State-led mental health reform has already failed. But 2022 is different.


The coronavirus pandemic has exposed the many overlapping mental health crises that have been simmering beneath the surface in America for years. Drug and alcohol use has skyrocketed since 2020 and suicide rates are on the rise, especially among young people. Therapists have waiting lists and access to services is delayed. Even the rollout of the new national crisis line, 988, could be hampered in several states because they simply don’t have the resources or trained personnel available to handle all the calls.

President Biden has advocated for mental health reform, but historically presidents have struggled to build the political will to pass meaningful legislation.

And yet, this time, the political will – despite all the volatility – seems more determined to rise to the challenge. It’s not just that mental health conversations are emerging from hushed silos. There also appears to be political support across party lines for local community funding. Along with the strong engagement of activists with lived experience of recovery and families dealing with mental health issues, there is a rising tide insisting that mental health is fundamental, not adjacent, to health. overall.

President John F. Kennedy was the first president to push for legislation to guarantee mental health treatment. In the early 1960s, drug addiction, depression, suicide, and other mental health crises were not openly discussed. About 550,000 American adults and children lived in 279 state institutions, most of which were overcrowded with fires and health hazards. Many patients had become “warehoused” and were presumed to be lifelong residents who could not get better.

The Kennedy family, for all its wealth and influence, was not immune to these challenges. Ever present in the president’s life was a quiet but pervasive sadness about his sister Rosemary, who had been placed in an institution after a lobotomy. His ambitions for people like her – and the lives they could lead if given the chance – led him to take this subject seriously. He made it his personal mission to change the way people with a diagnosis were treated.

Influenced by Robert Felix, a physician and former president of the American Psychiatric Association who ran the National Institute of Mental Health, Kennedy addressed both houses of Congress in 1963 to urge action on health mental. He explained how public hospitals across the country routinely left patients at the “mercy of solitary confinement” where they “wasted away”. It was a stain and a disgrace on the nation, he argued, and he considered the failure of institutionalization among the nation’s “most pressing problems”.

On October 31, 1963, he signed the Community Mental Health Act (CMHA) which provided for the construction of 1,600 community service centers across the United States. His assassination three weeks later, however, changed everything. The escalation of the Vietnam War by his successor, Lyndon B. Johnson, stripped funding of all of his domestic policy priorities, including the ACSM system. CMHA’s funding has decreased and national priorities have changed. Barely a third of the planned 1,600 community centers have been built.

Jimmy Carter was the next president to make mental health reform a priority. He too had a family experience that inspired him to take action. Her cousin Tommy went back and forth to the public hospital in Milledgeville, Georgia, for years. But it was Carter’s wife, Rosalynn, whose interest and influence led to this accusation. Although nepotism laws prevented her from formally chairing the President’s Commission on Mental Health, she played a key role in guiding congressional hearings and mustering public and political influence to pass the Mental Health Act of 1980. mental health systems.

The law called for a federal-state partnership to develop models of care and minimize the need for involuntary institutional confinement. At a time when there seemed to be no accountability for the thousands of patients that public hospitals had already discharged with little attention to their follow-up, the new law offered a national plan to fund a system that could improve lives.

Although the MHSA enjoyed near unanimous support in both the House (277 to 15) and the Senate (97 to 3), the election of Ronald Reagan as President brought an abrupt end to this unique opportunity. As he had when he was governor of California, Reagan opposed the use of public funds to help people with disabilities, including mental illness. He cut the $500 million budgeted to implement his predecessor’s sweeping reforms and removed the federal government from direct spending on services. Instead, the Omnibus Budget Reconciliation Act of 1981 provided global funds to states, merging research and services for mental health and addictions with those for black lung disease, rodent control, blood pressure reduction programs and lead reduction – anything but guaranteeing mental health would be neglected.

But despite these budget cuts, things began to change over the next two decades as the medical, psychological and political fields began to think differently about mental health and increasingly saw the essential and holistic relationship between our health mental health and our overall health. This sea change was confirmed with the publication in 1999 of the Surgeon General’s report on mental health which showed that people diagnosed with mental health problems could recover and that such a diagnosis did not necessarily have to be a life sentence. This report coincided with the 1999 Supreme Court decision Olmstead v. LC decision, an assertion of the Americans With Disabilities Act, which decreed that people with a diagnosis of “mental illness” or other disability should not remain institutionalized when they could live in the community.

President George W. Bush continued these achievements when he championed the implementation of the Olmstead decision. His commission, the President’s New Freedom Commission, wanted to lay the groundwork in 2002 to help people with disabilities live, work, learn and participate fully in their communities.

Bush’s ideals were ambitious but never fully realized. Despite the articulation of admirable goals and principles – for the first time by a Republican president who had openly acknowledged his own recovery from alcohol abuse – change happened gradually. Obstacles had been built into a system that remained fragmented, scarred by financial and racial disparities and unaccountable to stimulus principles. These have made the ultimate goal of transformation difficult to achieve.

Now, 20 years later, the pandemic has revealed that essential services are still lacking. Yet, significantly, the public is discussing more openly the imperative of mental health treatment. The problem is pervasive, for example, as seen in the advertising for new drugs shown on evening television. Elements of previous change plans have been widely accepted and generated the political will to fund Biden’s 2021 stimulus plan proposals, the US Bailout Plan (ARP).

ARP has allocated $4 billion to improve mental health treatment and services, expands access to care, and helps states plan for community crisis services through their Medicaid offices. Funding programs subscribe to the new Substance Abuse and Mental Health Services Agency (SAMHSA) Suicide and Behavioral Health Hotline, 988. health recovery) adding 277 of these positions. And the ARP is budgeting $300 million for youth mental health services in schools, which is key to identifying the first opportunity to help someone in trouble.

No one can yet declare whether the measure has been a success, but the implementation of the ARP, which is now underway in various agencies, would dictate the objectives and even some of the programs that Kennedy, Carter and Bush had long considered. Unlike years ago when mental health was seen as adjacent rather than essential to overall health, mental health is now understood to be mainstream health care and we can use the infrastructure to achieve to a fair, accessible and comprehensive approach without delay.

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