Ben, thanks for this provocative piece. i agree that we need to find local ways that fit local challenges and that, in part, help to finance them. But I would not scorn centralized financing. The delivery of mental health services is built on the foundation of a built-in market failure. The people with need are the least likely to have the money to pay for it. It’s a perfect example of John Tudor Hart’s Inverse Care Law “the availability of good medical or social care tends to vary inversely with the need of the population served”. Note that it specifies population. While it applies to individuals, its primary application is populations. This means local areas with populations in high need are not likely to have the resources to address them. Turning to them to fund them simply won’t work.
There are two options to get money to places and people where there is none. One i want to dismiss quickly, though it is all the rage. That is the idea of making a market for private money by awarding profits for money invested that reduces the costs of other services- the whole idea of cost offset. This is a set up for gamesmanship and corruption. Of note, the bigger the private money investment, the more problematic this method of obtaining funding becomes.
The second method- centralized taxation with redistribution- is time tested. when there are adequate taxes and ethical redistribution this method actually works and works at scale. it is not perfect-as you note it can be hard to adjust it to local conditions or to take in new innovations. we need to continuously improve these aspects. but i don’t think we want to throw the baby out with the bath. “From each according to their capability, to each according to their need”.
or, following willy sutton, we might want to continue to seek the money we need where it is (at least for now), in the federal coffers.
Ken, as always, you force us to think more on an important issue. I couldn't agree more about the need to have basic protections in place, and second your caution on being too independent of centralized funding. Your comment should be its own post - thanks for all you've done to help champion mental health!
As someone who teaches mental health policy to graduate students in Ohio, where we have county mental health boards, I see some possibilities for middle ground with some of these ideas. There are folks who know the local landscape of MH needs and the dynamic changes in each region. Where I see trouble is the rural mental health service deserts with little infrastructure and very little private funding to tap into.
Anyway, thank you for this deep dive into some new ways to think about funding. I should invite you as a guest speaker.
Headed into a behavioral health job fair at my university but I look forward to reading this pub. Also, if you’re serious about being a guest expert for my class (I teach that course in the fall) I can message you to discuss.
Ben - thank you for your continued incisive thinking and writing. In this article you mentioned "top down" solutions. In my view that is what has led us where we are and keeps us stuck there. Albert Einstein (a close personal friend of mine ...) said "We cannot hope to solve our problems by using the same thinking we used to create the." I'd like to invite you and others to view the "bottom up" thinking that governs our solution at www.thirdrail.info, and to comment. Thank you.
ben, i in am process, i hope, of following you into world of writing about this wild world we are in. i am taking your comment on my comment as encouragement!!!
Ben, in addition to your statements, we need a place for those who are SMI: Seriously Mentally ill. These folks will need care for the rest of their lives. They currently fill the jails and live in tents along the streets. I would include the chronically addicted in this category.
Ben, thanks for these thoughts. Of course there is some truth in them. local conditions can vary so solutions will need to vary with them. unfortunately that does not imply that funding will need to be local. the reason is is that the provision of mental health services is by definition a market failure. those folks with the most need have the least ability to pay. it’s an example of john tutor hart’s “inverse care law”-those folks with greatest need are least likely to have access to services. what goes for individual persons goes for communities, regions countries, continents. the more the need, the less the ability to pay.
the only possible solution is some method of securing funds from people and places with less need and more resources. some form of centralization of funds and then equitable distribution. it’s been said before. from each according to their capacity, to each according to their need. we can try to get blood from a stone. but it’s easier to follow willy loman and go to the banks, where the money is.
Ben, thanks for this provocative piece. i agree that we need to find local ways that fit local challenges and that, in part, help to finance them. But I would not scorn centralized financing. The delivery of mental health services is built on the foundation of a built-in market failure. The people with need are the least likely to have the money to pay for it. It’s a perfect example of John Tudor Hart’s Inverse Care Law “the availability of good medical or social care tends to vary inversely with the need of the population served”. Note that it specifies population. While it applies to individuals, its primary application is populations. This means local areas with populations in high need are not likely to have the resources to address them. Turning to them to fund them simply won’t work.
There are two options to get money to places and people where there is none. One i want to dismiss quickly, though it is all the rage. That is the idea of making a market for private money by awarding profits for money invested that reduces the costs of other services- the whole idea of cost offset. This is a set up for gamesmanship and corruption. Of note, the bigger the private money investment, the more problematic this method of obtaining funding becomes.
The second method- centralized taxation with redistribution- is time tested. when there are adequate taxes and ethical redistribution this method actually works and works at scale. it is not perfect-as you note it can be hard to adjust it to local conditions or to take in new innovations. we need to continuously improve these aspects. but i don’t think we want to throw the baby out with the bath. “From each according to their capability, to each according to their need”.
or, following willy sutton, we might want to continue to seek the money we need where it is (at least for now), in the federal coffers.
ken
Ken, as always, you force us to think more on an important issue. I couldn't agree more about the need to have basic protections in place, and second your caution on being too independent of centralized funding. Your comment should be its own post - thanks for all you've done to help champion mental health!
As someone who teaches mental health policy to graduate students in Ohio, where we have county mental health boards, I see some possibilities for middle ground with some of these ideas. There are folks who know the local landscape of MH needs and the dynamic changes in each region. Where I see trouble is the rural mental health service deserts with little infrastructure and very little private funding to tap into.
Anyway, thank you for this deep dive into some new ways to think about funding. I should invite you as a guest speaker.
Totally agree on the challenges around rural! That's where we have to get even more radical and begin to reimagine "care" and "delivery." While a bit biased, it's where I see models like this coming in to play: https://www.sciencedirect.com/science/article/abs/pii/S2212144722001211
And always happy to talk policy with the next generation of leaders!
Headed into a behavioral health job fair at my university but I look forward to reading this pub. Also, if you’re serious about being a guest expert for my class (I teach that course in the fall) I can message you to discuss.
Ben - thank you for your continued incisive thinking and writing. In this article you mentioned "top down" solutions. In my view that is what has led us where we are and keeps us stuck there. Albert Einstein (a close personal friend of mine ...) said "We cannot hope to solve our problems by using the same thinking we used to create the." I'd like to invite you and others to view the "bottom up" thinking that governs our solution at www.thirdrail.info, and to comment. Thank you.
Ben, my new book--HAS MEDICINE LOST ITS MIND?--is out. If you'd like a copy, please send me your mailing address to my email: smithrr@msu.edu
ben, i in am process, i hope, of following you into world of writing about this wild world we are in. i am taking your comment on my comment as encouragement!!!
Ben, in addition to your statements, we need a place for those who are SMI: Seriously Mentally ill. These folks will need care for the rest of their lives. They currently fill the jails and live in tents along the streets. I would include the chronically addicted in this category.
Ben, thanks for these thoughts. Of course there is some truth in them. local conditions can vary so solutions will need to vary with them. unfortunately that does not imply that funding will need to be local. the reason is is that the provision of mental health services is by definition a market failure. those folks with the most need have the least ability to pay. it’s an example of john tutor hart’s “inverse care law”-those folks with greatest need are least likely to have access to services. what goes for individual persons goes for communities, regions countries, continents. the more the need, the less the ability to pay.
the only possible solution is some method of securing funds from people and places with less need and more resources. some form of centralization of funds and then equitable distribution. it’s been said before. from each according to their capacity, to each according to their need. we can try to get blood from a stone. but it’s easier to follow willy loman and go to the banks, where the money is.