When Better Isn’t Enough

Bernie Sanders has stated “The only long-term solution to America’s health care crisis is a single-payer national health care program.” The Heritage Foundation recommends we repeal Obamacare and replace it with block grants to states. And the Mises Institute recommends we eliminate disability and health care funding altogether as “Subsidies for the ill and diseased promote carelessness, indigence and dependency.” Though opinions differ widely as to the fix, there is widespread consensus that American healthcare is broken. But any approach to present problems will benefit from a look at earlier solutions. Before rearranging the insurance, pharmaceutical and medical industries, we might explore the short and long-term effects of the mid-20th century’s mental health reforms.

By the 1950s there were over 500,000 people confined in American state mental hospitals. Many Americans had family members whose nerves snapped after they got back stateside, old college chums too fragile for this world, classmates who quietly moved not long after the nurses led their mother away. There was a fair bit of graveyard-whistling behind all those midcentury jokes about rubber rooms, loony bins and people who thought themselves Napoleon. Mental illness was both a personal and a political issue. And then as now, when faced with complex issues the public often seeks convenient villains.

As we focus on “Big Pharma” or “One World Globalists” midcentury activists set their sights on psychiatric hospitals. There was plenty to criticize. A 1946 Life article by Albert Q. Maisel exposed horrendous conditions at mental institutions: it was accompanied by photos smuggled out by conscientious objectors who had taken surreptitious pictures during their incarceration. In 1963 Ken Kesey’s book One Flew Over the Cuckoo’s Nest gave them a nightmare inspired by Kesey’s brief employment at an Oregon mental hospital. All this drew growing scrutiny to state mental institutions and growing calls for more humane alternatives. In 1963 President Kennedy signed legislation funding community-based mental health facilities.

But the 650 centers built by 1977 were less than half the number required to fulfill Kennedy’s vision of a center for every 125,000 to 250,000 Americans. The money allocated to short-term treatment and outpatient counseling was taken away from long-term institutions. And these new programs were ill-equipped to handle recently deinstitutionalized people unable to cope with freedom – especially after Reagan killed much of their funding. Whatever your vision for health care reform, you had best have plans for how it can be managed on unsteady funding and how it will fare when called to tasks beyond its original plan.

Efforts at reintegration also ran into pushback from local communities. Audiences that cheered for McMurphy and his ragtag band at Cuckoo’s Nest screenings were less enthusiastic about them moving into the halfway house next door. They felt no more charitable towards the growing numbers of floridly ill homeless released from the asylums into the streets. No matter how sympathetic they may be to your ideology, your constituents will fight tooth and nail against any plan that leaves them with higher coverage costs or less access to treatment. And while they will be easily swayed with promises of better and cheaper health care, sooner or later they will expect you to deliver on both.

In 1954 Thorazine (chlorpromazine) became available to American physicians. Before this there were few options for dealing with agitated patients. Restraints, cold baths and beatings were the regular tools of the asylum trade: electroshock therapy, insulin comas and prefrontal lobotomies were its cutting edge. With antipsychotics patients who had been unmanageable for years suddenly became tractable and even coherent. As pressure mounted and funds dwindled many hospitals discharged their newly medicated inmates with best wishes and a prescription. But post-release compliance with these pharmaceutical guidelines was spotty at best. There was little psychotherapy or supervision offered to these patients. Side effects and chaotic living conditions led many patients to quit taking their medications with predictable results. Medical advances will certainly shape future health reform efforts, but they will not serve as a panacea.

At the end of 1968 there were 399,000 patients in state mental hospitals and 168,000 inmates in state prison. By 1978 the hospital population had fallen 64% to 147,000 while the state prison population rose 65% to 277,000. A 2006 study found 64 percent of local jail inmates, 56 percent of state prisoners and 45 percent of federal prisoners had symptoms of serious mental illnesses. In the 19th century asylums were seen as a humane alternative to prisons. In the 21st century they have once again become the standard means of dealing with the troublesome and troubled. Disavowing responsibility for a social problem does not make it go away. It merely offloads its costs to different sectors.

Perhaps the most important lesson to be gleaned from the midcentury mental health reforms is their utter failure. Patients were liberated from oppressive institutions to sleep on steam grates. Communities were expected to rely on money that never realized: programs intended to prevent psychological crises were soon overburdened with people in their throes. The prison industry has proven no more effective than the asylum industry at providing humane mental health care. Neither has it made our streets safer or helped alleviate our homeless crisis. Before we set alight our current system, flawed as it is, we would do well to consider what will arise from the flames. And to contemplate the possibility we will be left with nothing but ashes.