How Health Care Policy and Laws Have Impacted Mental Health Delivery

By Daniels, Don; Ritter, David | Southern Law Journal, Fall 2018 | Go to article overview

How Health Care Policy and Laws Have Impacted Mental Health Delivery


Daniels, Don, Ritter, David, Southern Law Journal


I. INTRODUCTION

Mental Health care has gone through significant changes in the 20th and 21st century. Early in the 20th century, treatment consisted of institutionalizing patients. In the 1960s, legislation dismantled the notion of institutionalism in favor of community-based treatment. The introduction of psychotropic medication to treat the more severe mentally ill helped promote community-based care even further. However, with funding and reimbursement rates decreasing while regulations continue to increase, resources such as mental-health provider shortages left many patients vulnerable to exclusion from mental health resources.

During the 20th century, mental illness treatment consisted of institutionalizing patients. In the 1960s, legislation dismantled institutionalism in favor of community-based treatment.1 Although the change was considered revolutionary, more regulations, coupled with strategies to reduce fiscal deficits have created unforeseen consequences.2 According to Alakeson, Pande & Ludwig, access to community-based resources has decreased due to reduced state spending. Also, a lower reimbursement rate from Medicaid discourages community behavioral health services. The only option for many patients is to seek care in the emergency rooms. Patients endure long stays in the emergency departments waiting on state sponsored beds.3 These prolonged waits lead to uncompensated care and increased tax payer burden for state sponsored hospital utilization.4 America's prisons are crowded with mentally ill patients,5 and homeless with schizophrenia live on America's streets.6

Medical care in the United States (US) is complex, and fragmented. Physicians and hospitals must wade through a plethora of regulations directly or indirectly to deliver the health care. For example, Larrat, et al., state that clinicians have to consider the type of insurance coverage for each patient while managing their patients. Insurance company coverage, both public and commercial is dictated by federal regulation. Over the years, insurance companies have had to adapt to changes in the federal initiatives.7

II. 20TH CENTURY HISTORY OF MENTAL HEALTH LAW & POLICY IN THE UNITED STATES

The roots for early 20th Century institutions for the commitment of the mentally ill and early legislation probably began about 1848 with a woman named Dorothea Dix.8 She was an advocate for the indigent mentally ill who had been incarcerated in jails and prisons.9 She appealed to the United States Congress to support a "12,225,000 Acre Act."10 This act would have paved the way for "relief and support of the indigent curable and incurable insane."11 It passed Congress but President Franklin Pierce vetoed it because he could not find any authority in the Constitution that allows the Federal Government to provide public charity.12

Although this act was vetoed, her activities led to the building of many new state mental health hospitals.13 At the time Ms. Dix was advocating, there was approximately one public psychiatric bed for every 5000 persons. By 1955, there was approximately one public psychiatric hospital bed available for every 300 persons in the population.14

Following President Pierce veto, the Federal Government did not assume responsibility for a national health system or mental health until shortly after World War II.15 The states had the major responsibility for the care of the seriously and chronically mental ill. Prior to the mid-20th century, many of these patients received care in large state mental hospitals.

According to Accordino, et al.,16 by the 1930s and World War II, conditions in these state run mental facilities had deteriorated. The BardenLafollette Act of 1943 mandated that patients with mental illness receive federal and state rehabilitation/vocational rehabilitation services. This opened the door for vocational services. Furthermore, as more and more servicemen were diagnosed with service related psychiatric problems, the military experimented with new and different treatment modalities. …

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