For the past two and a half years, I’ve reported from across the country on the multiple, slow-burning financial disasters unfolding in low-income communities. One of the most common issues I’ve encountered, whether I’m speaking with moms in Kentucky or ex-offenders in Baltimore, is people living with untreated mental health problems. They live in states of constant stress—they can’t feed their children, they can’t repair broken cars and trudge to low-wage jobs on inadequate public transportation—and circumstances can push them over the edge.
America is depressed, anxious, panicked, and sometimes addicted, and we’re not getting help. We live in a society that tries to ignore the problems caused by or leading to poverty.
The Affordable Care Act gave many low-income Americans mental health coverage for the first time, but that program is struggling, according to a long, worthwhile article in The New York Times last week. To begin with, only half the states have expanded Medicaid, the health insurance program for the poor, which leaves those who live in the other half without help. More challenging, the mental health care providers willing to take Medicaid have to wait a long time to be approved and to receive payment—and those payments are already lower than those of private insurance companies. As a result, only 40 percent of mental health care providers accept Medicaid, so even in states with the Medicaid expansion, recipients are squeezing in too few appointments with the too few providers who will see them.
All of this stems from thirty years of neglect of the mental health care infrastructure in the United States, led by the gleeful government cutter President Ronald Reagan. (Indeed, if you ever wonder when a government program that once enjoyed widespread, bipartisan support started to fail, look to his tenure.)
The problems started when we needed to replace the institutions once known as insane asylums. These asylums weren’t just reserved for those who met a strict, medical definition of severe mental illness. They were a depository for groups marginalized by society, and so their makeup changed over the years—women, the elderly, black men—depending on how illnesses were defined and whom we decided to treat.
Most of these institutions were inhumane, and advocates had been writing for more than 100 years urging for their closure. In the 1960s, serious and popular books—like Erving Goffman’s Asylum and Ken Kesey’s One Flew Over the Cuckoo’s Nest— launched a move to finally deinstitutionalize patients. When Medicaid was signed into law, in 1965, it didn’t cover mental health institutions. The plan was for those with problems to be treated in their communities through a federally supported system of providers. It was never fully funded.
When Reagan got into office, he made matters worse by giving the little money set aside to treat mental illness to the states in block grants. The block grant system left the federal government with only a minor role in shaping the system and decreased funding for mental health care by 30 percent. By 1985, only 11 percent of the budgets for the mental health care system came directly from the federal government. Predictably, state funding for mental health services is sacrificed during downturns, like the Recession we just experienced. Private providers are expensive, and they aren’t evenly distributed around the country. Nearly 90 million Americans live in an area where there are too few providers to meet community needs.
We know what happens to people with severe mental illness who can’t get help. They wind up on the streets or in jail, environments that will exacerbate their problems. A report released in April showed that there are ten times more people with serious mental health illnesses in jail than in state hospitals. That means they’re in a different type of institution, one that’s even less humane and more poorly designed to provide treatment than the asylums we stopped tolerating fifty years ago. An investigation in July by The New York Times found that mentally ill inmates at Riker’s Island were routinely mistreated and severely beaten.
The real shame is that mental illness isn’t a static state. Healthy people facing impossible circumstances can reach a point at which they need professional help. Likewise, with proper treatment, someone with a more severe problem can live a healthy life. We don’t have a system, however, that reaches people before disaster strikes. It’s a situation that calls for more attention, and more government funding, than a health insurance expansion alone will provide.
