accountability Act (HIPPA): This was an attempt to protect the
privacy of an individuals’ health information and medical records; people who
disclose such information without the consent of the individual involved can be
fined up to $25,000 per year. HIPPA is widely regarded as having markedly
reduced the information available to families as they attempt to get treatment
for seriously mentally ill family members. This was recently illustrated by the
New York Times Magazine
cover story about a man with bipolar disorder. Blatantly psychotic, the family
finally got him hospitalized but then was unable to get any information, even
that he was in the hospital to which they had had him admitted:
“It
took a week just to get the social worker assigned to his case on the phone.
Although I had been sitting right next to my father at PESS when he was told
where he would be transferred, privacy laws prohibited the nurses at the new
facility from even confirming, without his written consent, that he had been
admitted. I asked if someone could tell him we called and have him sign a
consent form so that we could speak with his doctor or social worker.
Yes,
I was told, he would be given a consent form — if he was there, which again
they would not confirm or deny.
Eventually
one nurse took pity and told us that he had indeed filled out the form but had
granted access only to Barack Obama and Duke Ellington.”
Such examples
are the rule under HIPPA, not the exception.
Reference: Interlandi, J. Love and commitment:
What it takes to put your father away in a mental hospital. New York Times
Magazine,
June 24, 2012, pp. 26-47.
Thus, almost
everything the federal government has attempted to do legislatively has made
the problems associated with serious mental illness worse rather than better.
And if anyone has any lingering doubts about the ability of the federal
government to improve matters, look closely at the federal agency whose
official mission is to reduce the “impact of substance abuse and mental illness
on America’s communities.” This is the Substance Abuse and Mental Health
Services Administration (SAMHSA), a $3.6 billion component of the Department of
Health and Human Services. It has 537 federal employees whose average salary is $107,760. Its current
three-year plan, a 41,804 word document entitled “Leading Change: A Plan for
SAMHSA’s Roles and Actions 2011-2014,” does not even mention schizophrenia or
bipolar disorder because, in fact, SAMHSA has no interest in serious mental
illnesses. What does
interest SAMHSA are producing free coloring books and sticker sets for
children, such as their “Mental Well-Being Sticker Sets,” and producing a
musical for SAMHSA staff to celebrate World AIDS Day (cost of musical:
$83,625). SAMHSA also gives away lots of money. It gives $70,000 a year to
organizations in California and Pennsylvania that have lobbied against
legislation making it easier to treat seriously mentally ill individuals. And
it gives $330,000 a year to an organization in Massachusetts whose director
claims that “the covert mission of the mental health system…is social control.”
Indeed, SAMHSA has been described as “a federal health agency distinguished by
the fact that the health of its clients would improve if it went out of
business.”
Reference: Torrey, EF. Bureaucratic insanity:
The federal agency that wastes money while undermining public health. National
Review,
June 20, 2011, pp. 25-26.
Conclusion: The track record of the federal
government in its attempts to improve services for individuals with serious
mental illnesses is a record of well-intentioned programs which have made the
problem worse, not better. Rarely in the history of American government have
programs conceived with such good intentions produced such bad results.
