State Health Care Reform: Conflicting Perspectives on Consolidating Long-Term Psychiatric Inpatient Care at a Single State Hospital

Most states are downsizing their public psychiatric hospitals (1,2,3,4,5), and some states, such as California, Connecticut, Michigan, New Jersey, Pennsylvania, and New York, are consolidating their remaining long-term inpatient beds either in a small number of hospitals (5,6) or in alternative intermediate care facilities (7). Some of these consolidation plans involve merging two or more state hospitals and creating a smaller but more centralized inpatient capacity (6). Although consolidation may make economic sense, political difficulties often arise when the costs of such policies are concentrated in particular communities.

Consolidation policies are designed to have both therapeutic and economic advantages. They promote the public good and benefit society as a whole. Yet these policies are often associated with negative impacts that are concentrated at the local level. In reaction, the community chosen to bear the burden may resist the consolidation, seeking reparations that distribute the burden more fairly.

The impact of consolidation policies on affected communities is typically overlooked. It is implicitly assumed, or hoped, that communities will welcome the changes. However, evidence suggests that this assumption is false (8,9). Local residents have repeatedly resisted the placement of persons with severe mental illness in their communities, even if they reside in inpatient facilities.

This paper examines a case in a Northeastern state in which local residents resisted the state's decision to consolidate long-term inpatient care in a hospital in their community. The case is used to illustrate the importance of considering the host community's perspective in plans to consolidate state hospital services.

A host community's perspective

In July 1995 the state implemented a plan to consolidate all long-term inpatient behavioral care in a single state hospital in one city. The plan involved closing two other state hospitals and renovating and expanding the remaining hospital, which had been located in the host community for more than 100 years. In December 1995 the host community challenged the state's action in court on the grounds that the state failed to comply with a state law that requires an environmental impact study of construction plans that affect the physical environment.

In August 1996 the court ruled against the state, halting all further action until an environmental impact study was completed. In reaction to the community's impassioned testimony about the impact of the consolidation plan, the court broadened the definition of "environment" to include the economic welfare of the community, and it ordered an impact study of consolidation on both the physical and the economic environment of the host community.

The ruling of the court brought into sharp focus questions that heretofore have been neglected. What is being asked of a community that hosts a state hospital? What is fair to ask of a community? Is there a need to compensate the community for assuming this public-good function, and if so, what is appropriate compensation? These questions and their answers need to be incorporated into the policy-making process.

Researchers can help in this process by providing a systematic and comprehensive way of measuring and assessing community impact. The companion article to this column, "The Community Impact of Consolidating Long-Term Inpatient Care at a Single State Hospital," describes such a model (10). The model was used to estimate the impacts of state hospital consolidation on the host community during the 18 months after the plan was implemented. As described in the companion article, the consolidation plan had a positive overall impact on the community in the first 18 months of implementation (10). Although the court action stopped all renovation activity, the relocation of patients to the hospital was completed before the injunction.

Central to this evaluation of impacts on the community was developing a framework that fully captured the different perspectives and concerns of the state and host community but that pertained only to the host community. Because the impacts are diffuse and broadly distributed, measuring them requires data from every segment of the community, including the hospital, other local service providers, merchants, and community residents. During the data-gathering phase of the study, extensive interviews were held with state officials and town representatives. The interviews were supplemented by information from the court record, public hearings, and newspaper accounts of the consolidation process as well as a public opinion survey.

From the community's perspective, costs are of two general types. The first is public safety. Some local residents may associate severe mental illness with violence (11). They reason that public safety will be compromised if more persons with severe mental illness are located in their communities, either because the hospital disproportionately discharges patients to the community or because patients escape to the community. If the community becomes known as being unsafe, the residents' property values may fall, eroding their financial security. Furthermore, it is argued that as the community's reputation becomes more stigmatized, local and neighboring residents may be less inclined to shop in the town, shrinking the local retail base and contributing to the economic decline of the community.

The second set of costs is related to local services. It is expected that persons with severe mental illness will be heavy users of law enforcement, education (they may have children with special needs), housing, and other locally funded services. These extra costs will be borne by local residents, either directly in the form of higher local taxes or indirectly in a general loss in the quality or availability of local services. Residents may envisage this cost as a sort of tax on their civic goodwill.

In the case studied here, the hospital's perspective was markedly different. Hospital officials argued that security and discharge policies and practices were in place to limit the expected negative impacts. Furthermore, they argued that the hospital, through its expansion, would have a positive impact on the community by stimulating local employment and retail sales—directly through its local purchases or indirectly through the purchasing power of its expanded work force.

In cases like these, policy makers may anticipate some of the localized costs and proffer compensatory benefits. The benefits may be in-kind, such as deeds to state property, or monetary payments. Conditions may be placed on the benefits that limit their use, availability, or timing. It is expected that the benefits will, at least in part, compensate the community for any real or perceived costs associated with the relocation policy.

Issues of fairness are at the center of controversies over consolidation. The cause of the conflict between the state and the community can be traced to one factor: perspective. The study described in the companion paper showed that if the community focuses on safety and subjective impacts, it could reasonably argue that the costs are too high. In fact, 28 percent of residents in the host community who disapproved of consolidation reported that the burden was too great for the town (10). Another 14 percent of those who disapproved of the plan said that services should not be concentrated in one town. But it is important to keep in mind that those who actively opposed the plan were a minority of residents (27 percent). Although a larger proportion of the community either was unaware of the plan (30 percent), had no opinion (30 percent), or supported the plan (13 percent), it is typically a small, vocal minority that acts to shield the community from what it deems an unfair burden.

A vocal minority offers an important check against the decide-announce-defend approach to policy making (12). These forces of resistance, whether motivated by fear or lack of knowledge, place the burden on government to provide a fuller accounting of how the community is likely to be affected by government policy. Moreover, resistance brings differences among perspectives into the public arena where they can be openly debated and deliberated. "Constructive conflict" can be used to benefit all parties (13) by broadening the discussion to include subjective and objective impacts on the community environment as well as compensatory benefits. Without good information about the costs and benefits of these policies to the community, decisions about how to reorganize and where to locate inpatient behavioral health services may center on debates fashioned by fictions and fears, not facts, and mire the process of change in the politics of the uninformed.

Dr. Wolff is associate professor in the department of urban studies and community health and the Institute of Health, Health Care Policy, and Aging Research at Rutgers University, 30 College Avenue, New Brunswick, New Jersey 08901-1293 (e-mail, [email protected]). Howard H. Goldman, M.D., Ph.D., and Colette Croze, M.S.W., are editors of this column. A related article appears in this issue beginning on page 801.