ails them...and that's not including the legal system 'fees' that put them there...read what Sam Liccardo has to say about the drug/homelessness issue...
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More Treatment Beds: The Imperative for Inpatient Care
Although best practices call for treating drug addiction and mental illness in the least restrictive setting possible, there appears little question that we face a dearth of inpatient treatment for mental health disorders. In the 1960s, the United States had 337 psychiatric treatment beds available per 100,000 residents. Today, that number has plummeted to 12.29 For people suffering from severe mental illness, the reduction in the number of psychiatric beds correlates strongly with increased rates of homelessness, incarceration, and morbidity.30
This appears particularly true for substance use disorder. For unhoused residents addicted to methamphetamine, for example, inpatient care can be critically needed. There is no Federal Drug Administration (FDA)-approved pharmacological treatment for meth addiction, and meth use increases the risk of severe psychosis and violent behavior, often making outpatient treatment difficult. More treatable substance-use disorders—such as opioid abuse—are still evading treatment because of the difficulties of administering medications like methadone, buprenorphine, and naltrexone on an outpatient basis. One-third of the 1.5 million people who are enrolled in Medicaid and have opioid use disorder, for example, did not receive prescribed medication, according to the United States Department of Health and Human Services (HHS) Inspector General. While we should always prefer less restrictive care settings, too many unhoused and severely ill community members—particularly with dual diagnoses—aren’t getting the inpatient treatment that they need.
Federal restrictions haven’t helped. During a 1960s-era push toward community treatment, Congress prohibited the use of federal Medicaid funding for mental health in facilities with more than 16 beds. Known as the Institution for Mental Disease (IMD) exclusion, it largely cuts off federal funding to large inpatient facilities, making such care much more elusive.
Fortunately, some states have begun to reverse course, reinvesting in inpatient treatment within a continuum of care. California and several other states have applied for what are known as “Section 1115 waivers” to use federal money in larger institutions on an experimental basis for either addiction or mental illness. Only 19 counties in California have been approved to pilot the program, however, and the waiver appears revocable and is not permanent.31
One challenge with Section 1115 waivers is their uncertain duration. The public and/or private investment in larger facilities requires an ongoing commitment that the treatment will qualify for federal funding. A bipartisan bill, cosponsored by U.S. Reps Michael Burgess and Ritchie Torres, provides a good first step, allowing Medicaid funding to be used for mental health hospitals.
Some civil rights advocates have pushed back, fearing that it will merely “warehouse” mentally ill people into large institutions in the manner criticized through such portrayals as Ken Kesey’s “One Flew Over the Cuckoo’s Nest.” Fortunately, we’ve learned many lessons since that era and need not repeat the mistakes of the past. Moreover, equity demands a parity in resource availability for mental and physical health. Removing the IMD exclusion ensures that mental health facilities would have the same eligibility for Medicaid funding as other healthcare institutions. Eliminating the IMD exclusion also reduces some of the stigma that has often accompanied mental health treatment.
Congress can certainly require, as many critics insist, that Medicaid funding be conditioned on ensuring that people with substance-use disorders have access to other care they need, including preventive, treatment, and recovery services, all provided in accordance with evidence-based standards. One approach would require what’s known as “bundled reimbursement,” such that Medicaid guidelines would require a residential stay plus outpatient follow-up as a package of care.
Regardless, we simply need more inpatient care, and we can’t wait years for waivers and other bureaucratic processes. Let’s get Congress to eliminate this statutory relic of the 1960s and get more people the care they critically need.
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Fortunately, there are people who willing to face up to problems and work on real, long term solutions...then there are others who only know how to sweep challenges under the rug...and complain that they aren't being solved.