All mental health needs budget support

All mental health needs budget support
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The White House’s recent 2021 budget released from the Office of Management and Budget includes easing the decades-long Institutions for Mental Disease Exclusion for Medicaid payments. 

On the surface, this seems a good step. 

But when it comes to health care, the partisan discourse and absolute convictions by politicians of what is right and what is wrong about providing equitable and just care are simply not an either-or. 


Understanding the impact of any health care bill — including those for the most vulnerable — requires digging a bit deeper. 

As an occupational therapist for over 35 years I routinely witness how health care legislation impacts options to offer a client. Legislative consequences surface in the form of caps on allowable home therapy visits and a prohibitive waitlist for home services. These often govern discharge recommendations to an institution such as a Medicaid nursing home, versus a return to the client’s home. 

Enacted in 1965 as part of Medicaid, the mental disease exclusion prevents states from receiving Medicaid funds for mentally ill adults ages 21-64 in residential, large state psychiatric hospitals (larger than 16 beds). It does not prohibit Medicaid payments for inpatient hospital services or residential services in a mental health facility for up to 15 days in a month. 

This level of care is important, as 50 percent of Americans will be diagnosed with a mental disorder at some point in their lifetime. In 2018 approximately 47.6 million adults experienced mental illness. This means every person in this country likely has a family member or friend with mental illness.

The new 2021 budget calls for easing the exclusion to allow longer stays in inpatient mental health facilities to Medicaid beneficiaries with serious mental illness such as bipolar disorder, schizophrenia, and post-traumatic stress disorder. This is part of a comprehensive strategy that includes improvements to community-based treatment. 

It is critical for policymakers to ensure all components of this comprehensive strategy aim toward achieving health and wellness for clients to live in the community setting of their choice. 


Both inpatient and comprehensive outpatient care provide important functions in the continuum of care for individuals with mental illness. Advocates for the community of individuals with mental health challenges may fear a return to a time when prolonged institutionalization and a loss of citizenship was the norm and only alternative. 

Prior to 1965 individuals with mental illness would be admitted — often involuntarily — to IMD facilities and many remained there for the entirety of their life. 

Advocates of the current proposal claim closures of long-term residential facilities resulting from partisan policy changes have significantly contributed to increases in the homeless population and numbers of prison inmates with mental illness. 

Failed implementation of a comprehensive strategy for a streamlined approach from inpatient to community care is likely the greater contributor to this outcome. However, some proponents of building new institutions place little blame on the fragmentation and limited access to community mental health services. 

Certainly, if the intent of easing the policy is to expand funds to a mandated comprehensive approach to support community-living, this would likely strengthen mental health care in the country.

However, state practices often fail to comply with civil rights legislation that requires an effective working plan to adequately support the transition and maintenance services needed by individuals with mental health concerns to safely live in the community. 

The decades of work in moving individuals with mental illness out of the large institutions are part of this process. This type of plan also requires states and the federal government to increase the budget for community-based services. 

Since 1997, state-run psychiatric hospitals have reduced their numbers from 254 to 195 nationwide. Based on the original plan, community-based behavioral health centers need to be readably available. 

Yet, many mental health and substance use disorder care facilities are closing and the void left behind contributes to leading causes of disease burden in the U.S. The mortality rate for mental health and substance use disorders is higher here than in any other country. 

Statistics from 2015 show that just over 41,600 individuals on any single day are in state psychiatric facilities. The cost of this care varies significantly depending on individual patient needs. 

Non-institutionalized spending on mental illness amounts to $89 billion per year. While this seems staggering, spending has grown slowly compared to other diseases, at an annual rate of 3.1 percent from 2000 to 2012. Across other disease categories during the same time period, the average is 4.4 percent. 

To provide a different visual, in 1964 there were over 1,600 community-based outpatient clinics for clients with mental illness, in 2015, there were 1,375.     

Changing the structure of mental health care requires a dedicated commitment to strengthening and developing community-based long-term services and supports such as outpatient services, case management, medication management, supportive housing and homemaker services, as well as supported employment. 

But this does not appear to be part of the recommendations included in the 2021 budget. The 2021 budget includes drastic cuts to many of these services including cuts to housing benefits, cuts to food stamps, eliminating funding for Community Services Block Grants, and reduced support and services to individuals who are homeless, including the large community of homeless with mental illness. 

The disconnect between the different parts of the budget appears to ignore or be insensitive to the systemic problems impacting our countries citizens with mental illness. 

Instead, the language and the allotments appear to place the blame squarely on the person with mental illness.

When you compare recent statements by President Donald TrumpDonald TrumpSenators introduce bipartisan infrastructure bill in rare Sunday session Gosar's siblings pen op-ed urging for his resignation: 'You are immune to shame' Sunday shows - Delta variant, infrastructure dominate MORE claiming involuntary institutionalization as a valid option for dealing with people with serious mental illness, with the cuts to services and supports, the language of the changes to the IMD exclusion suggest funding will go primarily to reignite the institutional bias over community-integration for care of individuals with mental illness.   

In assessing the 2021 budget, policymakers and elected officials need to heed the call on behalf of behavioral health professional, advocates, families, and individuals living with mental health concerns to re-examine its recommendations to cut Medicaid funding for those services and supports to live in the community as well as carefully word how the IMD exclusion might be amended. 

The health and welfare of millions of Americans with mental illness are at stake.  

Laura VanPuymbrouck, Ph.D., is an assistant professor in the College of Health Sciences at Rush University in the Department of Occupational Therapy.