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Ask the Mental Health Expert Archives 2001-2004

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Federal and State Influence on Mental Health

Q. Do private health organizations do a better job of treating and increasing awareness for mental health patients rather than the U.S. government?

A. I am not entirely sure what you mean by private health organizations--but in general, I think that the government and private sector play somewhat different, but complementary, roles in mental health care and advocacy. The federal government essentially sets uniform standards that help establish the floor of mental health care--that is, standards that represent a bare minimum of care.

For example, in 1994, the Department of Health and Human Services (Department or HHS) published a Notice of Proposed Rulemaking to comply with the requirements of section 116 of the Protection and Advocacy for Mentally III Individuals Act of 1986 (Act) (42 U.S.C. 10801 et seq.). This act required that the Secretary of HHS promulgate regulations to protect and advocate the rights of individuals with mental illness (see Fed Regist 1997 Oct 15;62(199):53548-71). But in the end, it falls to state and often private organizations to implement federal guidelines.

In this, I think there is tremendous variation from state to state, and even city to city. In Massachusetts, for example, the trend has been to "privatize" a good deal of mental health care. I think this has been a mixed blessing, with some streamlining but also some curtailment of essential services. (See RL Wisor, Am J Law Med 1993;19(1-2):145-75 "Community care, competition and coercion: a legal perspective on privatized mental health care.")

To the extent that the private sector is driven by cost-effectiveness models, I have concerns that the bottom line sometimes takes priority over patients' needs. But then, I'm not sure the answer lies in federal bureaucracy or regulations, either. Ultimately, I think the best care is delivered at the community level, and has to do with local attitudes toward the mentally ill, how much to prioritize their care, how much to integrate the mentally ill into the community as a whole, etc.

If you want a more sophisticated inside look at these issues, I would strongly suggest you contact the National Alliance for the Mentally Ill (www.nami.org or 800-950-NAMI).

May 2002

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