Research: Topics: Health Care: Mental Health in New York State
Mental Health in New York State, 1945-1998
Mental Health in the Present Era, 1977-1998
Frustrated by the slow development of community-based mental health programs, the high cost of furnishing inpatient care, and what it saw as the DMH's inefficiency and lack of clearly defined priorities, the state legislature took action in 1977. It completely recodified the Mental Hygiene Law and reorganized the DMH. In the process, New York State's mental health agency acquired the structure that it has to this day; some of its components have of course been created, merged, phased out, or renamed in subsequent years, but its administrative hierarchies generally resemble those established in 1977. The DMH's obligation to care for and treat the mentally ill, the developmentally disabled, and substance abusers was partitioned and invested in three autonomous offices: the Office of Mental Health (OMH), headed by the Commissioner of Mental Health, the Office of Mental Retardation and Developmental Disability (OMRDD), headed by the Commissioner of Mental Retardation and Developmental Disability, and the Office of Alcoholism and Substance Abuse (OASA), headed by the Director of the Division of Alcoholism and Alcohol Abuse and the Director of the Division of Substance Abuse. The three offices were to consult one another on a regular basis and to work together to care for people who had multiple mental disabilities, but the framers of the law clearly hoped that disaggregating the DMH's responsibilities would streamline the department's administration and reduce waste and inefficiency.[132]
In an effort to insure that the New Yorkers who needed the services provided by the OASA, the OMRDD, and the OMH were given appropriate care and treatment, legislators mandated that "each local government [had to] submit a five-year plan and annual implementation plans and budgets which . . . reflect[ed] local needs and resources" in order to remain eligible for state reimbursement.[133] These local or unified services plans had to conform to the state's long-term plans and had to win the approval of all three offices.[134] In order to facilitate these complex and long-range planning activities, the new Mental Hygiene Law established or reformed a host of councils and committees designed to assist the DMH's three offices. The OMH was aided by the Advisory Council on Mental Health, which consisted of the Commissioner of Mental Health and fourteen other members appointed by the governor; at least seven members had to be former patients or outpatient clients, relatives of current or former patients or clients, or other "consumer representatives." The Advisory Committee on Youth, which was similar in composition to the Advisory Council on Mental Health, aided the OMH in identifying the special mental health needs of children and adolescents.[135] The heads of the state's CMHB's (now called community services boards, or CSB's) were incorporated into the State Conference of Local Mental Hygiene Directors, which was to review proposals for changes in local and state provision of care.[136]
These advisory groups and similar bodies established within the OMRDD and the OASA reported to the Council for Mental Hygiene Planning, which consisted of the heads of the OMRDD, the OASA, and the OMH, and fifteen mental health, mental retardation, and alcohol substance abuse experts and advocacy group representatives appointed by the governor. The council was to supervise planning, devise effective evaluation mechanisms, and ensure that local and state programs were working toward common goals. Its ultimate task was to produce a comprehensive and detailed five-year plan and budget that drew upon local government plans and the work of the various councils and committees that reported to it.[137] In addition, these groups were to help the OMH devise new standards for admission to and discharge from all in- and outpatient mental health facilities, provisions for local review of admission and discharge decisions, a state-wide "assessment, evaluation, and reporting system," standard per-patient payment rates for facilities upkeep and programming, and new labor and employment policies governing mental health facilities.[138]
In keeping with its legislative mandate, the OMH devoted increasing attention to planning for future needs. It put forth its first five-year plan in 1978, issued updates in subsequent years, and to this day continues to devise plans in accordance with the 1977 Mental Hygiene Law. It also took other steps designed to increase its accountability to politicians and the public and its ability to perform its mandated tasks. In 1979, it standardized the planning forms and terminology used by localities in order to speed processing and increase the accountability of local officials. A year later, many state and local mental health personnel were using identical service categories in their reports and all local providers were required to employ standard planning, budgeting, and service reporting formats when working with the state.[139] It also sought to standardize patient case records.[140] In addition to reducing the potential for fraud and inefficiency, these changes made it possible for the OMH to compile more detailed statistics about the people it treated.[141]
The OMH also sought to mitigate some of the problems associated with the ad hoc policy of deinstitutionalization. Some of its efforts to do so were mandated by new legislation. Politicians and other policymakers were still convinced that community-based outpatient treatment was far more humane and far less expensive than state hospital care, and they had few alternative options; had they questioned the wisdom of depopulating state facilities, economic circumstances and the newly-established right to refuse treatment would almost certainly have led them to reject the possibility of dramatically expanding state-furnished inpatient care. However, they were displeased by the unplanned and often ill-considered manner in which state facilities had discharged patients. Dismayed that that the overwhelming majority of discharged state hospital patients had no further contact with state or voluntary mental health personnel, in 1977 the state legislature compelled the OMH to locate and contact former patients and to formulate individualized treatment programs for those who needed and desired outpatient care. By December 1979, the OMH had identified 11,000 former patients in need of follow-up care and had contacted ninety-eight percent of them.[142] This effort to insure that the seriously mentally ill were not left to fend for themselves developed into an ongoing intensive case management program that exists to this day.
Other OMH initiatives, most notably the Community Support System (CSS) took shape within the agency itself. The CSS, which was implemented in 1978 and which was in all likelihood propelled in part by the desire to make the state eligible for funds from the NIMH's new Community Support Program for the seriously mentally ill, was funded entirely by the state, supervised by the OMH's five regional offices, and maintained largely by local and private agencies working under contract.[143] It was designed to furnish community-based outpatient treatment and other services needed by seriously ill people who had been patients in state, local, or private inpatient facilities. Almost eighty percent of the initial allocation of $15.1 million was targeted at the communities most profoundly affected by hospital discharges of the acutely mentally ill: Erie, Chemung, Niagara, Broome, Oneida, St. Lawrence, Dutchess, Rockland, Westchester, Sullivan, Nassau, and Suffolk counties, and nine areas within the New York City.[144] By 1984, the CSS, which received almost $50 million in funds, was treating some 20,000 former hospital patients on a regular basis and furnishing sporadic care to another 10,000.[145]
Aware of former patients' difficulties in finding suitable living arrangements, the OMH did as many other state mental health authorities were doing and began financing the establishment and operation of community-based residential facilities. Like its counterparts in other parts of the United States, the office did not become directly involved in the provision of such services; instead, it contracted out to voluntary and for-profit agencies.[146] It began working with a voluntary organization, the Association for Community Living Administrators in Mental Health, to build or subsidize appropriate facilities. The number of beds supported by the OMH grew relatively rapidly but consistently lagged behind need: in 1987, there were only roughly 5, 500 such beds in existence. Not surprisingly, the quality of these residences also varied considerably: a 1988 Commission on Quality of Care for the Mentally Disabled study of thirty-two OMH-sponsored residential facilities found that only one-third were completely "safe, nurturing, and rehabilitative," while half fell somewhat short of OMH goals and fifteen percent fell far short of meeting one or more of the OMH's standards concerning the safety, hygiene, health, recreational, and rehabilitative needs of residents. The commission also found that the OMH had failed to create programs for people who were ready to move out of these residences but were not yet capable of leading completely independent lives; as a result, residence administrators had to choose whether to continue housing people who were ready to assume greater responsibility for their own well-being or to cast them adrift and hope that they would be able to fend for themselves.[149]
The OMH also sought to improve standards of care in state inpatient facilities. Since the passage of the 1890 State Care Act, the DMH sought to insure that state facilities served clearly defined regional cachement areas, but the OMH increasingly felt that simply directing all patients from a given region to a single psychiatric center was wasteful and detrimental to patient well-being. From 1980 onward, it began grouping patients according to degree of treatment needed and level of functioning instead of geographic origin; in doing so, it was emulating the organization of other residential facilities that cared for the mentally ill.[150] The public embarrassment of having two state psychiatric centers denied reaccreditation was also a concern: in 1978 it created a Bureau of Accreditation that conducted preparatory reviews of all facilities awaiting accreditation inspections and in 1981 entered into an agreement with the Joint Commission on Accreditation of Hospitals that allowed it to direct most capital funds away from facilities that were being phased out of existence.[151] Efforts to insure that state psychiatric centers remained accredited also led the OMH to increase staffing levels; of course, continuing political pressure from the CSEA and other unions and the Morgado memorandum also guided its actions.[152] Increasing public concern about the abuse of patients, which culminated in a legislative inquiry into the problem, also goaded it into action. It began implementing reporting and investigative programs designed to uncover such problems, and sent employee representatives from state psychiatric centers to classes at Cornell University's School of Industrial and Labor Relations that detailed how to detect and respond to instances of abusive behavior.[153]
However, the OMH's efforts to improve inpatient care standards in large part grew out of its increasing awareness that serious mental illnesses such as schizophrenia could not be cured and that some patients simply could not function in community settings. During the late 1970's and the 1980's, the population of adult patients in state psychiatric centers declined only one to three percent each year, and the OMH acknowledged that the reduction in the inpatient census was due solely to the deaths of elderly patients; had it not been for these deaths, state hospital populations would have increased slightly during these years.[154] The OMH was also faced with the rapid growth of a new type of patient: the chronically ill young male adult. Men between the ages of eighteen and thirty-four made up an increasing percentage of the inpatient census, and the emergence of this patient cohort baffled OMH officials and other mental health professionals.[155] It is not at all surprising that the number of mentally ill young adults increased at this time: the number of adults between the ages of eighteen and thirty-four swelled as the baby-boom generation came of age. This increase in the absolute number of young adults, not a dramatic rise in the percentage of young adults afflicted by serious mental illness, was most likely responsible for the emergence of this patient cohort.[156] However, the characteristics of this group were in some respects unique: like others their age, acutely ill young adults were suspicious of authority, highly mobile, and unprecedentedly tolerant of illicit drug use. Many refused treatment, tried to run away from their problems (and sometimes ended up on the streets), and descended into alcohol or drug addiction.[157] Legal restrictions, funding shortages, and prevailing treatment philosophies militated against long-term institutionalization of this cohort of patients, but the OMH, other mental health agencies, and policymakers were increasingly forced to acknowledge that some forms of mental illness were hard to treat in outpatient settings and that some people who were capable of living outside of state facilities might never be capable of living independently of some sort of intensive support network.
The OMH also had to contend with a growing number of mentally ill people who were not eligible for any form of outpatient treatment: those who committed serious crimes. The state's prison population increased dramatically during the late 1970's and the 1980's, bringing increasing numbers of mentally ill people into contact with the criminal justice system. The office's increasing responsibility for caring for mentally ill criminals is evident in the rapid expansion of facilities designed specifically for them. In the mid-1970's, the DMH had taken over a reformatory established by the New York City and created the Mid-Hudson Psychiatric Center, which treated those who were deemed incompetent to stand trial or judged not guilty by reason of insanity. In 1977, the OMH established the Central New York Psychiatric Center, which was intended specifically for treatment of mentally ill prison inmates, and started outpatient programs in seven prisons around the state.[158] Between 1977 and 1985, the office also established regional forensic units at the Hutchings, Gowanda, Manhattan, Rochester, and Sullivan Psychiatric Centers.[159] From 1980 onward, the Insanity Defense Reform Act required that the criminally insane be institutionalized for lengthier periods of time and evaluated regularly, thus further increasing the demand for forensic services.[160] As a result, the OMH opened the Metropolitan New York Forensic Center in 1984 and the Kirby Forensic Psychiatric Center in 1985; both of these facilities were intended to relieve persistent overcrowding at the Mid-Hudson Psychiatric Center, which underwent expansion at roughly the same time.[161] Relying in part upon NIMH funding, the OMH also worked with local corrections officers, creating a demonstration program intended to identify and treat suicidal and potentially suicidal county and city jail inmates.[162] This program soon became a full-fledged component of the OMH's forensic responsibilities and helped to spawn a joint OMH-Department of Correctional Services program that trains police officers how to recognize signs of mental illness and how to respond to mentally ill people they encounter while working.[163]
The OMH also implemented a number of new outpatient treatment initiatives that targeted specific groups of New Yorkers. Aware that African-Americans and Latinos were slightly overrepresented in the state's patient population, the OMH sponsored a number of research projects intended to identify the particular needs of mentally ill African-Americans and Latinos and demonstration programs that sought to provide culturally sensitive treatment; the need to furnish such treatment is to this day one of the office's key concerns.[165] The OMH also devoted increasing attention to treating mentally ill senior citizens. Even though the state had since the mid-1960's sought to place patients over the age of sixty-five in nursing homes and other facilities, the elderly remained a substantial part of the inpatient population in state facilities and the OMH continued to it difficult to find appropriate placements for patients who no longer needed intensive inpatient care. Increasing knowledge about some forms of mental illness that afflict older people and the concomitant formation of new advocacy groups also prodded the OMH into action. In the early 1980's, the degenerative phenomena that had formerly been attributed to arteriosclerosis or to the process of aging itself were increasingly recognized as symptoms of a distinct and progressive disorder known as Alzheimer's disease. The office sought to provide guidance to families caring for those who suffered the disease and to create day and respite care programs for elderly New Yorkers suffering from Alzheimer's disease or mental illness.[166] From the mid-1980's onward, it also paid increasing attention to the mental health needs of the growing number of people suffering from the newly-defined physicial illness known as Acquired Immune Deficiency Syndrome, or AIDS.[167]
With the probable exception of its new forensic programs, the OMH's efforts were guided not only by legislative mandates, public-relations considerations, and internal concerns about patient welfare but by pressure from a growing number of citizen advocacy groups. In 1979, the National Alliance for the Mentally Ill (NAMI), a support group for people with serious mental illness and their families, a lobbying organization that sought to increase funding for and levels of care, and a sponsor of research concerning the etiology of mental illness, was founded in Madison, Wisconsin. The NAMI grew rapidly, its membership swelling in large part due to the deep frustration felt by many people who had acutely ill relatives: the absence of appropriate treatment programs for relatives who had been discharged from state facilities or who had repeatedly been hospitalized for long periods of time led many family members to make great personal sacrifices and made many of them feel bewildered and isolated. In the early 1980's twelve New York State NAMI chapters formed the Alliance for the Mentally Ill in New York State, which currently has over seventy chapters and remains dedicated to helping mentally ill people and their families.[168] In subsequent years, groups for relatives of people suffering from specific disorders such as depression and bipolar disorder were formed; they often joined forces with the NAMI.
Relations between these groups and the OMH and other mental health care providers have not always been ideal: like others who care for chronically ill relatives and lack adequate resources or support, many of those drawn to them were (and are) profoundly dissatisfied with the status quo. Searching for effective alternatives to institutionalization and in many instances convinced that outpatient care was simply not suitable for their relatives, they have often been convinced that state mental health agencies, the state and federal courts, and mental health professionals had failed them; some have openly yearned for a return to long-term institutionalization.[169] As a result, these organizations were at times impatient with and publicly critical of the OMH. However, these groups also sought to work with the OMH and other state agencies, which in the long term probably benefited from their involvement. The OMH's programs for people suffering from Alzheimer's disease were developed in tandem with a new voluntary organization, the Alzheimer Disease and Related Disease Foundation, and in subsequent years the office worked with other citizen advocacy groups when developing new mental health programs.[170] Cooperative efforts such as these may have initially magnified frustrations, but they may also have served to create lasting working relationships between the OMH and the new advocacy groups. In addition, these organizations performed much-needed educational and support functions at little cost to the OMH or other state agencies and pressed legislators to increase funding for mental health treatment and research.
The emergence of this growing citizen constituency was in part propelled by the mounting fiscal difficulties faced by the OMH and social welfare and mental health agencies across the nation. From the late 1970's onward, the OMH shouldered an increasing share of the cost for the care of the mentally ill. The goal of making county and city governments assume a greater share of the burden was increasingly recognized as unworkable, and federal monies earmarked for mental health research and treatment declined substantially. The federal government's intent to decrease funding for mental health care first became evident during the administration of Jimmy Carter. State policymakers, mental health professionals, and advocacy groups had hoped that the Carter administration would produce significant advances in federal support for mental health: First Lady Rosalyn Carter was a prominent advocate of better care for the mentally ill, and the creation in 1977 of the highly publicized President's Commission on Mental Health seemed to portend an expansion of federal support for mental health initiatives. However, the federal government's ability to do so was limited by spiraling inflation, the escalating cost of Medicare, Medicaid and other federal entitlement programs, the absence of vocal champions at the NIMH and other government agencies, and the lack of consensus about priorities; the community mental health centers' many responsibilities and the increasing prominence of psychologists and social workers in the mental health field virtually guaranteed that there would be no agreement as to which forms of mental illness or treatment were to be emphasized. These contradictions were reflected in the 1980 National Mental Health Systems Act, which stressed the need for improving linkages between mental health and other forms of health care, increasing provider accountability, improving care for the acutely ill, and safeguarding patients' civil rights but did not detail how these aims were to be accomplished. In addition, the act stressed that the federal government would continue to help shape mental health policy even as federal funding for community mental health centers would eventually cease.[171]
From 1981 onward, the federal government's reluctant disengagement from mental health policy quickly gave way to a determined retreat. Seeking to cut federal taxes and expenditures, President Ronald Reagan sought to dismantle or shrink many social welfare programs. One of the aims of aims of his first administration was to take apart federal mental health and substance abuse programs, cut federal support for them by twenty-five percent, and forward federal monies to the states in the form of block grants that would allow each state to devise its own mental health and substance abuse treatment policies policies. With the passage of the 1981 Omnibus Budget Reconciliation Act of 1981, which revoked the Mental Health Systems Act, this goal was made into policy.[172] Gerald Grob argues that the Omnibus Budget Reconciliation Act constituted a dramatic rejection of the federal mental health policy that had taken shape during the 1960's. In its wake, American mental health policy was once again the responsibility of the states and of localities. However, the federal government's abdication of responsibility occurred "at precisely the same time that states [and local governments] were confronted with monumental social and economic problems that increased their fiscal burdens" and was as a result particularly disastrous for the mentally ill.[173]
Part of the states' fiscal difficulties stemmed from other federal policy changes. During the Reagan years, the executive and legislative branches of the federal government sought to curb Social Security expenditures. Rejecting the call of the President's Commission on Mental Health, which issued its final report in December 1980, to integrate federal entitlement programs and mental health treatment, both the president and Congress sought to shrink the SSI and SSDI rolls and curb abuse of these programs. Under the provisions of the 1980 Disability Amendments Act, each SSI and SSDI recipient was to undergo a benefits review every three years. Under pressure from the Reagan administration, the Social Security Administration used these reviews to cut large numbers of mentally ill and other disabled recipients from these programs. It created definitions of mental disability that differed considerably from those it had employed in the past and from prevailing professional definitions of acute mental disorder, and its actions resulted in a dramatic decline in the number of mentally ill people receiving SSI and SSDI. Mentally ill people, who constituted roughly eleven percent of recipients, made up some thirty percent of those dropped from the SSI and SSDI rolls. The vast cuts in SSI and SSDI expenditures, which produced savings far greater than that anticipated by the Reagan administration, ultimately produced a public uproar that compelled the Reagan administration to reverse course.[174] However, the hardships and dislocations that grew out of this policy were no doubt substantial; at least some of those who were denied benefits became homeless and severed all contact with mental health and social service agencies.[175] Decreases in federal support for low-income housing and other social-welfare programs made it even more difficult for mentally ill people to adjust to being removed from the SSI and SSDI rolls.[176]
Federal funding cuts and the state cuts that followed them clearly affected mental health care in New York State. The OMH noted in 1982 that fourteen of the twenty-six community mental health centers that had constructed and staffed under the provisions of the CMHCCA and other federal laws had "graduated from federal funding" and were being supported largely by the state.[177] The state's fiscal difficulties were also noted by the Governor's Select Commission on the Future of the State-Local Mental Health System, which predicted that New York State would eventually face a fiscal nightmare if it did not integrate state and community-based programs more effectively and that it could no longer expect substantial assistance from the federal government.[178] By 1983, funding for a number of OMH programs had been slashed, and the office laid off some personnel and transferred responsibility for the office's Long Island Research Institute to another state agency in hopes of saving money.[179] The office, goaded perhaps by a report from the New York State Division of Audits and Accounts that charged that slipshod OMH managerial practices denied the state some $4.5 million in Medicaid and Medicare reimbursements every year, also automated its billing procedures and took over responsibility for setting Medicaid reimbursement rates in order to insure that it got as much money as possible from remaining federal sources.[180]
In the wake of federal cutbacks, policymakers in New York State and other states were more firmly committed than ever to community-based provision of mental health. Some still hoped that community programs would be much cheaper than inpatient care at state psychiatric centers, but most were guided by the realization that the current fiscal and legal climate militated against any dramatic expansion of inpatient care and remained convinced that inappropriate institutionalization remained a problem. As a result, the OMH sought improve community-based care for the acutely ill. The office created a program designed to support voluntary agencies' efforts to acquire real property and create residences for mentally ill people and sought to boost funding of community-based service programs.[181] In addition, the OMH used the federal block grant funds it received to expand the CSS, and in 1987 streamlined funding for the program by inducing the legislature to merge monies allocated for the CSS with those earmarked to fulfil the state's legal obligation to pay for the aftercare of former state psychiatric center patients.[182]
The OMH also undertook a number highly-publicized efforts to address the problem of homelessness, which grew in part as a result of federal and state cuts in social welfare spending and was particularly pronounced in New York City. The office's drive to furnish care to the homeless was in large part the result of mounting public criticism of past mental health policy: many citizens and politicians had become convinced that almost all former state hospital patients ended up on the streets, that all but a few of them were belligerent, socially disruptive, and potentially dangerous, and that deinstitutionalization was solely to blame for the phenomenon of homelessness and the urban decay associated with it. In reality, only a highly visible subgroup of mentally ill people became homeless and the problem had multiple roots: the shortage of aftercare, the refusal of some acutely ill people to undergo treatment, the reductions in the SSI and SSDI rolls, alcohol and drug addiction, and New York City real-estate tax and abatement codes that encouraged ruthless (and often illegal) evictions from and demolition of SRO's and other residences inhabited by low-income people.[183]
Aware of the complexity of the problem, the OMH sought to defuse public criticism by addressing the existence of mental illness among the homeless population of the New York City. It cooperated with the Governor's Task Force on the Homeless and, in conjunction with the State Department of Social Services and the New York City Human Resources Administration, created short- and long-term programs for the homeless at the Creedmoor Psychiatric Center.[184] In addition, the OMH, acting in tandem with the Human Resources Administration, placed mental health screening teams in a number of municipal shelters for the homeless; after the Creedmoor facility for the homeless opened in 1985, the OMH screening teams directed those in need of immediate and intensive inpatient care to the city-operated Bellevue Hospital and those requiring less intensive care to Creedmoor.[185] The OMH's efforts did not hold back the swelling tide of public criticism; however, given the multiple causes of homelessness and the simple fact that not all homeless people are mentally ill, no amount of action taken by the OMH would have completely resolved public concern about (and fear of) homeless people.[186]
The financial hardships that the OMH and other mental health authorities endured during the early 1980's became less acute during the second Reagan administration and the administration of George Bush. Advocacy groups and mental health professionals supportive of the reforms outlined by the President's Commission on Mental Health were galvanized into action by dramatic federal funding cuts, and they increasingly made common cause with advocacy groups representing people with other forms of disability. The resulting alliances made it easier for supporters of mental health care expansion and reform to influence the formation of policy. In addition, the Social Security Administration implemented a number of desirable changes after it was forced to stop purging mentally ill persons from program rolls. It altered the requirements of SSI (but not SSDI) to allow mentally ill people to remain eligible for partial benefits after they found paid work and expanded Medicaid support for mental health care. These reforms may have stemmed partly from the involvement of the agency's fiscal experts in the work of the President's Commission: as a result, key Social Security personnel became aware that some SSI provisions did not meet the needs of mentally ill recipients.[187]
These changes were accompanied by modest increases in federal spending for mental health research and treatment. These increases were typically implemented with little fanfare: high-profile initiatives such as the 1992 Community Mental Health and Substance Abuse Services Improvement Bill, which sought to make federal funding more equitable and expand community programs, did not become law.[188] Mental health advocacy groups and their friends in the Democratic-controlled Congress soon learned that the most effective way to increase federal mental health expenditures was to bury funding mandates in mammoth budget reconciliation bills that retarded close scrutiny.[189] However, some federal measures explicitly dedicated to improving mental health care did become law. In 1984, Congress succeeded in overcoming the objections of the Reagan administration and bestowed full legal status upon the NIMH's Community Support Program, which for the next five years continued to induce the states to improve services for people with serious and chronic mental illness.[190] In 1986, the State Comprehensive Mental Health Services Plan Act (SCMHSPA), which compelled the states to devise detailed service plans that emphasized improving outpatient-based care for the chronically mentally ill in order to receive federal mental health monies, became law.[191] The planning provisions of the SCMHSPA, which mark a low-profile return to direct federal involvement in the shaping of mental health policy, bear more than a passing resemblance to those contained within the 1977 recodification of the New York State Mental Hygiene Law.
During the presidency of Bill Clinton, the executive and the legislative branches of the federal government have cooperated in increasing both the amount and the number of strings attached to the block- grant funds disbursed by the Center for Mental Health Services (CMHS), which is a component of the Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA).[192] In addition to controlling block-grant monies, the CMHS also administers grant funds targeted for demonstration projects involving mentally ill children, programs for the homeless and people with HIV disease, legal advocacy and information groups serving the mentally ill, and training of mental health personnel. The center is also responsible for compiling statistics concerning mental illness, treatment, and research, and furnishing assistance to those devising programs for select populations (e.g., women, African-Americans, Asian-Americans, Latinos, prison inmates, those living in rural areas) or working with disaster survivors. Most recently, the CMHS has begun the National Mental Health Services Knowledge Exchange Network, an information clearinghouse for mentally ill people, their family members, and others interested in mental-health issues.[193]
Apart from these incremental increases in federal responsibility and funding for treatment, research, and public education, federal mental health policy has undergone little change during the Clinton years. The first Clinton administration's highly publicized national health insurance plan was notable for its relatively generous provisions for mental health treatment. However, in the wake of the plan's rejection by Republicans and many Democrats in Congress and the 1994 elections that gave control of both houses of Congress to the Republican Party, the Clinton administration has been loath to press for dramatic expansions of social welfare programs. Instead, the administration and Congress have sought modest improvements in third-party insurance coverage of mental health treatment. The Mental Health Parity Act (MHPA) of 1996, which went into effect upon 1 January 1998, compelled corporations that offered mental health benefits to their employees to increase annual and lifetime caps to match more closely those set for physical disorders.[194] These changes have at best meant a modest improvement in the insurance benefits of some seriously or moderately mentally ill people, but mental-health professionals and advocacy groups heralded the MHPA as a first step toward equal coverage of mental and physical disorders.[195] The MHPA did not prohibit the states from enacting more stringent parity legislation, and in its wake a number of states did so.[196] However, New York State was among neither the pioneers that had acted in advance of federal legislation nor among those propelled into action by it. At the present time, state lawmakers apparently believe that the MHPA's provisions are sufficient; apart from a bill improving insurance coverage of treatment for serious mental illness, which is at the time of this writing being studied by the New York State Insurance Department, politicians have been loath to press private insurance companies to offer more comprehensive mental health benefits.[197]
New York State legislators have been much more eager to adopt some of the cost-containment strategies devised by commercial and not-for-profit health insurers. In 1991, they compelled counties to devise managed care programs for Medicaid recipients, including those who are mentally ill, and in 1996 subsequent legislation mandated the creation of Special Needs Plans (SNP's) for mentally ill adults and children who receive Medicaid benefits; pending federal approval, the 1996 legislation also gives the state the power to force the mentally ill into these managed care programs.[198] As of late 1997, the OMH, which has played a substantial role in determining the provisions of the SNP's, anticipated that the plans designed for adults would be implemented in the summer of fall of 1998 and that those for children and adolescents six months to a year later.[199]
The drive to cut costs also spurred the OMH to close a number of its psychiatric centers. However, declining inpatient populations also drove the closures: the inpatient census declined from 22,724 in 1980-81 to 10,500 in late 1993 and that admissions rates, which had remained constant throughout the 1980's, dropped substantially in 1991-92. In response to this rapid drop in population, the Harlem Valley, Gowanda, Central Islip, Willard, and King's Park Psychiatric Centers all ceased operations during the mid- to late 1990's.[200] The closure of these facilities, coupled with sustained efforts by Mario Cuomo and George Pataki to reduce the number of state employees, produced a dramatic decrease in the number of people employed by the OMH: between 1988 and 1997, transfer programs, retirement incentives, and attrition contributed to a forty-seven percent drop in the agency's workforce. As of late, the OMH anticipates that community-based outpatient programs and the growing number of inpatient psychiatric beds in general hospitals (which are eligible for Medicaid reimbursement) will in the future produce a further decline in the state's inpatient population.[201]
The OMH's closure of facilities and declining workforce gave rise to concern that the welfare of the seriously mentally ill would be sacrificed in the name of cost-effectiveness. In an effort to insure that psychiatric-center closures do not produce the problems associated with deinstitutionalization in the 1970's and that efforts to pare the OMH workforce and close facilities that it operates are not propelled solely by the desire to reduce mental-health spending, the Community Mental Health Reinvestment Act (CMHRA) of 1993 mandates that the savings realized from the closure of Harlem Valley, Gowanda, Central Islip, Willard, King's Park, and any other state psychiatric centers be directed to community-based treatment, residential, and support programs for people with severe mental illnesses.[202] Although Governor Mario Cuomo initially objected to the CMHRA on the grounds that it would tie the hands of his successors and the CSEA was opposed to any facility closures, the Mental Health Action Network, an informal coalition of politicians, mental health professionals and advocacy groups that pressed for the law's passage and shaped its provisions, successfully overcame this opposition and secured its passage. Despite Governor Pataki's efforts to undercut it, the CMHRA remains in effect.[203]
