Our mental health system is in shambles and many of the most severely ill are being excluded from the treatment system. For the most severely ill, many of whom are destitute or homeless, private health insurance is not an option – leaving Medicaid the only way that many low-income people can afford to get healthcare.
However, the Institutions for Mental Diseases (IMD) Exclusion prohibits Medicaid from paying for care received in mental health institutions if the hospital has more than 16 psychiatric beds. Not only is this a barricade to treatment for those who need it most, the IMD Exclusion is very costly to state and federal governments when untreated patients are stowed away in correctional facilities or living on the street.
Seventy years ago, there were 550,000 inpatient psychiatric beds for a country half the size it is now. Today, there are fewer than 40,000 inpatient psychiatric beds. The IMD Exclusion has accelerated the shortage of psychiatric beds during the “deinstitutionalization” process several because it gives states an economic incentive to close hospitals.
This provision of Medicaid has inadvertently caused our jails and prisons to become warehouses for the mentally ill and for our homeless population to grow exponentially.
People with untreated psychiatric illness now make up one-third of our estimated 600,000 homeless population. Studies from Massachusetts and Ohio show that between 27 and 36 percent of discharged patients from state mental health hospitals had become homeless within six months.
We must recognize the price that we pay when untreated individuals with mental illness find themselves imprisoned. In 2012, there were an estimated 356,268 inmates with severe mental illness in prisons and jails across the nation. In the vast majority of states, prisons or jails in each state hold more individuals with SMI than the largest remaining state hospital. In Texas, there are 35,000 prisoners with a severe mental illness but just 4,500 psychiatric units in all Texas general hospitals combined.
Prison is also one of the most destructive environments for individuals with mental illness.
Mentally ill prisoners often become much sicker in prison because they are likely not being treated. By no fault of their own, people with severe mental illness often refuse treatment because they do not believe they are mentally ill, also known as “anosognosia.” Though this occurs inside and outside of prisons, mentally ill prisoners who “misbehave” and refuse medication spend additional time behind bars and are more likely to spend time in solitary confinement, which only worsens symptoms.
On top of all of this, the IMD Exclusion creates even more barriers to treatment for minority communities since many individuals in these communities rely on Medicare and Medicaid for health insurance. According to recent studies, African American and Hispanics living in poverty are three times more likely to have psychological distress.
We must act to ensure that we do not warehouse our most vulnerable people with serious mental illness in prisons or leave them untreated and living on the streets. We must work to eliminate barriers to better mental health treatment for our underserved minority communities.
Repealing the IMD Exclusion can help those with mental illness regain access to the treatment they deserve. It could also save taxpayers the burden of costly emergency room visits for patients with severe mental illness and the expense of incarcerating prisoners with severe mental illness. It can help us decrease our homeless population and instead help people gain access to treatment and stable housing by making it more economically viable for hospitals and other residential psychiatric facilities treat them when they are in crisis or recovering from crisis. We must make treatment available for low-income people with mental illness and, to do that, we must do our best to repeal the IMD Exclusion.
While many individuals with mental illness can be treated successfully in the community, there is a small population of people with serious mental illness who cannot. I strongly believe and advocate that this population of people deserve and have a right to be treated. Transferring them from mental health facilities to cells and the streets – or worse – is inhumane, immoral and hurts all of us.
Congresswoman Eddie Bernice Johnson (TX-30)