50 Years After: Will We Realize JFK’s Vision for Mental Health Care?

In October 1963, a half century ago, President John F. Kennedy signed the landmark Community Mental Health Act (CMHA) into law. “The time has come for a bold new approach,” he’d declared in urging congressional action. “If we apply our medical knowledge and social insights fully, all but a small portion of the mentally ill can eventually achieve a wholesome and constructive social adjustment.”

While the intent was noble, the vision was never realized.

The CMHA was intended to set the foundation for contemporary mental health policy, one premised on the establishment of community-based care as an alternative to institutionalization. Yet its vision—for persons with mental illness as well as for the country—was doomed almost from the start.

In 1963, U.S. public psychiatric hospitals had more than 500,000 beds. In these institutions, some patients had been held for years. When states began to discharge patients from these hospitals in accordance with the new policy of deinstitutionalization, local communities had neither the expertise nor infrastructure to care for the influx of patients suddenly in their midst. Adequate funding for treatment and programs never followed, and many people were left without the support they desperately needed. Consequently, many patients wound up homeless or incarcerated.

It’s a tragedy that endures today; 20 percent of the inmates of jails and prisons are persons with mental illness, and the penal system is now the nation’s biggest provider of mental health services. In addition, 30 percent of homeless persons are mentally ill. But on the 50th anniversary of the act’s passage, we have a chance at last to realize President Kennedy’s vision, if only there is the will to fully advance the goals of quality and comprehensive community-based mental health care.

Today mental health is once again at a historic crossroads, as embodied in the issues of parity and health care reform.

Let’s look at each issue separately. The first, parity, was supposed to have been resolved with the 2008 Mental Health Parity and Addiction Equity Act. Under the law, employer-based insurance plans that offer coverage for both physical and mental health/substance use disorders are required to do so comparably. But the impact to date has been limited.

As a series of hearings across the country revealed last year, key provisions of the act’s implementation have been twisted and manipulated by insurers to restrict coverage. This abuse has endangered lives by denying mental health patients the care they need and are entitled to legally. APA has filed suit against some insurers who have been the worst offenders.

Soon the Obama administration is expected to release the final rule implementing the legislation, a long-awaited move that will provide meaningful protection to millions of Americans so that they can easily access mental health treatments. It’s our hope and expectation that the rule will put power behind enforcement, offering the clarity and direction that these patients need to hold insurers accountable.

Yet parity, critical as it is, doesn’t finish the job. Many individuals with mental illness do not have health coverage through a job. They not only need benefits on par with physical health coverage but also access to those benefits, and the Affordable Care Act provides both. It ends insurers’ practice of denying coverage based on preexisting conditions—mental disorders prime among those—and extends coverage to people who previously were unable to afford it. And starting in 2014, the health reform law mandates that plans in the new health insurance exchanges provide equity in insurance coverage between physical and behavioral health benefits.

As a result, the Obama administration estimates that as many as 62 million more Americans will be able to obtain mental health coverage (if all states participate). That’s nearly a fifth of the country, a significant accomplishment by any measure.

We cannot ignore the mistakes and shortcomings of deinstitutionalization, but we should mark the extraordinary progress made since 1963—in the public’s understanding of mental illness, in our capacity to treat it and the breadth of services now offered in communities, and in the effective advocacy by people with firsthand experience of problems like depression and schizophrenia.

Now is the time to build on this progress by addressing the continuing challenges to quality mental health care. One of the most daunting is the shortage of mental health professionals in many areas, and efforts to integrate psychiatric care into primary care practice deserve increased support.

In introducing his proposed legislation 50 years ago, President Kennedy made clear that “inadequate funds, further studies, and future promises” would no longer be grounds for inaction. “Governments at every level—federal, state, and local—private foundations and individual citizens must all face up to their responsibilities,” he stated.

Echoing this sentiment, his nephew and former congressman Patrick Kennedy convened many leaders of the mental health community in Boston on October 23 for the launch of the Kennedy Forum, a new initiative designed to unite the mental health community in common purpose, celebrate the 50th anniversary of CMHA, and set a course for the future. (See the next issue of Psychiatric News for coverage of this event.)

We must seize this opportunity and not fail this time to realize the vision of ensuring that affordable and accessible quality mental health care is provided to the people of this country. ■