Psychiatric Deinstitutionalization and the Patient “Dumping” Argument

Alix Rule, New York University (NYU)

This paper revisits the question of what mechanisms drove the rapid depopulation of public mental hospitals in the US during the second half of the twentieth century. New analysis of state level data yields scant evidence to support the long-accepted argument that States governments purposefully leveraged the federal Medicaid program to depopulate their mental hospitals. In 1955, nearly as great a proportion of Americans lived in state custody as do today -- the largest part of them, in state mental hospitals. Like mass incarceration in more recent times, the country’s heavy reliance on the state hospital system was recognized by many contemporaries as a social and moral crisis. By 1980, the population of the country’s state mental institutions had been reduced to less than 25% of its mid-century peak--and the imperative of “deinstitutionalization” had also seen serious reconsideration by policymakers, psychiatrists, and advocates on behalf of the mentally ill. Social scientists in the late 1970s and 1980s sought to identify the drivers of the relatively rapid depopulation of state mental hospitals, many ultimately laying the blame for deinstitutionalization’s failure as policy with the cost saving prerogatives of the governments of the States. Among the most influential was William Gronfein’s (1985) argument that states availed themselves of the Medicaid program to shift responsibility to the federal government. I revisit Gronfien’s analysis: replicate his results, and conduct new analysis on his original dataset, supplemented with more granular data on state Medicaid uptake, and detailed case studies of the trajectories of select states.

No extended abstract or paper available

 Presented in Session 132. State Politics: Social and Educational Policy