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City Journal

April 30, 2002

Reprinted with permission. All rights reserved.

Failing the mentally ill: New York State's richly funded mental-health system needs fixing

By E. Fuller Torrey

The New York Times should be congratulated for its excellent series on mentally ill persons living in group homes in New York, which concludes today. It is stunning to realize the extent to which a civilized society has neglected its responsibilities toward its most vulnerable citizens. The failure of the New York State agencies charged with overseeing the group homes has reached a new low for state government.

It would be easy to say that the horrific living conditions and other problems the Times series describes are simply the result of a lack of funds. But in fact New York State annually spends more per capita ($112.57) on mental-health services than any other state—indeed, spends twice as much annually as the median per capita expenditure ($56.38) of the other 49 states. It is not a lack of funds but rather how the funds are spent that is the problem. Many states deliver better mental health services than New York while spending significantly less.

We know how to provide good care for individuals with severe psychiatric disorders. We know, for example, that private, nonprofit organizations such as New York City’s Fountain House deliver high-quality, cost-effective services. We know that continuity of caregivers is essential, as are Assertive Community Treatment teams—squads of mental-health professionals and paraprofessionals, associated with a hospital or a community mental-health center, that take responsibility for up to 120 severely mentally ill individuals round the clock. Above all, we know that there must be periodic, unannounced inspections of group homes, with prompt penalties, including closure of the home, for violations. Unfortunately, New York State ignores these key principles, condoning minimum wages and high job turnover in crucial care-giving roles and failing disastrously in its inspection duties. 

Much of the problem arises from New York State’s efforts over the last few decades to shift the fiscal burden of care for its mentally ill to the federal government, which today, through Medicaid and Medicare, pays for two-thirds of the cost of the nation’s mental-illness system, compared with an insignificant amount back in the early 1960s. As the feds picked up more and more of the tab, they also took responsibility for deciding which mental-health services deserve funding, and which don’t—a job that federal bureaucrats, many of whom have never met a mentally ill person, proved utterly incompetent to perform. The state, meanwhile, all but washed its hands of the mentally ill, deeming them a federal problem.

In a speech yesterday, President Bush put the mental health care reform issue on the national agenda. “Remarkable treatments exist, and that’s good,” he noted. “Yet many people—too many people—remain untreated.  Some end up addicted to drugs or alcohol.  Some end up on the streets, homeless.  Others end up in our jails, our prisons, our juvenile detention facilities.”  Bush promised to address what he called “our fragmented mental health service delivery system” through a new Commission on Mental Health. The challenges for such a Commission are enormous, but if it is successful, it could potentially be one of the president’s greatest accomplishments and a hallmark of his compassionate conservatism.

Whatever solution the new Commission devises will have to center on reform in the way the $40 billion in federal funds that now drive the mental-health system is spent. Block granting the money to the states and then holding the states responsible for the outcomes would put the accountability for the care of mentally ill individuals back squarely on the shoulders of state and local government—where it belongs, and where it was before Washington messed things up. Only then can we hope to fix the problems the New York Times describes.