Stephen Eide joins Brian Anderson to discuss his new report on the continuum of care, proposing a structure for mental-health systems across the United States. The report, authored with MI adjunct fellow Carolyn Gorman, is out this week.

Audio Transcript

Brian Anderson: Welcome back to the 10 Blocks podcast. This is Brian Anderson, the editor of City Journal. Joining me on the show today is Stephen Eide. He's been on the show before. He's a City Journal contributing editor, a senior fellow at the Manhattan Institute and the author of a brand new book called Homelessness in America, which has been published by Rowman & Littlefield. He also has a new report due out this week from the Manhattan Institute, co-authored with adjunct fellow Carolyn Gorman, and it's called "The Continuum of Care: A Vision for Mental Health Reform." So Steve, as always, thanks very much for coming on the show.

Stephen Eide: Thanks for having me, Brian.

Brian Anderson: This new report, which I'd like to talk about, does not propose a single nationwide system for mental health care in America, but it does sketch a kind of structure that communities can adopt. So what is the continuum of care that you're referring to?

Stephen Eide: Well, we're trying with this report to take seriously the idea of a community-based system of mental health care. This has been the ideal in mental health-care policy debate, going back many decades, when we decided to phase out the old asylum system, but we've always come very short of that ideal. And even though there seems to be ever more interest in mental health, that debate, the coverage of mental health, just continues to have this just very vague character. And so with this report, we're trying to give a little bit more focus and just concreteness as to what exactly a community-based system with mental healthcare with real integrity would look like. So most people would be living in the community in accord with the ideal. They would know where to find their programs, but it would just work more effectively than the system that we have.

Brian Anderson: Well, you say that it's community-based in two ways, so first, it's non-institutional, so that would mean it's providing services in a less restrictive setting than the older asylum system. And then second, that mental health service programs would be local and, as you just said, they would differ based on local conditions. So what in your view is the kind of advantage of this particular approach?

Stephen Eide: Well, you need to be talking about programs that are focused on serious mental illness, primarily, focus on helping people with serious mental illness before, during, and after a psychiatric crisis. It needs to be a residential system, mainly: that is, programs that have a residential component that provide people with place to sleep and live temporarily. And you need to be talking about a set of programs, not just one program in the case of the old asylums. It has to be a system that coordinates, such as, for example, by data sharing. And this would be a better system than the one we'd have now, because you would see fewer people falling through the cracks, as happens so often with seriously mentally ill individuals these days.

Brian Anderson: I see. So as you write in this report, mental health care in America has undergone a series of reforms over the last several decades. There are pharmaceutical interventions now like lithium that are widely available. Most of the population actually does have some form of health insurance now. Programs have shifted from inpatient to outpatient care, and there's been a proliferation of mental-health professionals, including doctors, of course, but also social workers. Yet despite these kind of reforms, the conditions are pretty bleak for the mentally ill still. I think you say that over 13 million adults have a serious form of mental illness in the country. And one-third of that number receives no treatment at all. So what is the reason for that gap between inputs and outputs?

Stephen Eide: Well, I do think that there is a tendency to keep expanding the system, keep spending more on programs, but not focusing enough on the hardest cases, the most troubled cases, which many people just say they can't handle, but these drive so much of the debate, the subway pushings, the mass shootings. And there's an inattention to, I think, involuntary approaches to treatment. And also just an inability to really kind of knit these programs together. It's like, okay, I understand that people don't want to bring back the old asylum system. I mean, I think that's an important debate to have, there are many excellent City Journal articles that have contributed to that debate, but in the near term, just practically speaking, we need to think more about how to make a community-based system that works better. But what would that really mean? And I think the kind of discussions about data sharing and focus on crisis always tend to move in kind of uncomfortable directions for a lot of people. And that's why we continue to make so little progress.

Brian Anderson: You observed in the report that inpatient hospitalization should be a last resort and utilized when patients need crisis intervention and stabilization that you can't manage in a outpatient setting. So mental hospitals are central to the continuum of care. Maybe you could say a little bit more about why they're so important and what can inpatient hospitalization accomplish that community settings cannot. And what are the obstacles in the way of expanding that kind of inpatient care? I guess a lot of the asylums were shut down and there's not a lot of beds available. So what does that picture look like right now?

Stephen Eide: I think when we moved away from the old asylum system, what we really moved away from was long-term institutionalization. City Journal ran this really interesting article years ago by Howard Husock about his great-uncle. It was common that people would spend essentially their entire adult lives in a mental asylum and that we really moved away from. So we still have tens of thousands of psychiatric hospital beds, but they're mostly oriented towards short-term, intermediate-term stabilization of people in crisis. These are chronic diseases. It's expected that often they're going to be recurring crises. So how do you respond when crisis hits?

The barriers to using more psychiatric hospitalization, I think a lot of the attention is on the legal barriers, the legacy of the civil-liberties movement. It's very difficult to persuade a court to allow someone to go into a hospital against their will if they don't want to go. But there are also these very important fiscal barriers in terms of the way that we fund mental healthcare, even in inpatient mental healthcare in America through insurance, Medicaid. There is a way in which that system, which ramped up in the latter decades of the twentieth century was never really built to pay for long-term institutionalization. And so if we want to open up that possibility for certain types of people, we really need to think more about how we pay for inpatient psychiatric care in addition to the legal question.

Brian Anderson: You talk in the report about the importance of non-hospital transitional residential services and the need to close gaps between the host of different mental health care programs, that as you've been suggesting here, they don't always operate cohesively. So maybe talk a little bit more about why that matters and what the problem is there in terms of the cohesiveness of service.

Stephen Eide: Well, there are various different funding systems that get set up. New York and California are a good examples of this because these are places with, because of homelessness, crime, and disorder, mental health problems that often seem so out of control, but it's easy to forget that these are very resource-rich environments. They have all kinds of programs to divert mentally ill people out of the criminal justice system. And New York has been doing that forever. So why do we still have a problem? I think that a lot of it comes down to this falling through the cracks thing, where in the wake of a subway pushing, there's some sort of reporting or investigation done. What happened to this guy? Wasn't somebody looking after him? And a lot of times answer seems to be well, people just stopped, lost sight of him.

He was showing up for a program. He stopped showing up and people just sort of shrugged and moved on. So how do you set up these systems of providers who can deal with people in different stages of recovery, who deal with people with different kinds of serious mental illnesses, but who somehow coordinate or who is somehow talking to each other to make sure that if one person loses sight of someone, another person is trying to stabilize them. If we're serious about doing this community-based system, we need to be far more serious about that type of coordination, which is not happening now.

Brian Anderson: Do you think, and this is the final question, do you think that the impetus for reform that might make this kind of continuum of care vision possible, would it be coming from the states on the level of state governments or would there be a federal role here?

Stephen Eide: I think there really does need to be an important federal role in terms of removing certain prohibitions on funding, such as the so-called IMD exclusion, which prevents Medicaid from funding inpatient psychiatric care in specialized psychiatric hospitals, and also just specialized psychiatric programs, residential programs that operate with real scale. That is a really important reform that's going to need to happen. And also in other ways, the federal government may need to be talking about other kind of targeted funding streams for this particular population, this particular system. It is the case that there are probably some jurisdictions, rural places that are just not going to have the resources to do this right, do this effectively. It's not a problem as much in New York or California, but does point to a federal role if we really want to make headway with this crisis.

Brian Anderson: Okay. Well, thanks very much, Steve. The report is called "The Continuum of Care: A Vision for Mental Health Reform." It's out this week from the Manhattan Institute. Stephen Eide, he's co-authored it with Carolyn Gorman. He's also the author of the new book, Homelessness in America, which I encourage you all to pick up and read. It really is the definitive history of homelessness in America. Don't forget to check out Stephen Eide's other work on City Journal's website, We'll link to his authored page in the description. And you can find City Journal on Twitter @cityjournal and on Instagram @cityjournal_MI. As usual, if you like what you've heard on today's podcast, please give us a five star rating on iTunes. Stephen Eide, always great to talk with you.

Stephen Eide: Thanks for having me, Brian.

Photo: stellalevi/iStock

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