Or is "compassionate conservatism" the same old thing, just repackaged, promoted, and implemented by Republicans, which is what this looks like?
I'm several vollies behind here, I see, so let me skip ahead. ;)
The truly "conservative" solution would be to abolish Federal welfare altogether, and return the responsibility to the States for the mentally ill. That isn't going to happen, not now and possibly not ever. So you do what you can get done - get the aid directly to the recipient and cut out the middlemen in the "do gooder" industry that adds cost without adding benefit.
The problem really is a structural one. I found the website below that gives a pretty good historical overview. The states aren't going to burden themselves again with the costs of state hospitals. The genie is out of the bottle. It's either in the Fed's laps, or the patients are on the streets.
The website also has a bit on the assisted outpatient treatment I mentioned in my last post.
psychlaws.org
Prior to the 1960s, when federal funds for psychiatric care became available, the public psychiatric care system was almost completely run by the states, often in partnership with local counties or cities. Since then, the public psychiatric care system has become a hodgepodge of categorical programs funded by myriad federal, state, and local sources. The primary question that drives the system is not "what does the patient need?" but rather "what will federal programs pay for?"
Deinstitutionalization A Rocky Road To Nowhere
Deinstitutionalization, the name given to the policy of moving people with serious brain disorders out of large state institutions and then permanently closing part or all of those institutions, has been a major contributing factor to increased homelessness, incarceration and acts of violence.
Beginning in 1955 with the widespread introduction of the first, effective antipsychotic medication chlorpromazine, or Thorazine, the stage was set for moving patients out of hospital settings. The pace of deinstitutionalization accelerated significantly following the enactment of Medicaid and Medicare a decade later. While in state hospitals, patients were the fiscal responsibility of the states, but by discharging them, the states effectively shifted the majority of that responsibility to the federal government.
In 1965, the federal government specifically excluded Medicaid payments for patients in state psychiatric hospitals and other "institutions for the treatment of mental diseases," or IMDs, to accomplish two goals: 1) to foster deinstitutionalization; and 2) to shift the costs back to the states which were viewed by the federal government as traditionally responsible for such care. States proceeded to transfer massive numbers of patients from state hospitals to nursing homes and the community where Medicaid reimbursement was available. (Note: IMDs were defined by the federal government as "institutions or residences in which more than 16 individuals reside, at least half of who have a primary psychiatric diagnosis.")
Since 1960, more than 90 percent of state psychiatric hospital beds have been eliminated. In 1955, there were 559,000 individuals with serious brain disorders in state psychiatric hospitals. Today, there are less than 70,000. Based on the nation’s population increase between 1955 and 1996 from 166 million to 265 million, if there were the same number of patients per capita in the hospitals today as there were in 1955, their total number today would be 893,000.
The pace of psychiatric hospital closures has accelerated. In the 1990’s, 44 state psychiatric hospitals closed their doors, more closings than in the previous two decades combined. Nearly half of state psychiatric hospital beds closed between 1990 and 2000.
Because of incentives created by federal programs, hundreds of thousands of patients who technically have been deinstitutionalized have in reality been transinstitutionalized to nursing homes and other similar institutions where federal funds pay most of the costs. These alternative institutions, however, lack the full range of services needed to adequately care for persons with severe brain disorders.
Psychiatric Patients Dumped into Nursing Homes and General Hospitals
As state psychiatric hospitals improved in quality in the 1970s and 1980s, it became increasingly common to discharge patients from relatively good hospitals with active rehabilitation programs and transinstitutionalize them to nursing homes, general hospitals or similar institutions with markedly inferior psychiatric care and no rehabilitation at all. States save state funds, but transinstitutionalized patients pay a substantial price for the substandard care.
By the mid-1980s 23 percent of nursing home residents, or 348,313 out of 1,491,400 residents, had a mental disorder.
Costs in general hospitals are often $200 per day or more than the costs in public psychiatric hospitals. These additional costs are of little consequence to the states since federal Medicaid dollars are paying the majority of the bill; the states’ costs are lower and that is the limit of their concern. Unfortunately, evidence shows that general hospitals admit psychiatric patients with less severe illnesses, but turn away those who are more seriously ill. Inpatient stays for people with serious brain disorders are typically shorter in general hospitals, which compromises the person’s ability to stabilize on medication. |
