September 2, 2016; Boston Globe
With the enactment of Medicaid in 1965, states were strongly encouraged to move mentally ill individuals out of state mental institutions and either back into the community or into nursing homes. This was due in part to ethical reasons: Around that time, it was becoming clear that institutions were not treating patients humanely. There was monetary encouragement as well, since both community options and nursing home placement are reimbursable services and institutions are not. Further, the U.S. Supreme Court ruled in 1975 that persons with mental illness could not be institutionalized if it could be demonstrated they did not pose a danger to themselves or others and could live in society, either independently or with the support of friends and family.
In many cases, deinstitutionalization helped individuals who could function in the community be reunited with family and become contributing members of society. Unfortunately the severely mentally ill were left in a worse-off situation as these individuals and their families, if they had any, had to figure out how to navigate a fragmented health system with little support. People whose ability to be successful in society is dependent on adherence to regular medication are especially vulnerable. Often, these individuals ended up making frequent emergency room trips or becoming incarcerated. This is particularly true in states that were ill prepared for deinstitutionalization and did not have readily available community based mental health services.
Although Massachusetts was once a leader in mental health care, over the last five decades numerous administrations have cut funding for services, leading to a steady decline in services available for mentally ill individuals. Recently, the closure of many mental health practices in Massachusetts has left thousands without access to treatment, endangering the patients as well as the public. The Boston Globe Spotlight team reports that about one third of the mental health providers in Massachusetts closed their doors between 2013 and 2015, with that pattern continuing into the current year. With reimbursement rates so low that providers lose money on each client, it’s no wonder that practices cannot stay afloat.
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Further, according to a Kaiser Family Foundation study, Massachusetts spends less per capita on mental health care than other states of comparable means. Over the last twenty years, the state has cut spending on in-patient mental health services by half, but outpatient funding remained stagnant.
While the state cut funding for mental health programs to close its budget, it is the public who has paid the ultimate price. The Spotlight team uncovered multiple stories of severely mentally ill individuals falling through cracks in the system and hurting either themselves or others. While the vast majority of individuals with mental health issues will never become violent, the few that have that potential need treatment and close monitoring—neither of which is guaranteed with Massachusetts’ fragmented system.
After five decades of a system that has failed patients, their families, and the public at large, Massachusetts must start fixing this broken system. Barbara Rhuda of the Massachusetts branch of the National Alliance on Mental Illness perhaps explained it best: “The state did not want to put the kind of money in that needed to be done to make a viable system. I think it’s come back to kick them all in the you-know-what.”—Sheela Nimishakavi