In Reply: I join Dr. Kuehn in doubting that clinicians will ever see single-payer funding—even those in my age group (late 40s). However, with any luck, we may be able to radio the Carpathia and stop rearranging deck chairs aboard a mental health system fraught with Titanic inefficiency.
Unless there is a resurgence of "treatment" interventions sanctioned in Nazi Germany, we will have to continue providing citizens who have mental illness with subsistence-level support and health care (1). Any move to renege on disability payments, and we're right back to the 1950s, providing custodial care. I agree with Dr. Kuehn that reform on the state level can be accomplished; however, there are significant barriers. Mental health authorities, either local or centralized, tend to function, as Dr. Kuehn points out, as a welfare program for administrators.
Whether administered by a central authority or local boards, the provision of clinical care has shifted from state and county governments to nonprofit agencies over the past ten to 15 years. Recently, the nonprofits have boarded the compensation gravy train made famous by Fortune 500 companies. Consequently, we have administrators at nonprofit mental health centers making two to nine times the salary that they would receive as a clinician who actually provides services. In my home state of Missouri, the director of psychiatric services for the state department of mental health is paid less than 21 of the 25 directors of private mental health centers, some of whom are paid two to four times as much. Politicians are not blind to such public-to-private largesse, and the ideologists among them, who know nothing of treatment issues, have apparently decided to starve us out.
My experience has been with a highly centralized state authority, and local boards are therefore appealing. Dr. Kuehn, on the other hand, advocates for the opposite—funneling all available funding into a central mental health authority. Perils are inherent in either model, and currently each state is free to decide how to configure its system.
This discussion would be moot if Harry Truman had succeeded in 1946 with his national health plan that promised that Americans would receive health care "just as they do now" (2). His bill was denounced as "socialistic," as was the Clinton plan in 1994. Recent Medicare legislation is yet another reminder that as health care becomes more privatized, marketized, and uncoordinated, persons with serious mental illness will be shortchanged.
Had I been in Dr. Hogan's shoes, given a mandate for a "budget neutral" New Freedom Commission report, my resignation would have been submitted the next day. If we have no hope of a single-payer system, or even of consolidating all of the federal funding directed to mental health services, state governments will have to create their own unitary funding streams and do a radically better job of expending dollars on direct care—and also find additional funds somehow.
The share of state budgets devoted to mental health has declined precipitously in the last three decades, and although some savings were realized by closing large institutions, atypical antipsychotics, independent housing, and assertive community programs are costly as well. Sadly, bureaucrats and politicians have learned that patients are more readily underfunded when they are in the gutter than when they are in a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations.