More beds, more problems?
A renewed push to invest in the right solutions
In 1963 when President John F. Kennedy signed one of the most consequential pieces of legislation for mental health, the intent was to shift treatment of mental health and substance use disorders from the psychiatric hospitals, where people often languished, to community-based settings where the evidence was more suggestive they would improve in their treatment. As I have written about here extensively, this law was the right idea - get people what they need in the places they need it most. The problem was that due to politics and implementation tactics, community-based supports never really had a chance to become all that they could have been.
Throughout history there are so many examples where we underinvest in things we know to work. Look at public health. There’s no doubt that having a robust and properly funded infrastructure for public health will lead to more lives saved, fewer people sick, and better population health. But the problem with public health, is that because there’s such an emphasis on actually preventing people from getting sick, we can’t “see” our investments like we can other health related services. Policy makers and the public alike have been guilty of looking past all that public health helps prevent and assume its over funded or the funds it has been allocated can be cut as surely they don’t need all that money.
The problem with this approach is that we create a paradigm of never giving the public health system enough resources to have capacity to manage any current or future crisis. In fact, this mentality is so strong that public health infrastructure has been chronically underinvested in for decades. My friends over at Trust for America’s Health have pointed this out over and over. Consider how in 2020, our nation allocated a total of $4.1 trillion towards health care; however, a mere 5.4 percent of this expenditure was directed towards public health and prevention. They point to the historical trend of allocating substantial funds to public health only during emergencies, only to neglect it during other times.
Sound familiar yet?
There’s so many problems with this logic of only funding services during a crisis. Yes, I am looking at you COVID-19. Sure, we needed more resources in public health during the pandemic, but that set a precedent that’s hard to change where we only put the resources there in a crisis. I think it’s safe to say, but if patterns like this persist, the consequences of inadequate funding public health are far-reaching, meaning that highly effective public health initiatives targeting issues such as suicide prevention, obesity, and environmental health hazards can only reach a limited number of people, communities, and states. And to point out an obvious trend, we alarmingly had high rates of chronic disease and ongoing health disparities to begin with that are simply not going to get better without the right size long term funding.
Back to mental health, though I think you can already see where I am going.
In 1965 when Congress created Medicare and Medicaid, there were key considerations taken in the law to help the previous legislation passed in 1963 for community mental health centers. For example, in the Medicaid Act, there was an exclusion of federal financial reimbursement for mental health and SUD inpatient facilities, which were called Institutions for Mental Diseases, or “IMDs.” These “ IMDs” were facilities who had more than sixteen beds, and treated people under age 65 (the age for Medicare eligibility). The language clearly defines an IMD as “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.”
Most people see this exclusion as preventing many individuals from accessing necessary mental health and substance abuse services, leading to inadequate treatment options and potential gaps in care. As a colleague and I wrote for Health Affairs, “The intent behind including this policy in Medicaid law was to help encourage states to move people with mental health and addiction needs from the hospital to the community, building upon federal dollars to support this shift. Mental health care had historically been under the jurisdiction of the states, and in establishing the Medicaid program, the federal government was concerned that states would shift their spending from state funds to federal dollars.” I wont rehash the whole article here, but it’s worth a read.
In one study looking at the impact of potential IMD repeal, researchers found that “providing access to IMD services may not be able to address the numerous reasons other than inpatient bed searches that contribute to long stays of psychiatric patients in EDs. Given the high cost of inpatient care relative to community-based care and major shortages in the availability of community-based care and psychiatric ED services across the country, future initiatives may wish to balance consideration of potential increases in funding for IMD and general hospital inpatient services within the context of a more comprehensive approach that considers distribution of new resources across all aspects of the system (inpatient, emergency, and ambulatory care).”
I’ve been in the mental health field a while now. There are very few issues as divisive as this one, and for good reason. The need to have more help for our friends is so profound that we will look for any and all answers that give us a solution. It feels personal to have a policy that limits things like IMD right in front of us and not do something about it.
Turns out, something has been done about it, but few people are aware of it. Under both the Obama and Trump administrations, states were given the chance to expand inpatient care through their Medicaid programs and receive federal funds for this care. In short, it became a new way to use policy to address the issue of the IMD exclusion. While some argue that a full repeal solves many problems, there are concerns about potential challenges in managing increased costs and ensuring the quality of care, which as we know from the mental health field, remains lacking. Plus, there’s not a stellar track record of psychiatric hospitals and mental health outcomes. It’s worth mentioning that the effectiveness of psychiatric hospitals varies greatly depending on various factors, such as the specific condition being treated, the quality of care provided, and the individual's response to treatment. Additionally, the length of stay in a psychiatric hospital must be be carefully examined, as prolonged hospitalization is not always the most effective or appropriate approach for long-term recovery and community reintegration. But the biggest point here? There’s a risk of shifting resources away from community-based and outpatient services, which we already knew were underfunded and played a crucial role in providing comprehensive and long-term care for individuals with mental health and substance abuse needs.
There is no doubt that we need more avenues for care, both inpatient and outpatient. However, our decisions need to be ground in several factors, including the evidence, the communities desire, and outcomes. This is not a simple issue. If it were, just expanding hospital beds would solve all our problems, but reality, it likely will solve very few problems for most communities. We know that many who can’t get beds are placed in the emergency department for prolong and inexcusable periods of time, or in too many cases, jails and prisons. Addressing the IMD exclusion isn’t going to come close to touching this problem no matter how much we think it will. It’s the equivalent of only funding public health during an emergency and ignoring it the rest of the time. We can’t afford to only look at our downstream services as our solution for the crisis we are facing.
When I read articles about a new 144 bed psychiatric hospital in Colorado, I can’t help but think about how expensive this is going to be, what impact this will actually have on improving mental health outcomes, and what would happen if we actually used some of those resources in our community based solutions. No, I am not simply referencing community mental health centers, which most people think about in this case, I am referring to an actual community infrastructure that works to prevent, identify, and help all those who need it, wherever they need it. You see, when you look back to seminal dates like 1963 or 1965, you see an intent to do more in our communities. The difference between now and then? We know a whole lot more about what works and what doesn’t and can be targeted with our investments.
Did you know that Italy hasn’t had a mental health hospital since 1978? Over the past four decades, Italy has transitioned from psychiatric hospitals to a community-based system of mental health care. There’s amazing places to look at in Italy, including the Trieste model, which goes back to the 1960s and is recognized by the World Health Organization and seen by many as as one of the most advanced, community-based mental health care systems in the world.
In reflecting on the historical context and current challenges surrounding mental health and comparing it a bit to public health funding, it becomes evident that underinvestment in effective community-based solutions has hindered progress in improving access to care and achieving better outcomes at quality. While the intention behind policies such as the IMD exclusion and the emphasis on crisis-driven funding may seem logical, it fails to address the underlying systemic issues that have plagued us for decades. Instead, a comprehensive approach is needed, encompassing evidence-based practices, robust community infrastructure, and equitable allocation of resources into the places it can have the biggest impact. By prioritizing prevention, early intervention, and a full continuum of care, we can build a stronger foundation for mental health support and tackle broader health disparities within our society. It is time to learn from past mistakes, leverage our knowledge, and invest wisely to create a truly effective and inclusive mental health system.