In its latest Letter, the Health Group for Research and Training in Mental Health (GCS) interviews Kenneth Thompson, medical director of Pennsylvania Psychiatric Leadership Council, former medical director of Center for Mental Health Services, Substance Abuse and Mental Health Services Administration,US Department of Health and Human Services (2007-2010). Extract.
Can you tell us about the state of the mental health care system in the United States?
“The United States of America has 50 states and some territories. Historically, each state and territory has controlled the operation of its mental health services, with significant differences between them and, initially, no federal government intervention. During the 20th century, community mental health developed alongside a movement toward deinstitutionalization. After World War II, the federal government began to get involved, first in research, then in the coordination of services. The Community Mental Health Act, signed under President JF Kennedy, created a national network of public community mental health centers. This network continued to develop until the presidency of R. Reagan, who practically stopped funding it. At the same time, private psychiatric services developed with the establishment of the health insurance system. Most people are insured by their employer. If they are self-employed, they must pay for their own insurance, and if their income is insufficient, they may receive public assistance. The latter, a federal program created in 1965 called Medicaid, covers about 20% of the population. Medicaid is a joint federal and state program, funded by both federal and state funds. Medicaid now funds most community mental health centers, which are used primarily by people with few or no resources. Community mental health is therefore primarily the responsibility of the public sector. We also have Medicare, a health insurance plan for people over 65 (funded by them during their working lives) and for people with disabilities who have been able to work. For people with permanent disabilities who cannot work, pay into Medicare and Social Security, we have Supplemental Security Income (SSI). These individuals may also qualify for Medicaid. The establishment of Medicare and Medicaid in the 1960s allowed states to close or reduce the number of public psychiatric hospitals and shift their costs to the federal budget, which states did especially since public hospitals represented the most expensive budget item. Deinstitutionalization was also made possible because people with psychiatric disorders became eligible for SSI and could pay their own rent and buy food. In 2010, Obama passed the Affordable Care Act, which increased the number of people eligible for Medicaid and increased the share of federal funding from 50% to 90%. Donald Trump’s first presidency slowed federal funding, but Joe Biden, with the Covid-19 crisis, significantly increased mental health funding again. In some states, policies focused on the determinants of mental health have even begun to develop through Medicaid (e.g., on nutrition). Where I live in Pittsburgh, this has led to the creation of different types of reception and care facilities, such as crisis houses, personal care homes (accommodating 6-12 people with professionals on site). We also have seven community mental health centers, which promote connections to primary care and addiction services. »
And since the re-election of Donald Trump?
“Donald Trump has appointed a group of advisers and politicians who propagate the idea that many people with mental illness are dangerous and should be removed from society, confined and subjected to coercive measures. In other words, reinstitutionalization. These ideas have always existed, but today they are shared by the majority of people who run the federal administration. As in other countries, there is a dangerous confusion between mental illness, substance abuse, homelessness, transgender identity, immigration, insecurity and crime. Issues of social class and skin color obviously play a major role: people of color, indigenous populations and Latinos are overexposed to social exclusion, xenophobia and stigma, which harms their mental health. D. Trump also significantly reduced funding for federal agencies responsible for coordinating policies across the country. The administration also announced plans to cut Medicaid funding by $1 trillion over the next ten years, which will of course have a major impact on those most in need. The current policy towards “illegal immigrants” (which I prefer to call undocumented migrants) is extremely worrying: detention centers and even murders of protesting American citizens are strongly reminiscent of a fascist state. This reign of terror is not without consequences on the mental health of the entire population. In short, while recent history of the Biden era inspired hope, stress and fear now dominate…”
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