President Kennedy's Unrealized Promise

Exactly a half century ago, in October, 1963, President John F. Kennedy signed the Community Mental Health Centers Act into law.  It affected two very different classes of people - people with mental illness and people with developmental disabilities.

In many ways, it was a civil rights act, promising to replace large, segregated institutions with integrated, community-based services.

It made a huge difference for people with developmental disabilities. 

But for people with mental illnesses, its promise is unfulfilled and the dream sometimes feels like it is dying.

When President Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Acton October 31st, he did so with optimism. The law specified that the new community mental health centers would offer four services – prevention, diagnosis, treatment, and rehabilitation or recovery – to people with mental illness.  And the result would be that all people, no matter what their disability, would live freely and comfortably in their home communities.

Had he lived to today – into his late 90s – President Kennedy would be appalled at what became of this vision.

He would have witnessed in 1981 the replacement of direct federal funding for community mental health services with an inadequately-funded mental health block grant to the states.  And he would have seen the result.  Chronic homelessness grew, and jails and prisons became the new warehouses for adults with mental illness.  Here is a statistic that would have stunned President Kennedy – women in prison today are twice as likely to have serious mental illnesses as are men.

President Kennedy would also be dismayed that his vision for community-based special education for children with emotional disturbances became so clouded, and with such tragic consequences.  The Act provided for demonstration grants to improve special education services.  He never could have imagined that fifty years later, only 389,000 children would be receiving special education services because of emotional disturbances.  And if one in five school-aged childrenactually has a mental disorder, then this means that we are identifying only one in every 28 for special education services.

And, notwithstanding the promise of the Affordable Care Act, President Kennedy would also be far from satisfied with some recent federal foot-dragging.  In 2008, the Mental Health Parity and Addiction Equity Act passed with the help of his brother and nephew.  It guaranteed equitable insurance coverage for mental health and health conditions.  But it has taken five years for a final rule to implement that law (a rule now promised within days or weeks).  And at the same time funding for SAMHSA – through which federal block grant dollars flow – has declined.

He would have seen states do no better.

I was in the Connecticut State Legislature when we received our first block grants in the early 1980s.  There was zero interest in using state funds to continue building the community mental health center program. 

That was long ago.  So let’s look at today. 

In the five years between 2008 and 2013, states cut $4.6 billion from mental health services, often citing an unwillingness to burden state taxpayers with these services. 

But even when states were offered a free ride, many still refused to authorize additional spending on mental health services.  This year, twenty-two states refused to expand their Medicaid programs, even though the federal government agreed to pay 100 percent of the cost for three years and told states that they could contract the programs again as the federal share went down.  No surprise – many of the 5 million left behind will be people with mental illnesses.

If we wanted to realize the vision of President Kennedy, it would not be hard.

We could offer all children mental health screening as part of well-child exams, and admit more children with mental illnesses to special education services.

We could provide insurance coverage to more people with mental illness, and appropriate more funding to community mental health services. 

And we could opt not to send adults with mental illness to prison, at least until we have guaranteed them access to care and worked with them to develop a meaningful recovery plan that might help them avoid hospitalizations, homelessness, and imprisonment in the future.

If we did these five things, we could give vigor to the dream and honor the promise President Kennedy made when he signed the Community Mental Health Centers Act into law:

“It was said in an earlier age that the mind of a man is a far country which can neither be approached nor explored.  But today… it will be possible for a nation as rich in human and material resources as ours to make the remote regions of the mind accessible.  [People with mental illness]… need no longer be alien to our affections nor beyond the help of our communities.”   

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

When George McGovern Made Mental Health A Campaign Issue

When Senator George McGovern, who died this past weekend, decided to run for President, he did so as a World War II hero who opposed the Vietnam War. 

A respected South Dakota senator, he helped galvanize anti-war sentiment among young people and ride it to the Democratic Party’s nomination in the summer of 1972.

His election prospects that year were as remote as Senator Goldwater’s had been just eight years earlier.  From opposite ends of the philosophical spectrum, there was much to admire about both of them.  But they were also both too removed from the center of the political spectrum to be electable in the moderate America of those times.

As a vocal McGovern supporter back in 1972, I have long wondered how he felt about the one thing I admired least about his political career – the moment when he let fear about mental illness alter the course of our public policy history.

There is an excellent and recent brief story about this on the National Public Radio website, summarizing a book written by Joshua Glasser entitled The Eighteen Day Running Mate.

Despite growing opposition to the war, Senator McGovern’s path to the Democratic Presidential nomination was far from easy.  By the time he won his nomination, he was a polarizing figure who was behind in the national polls. 

President Nixon’s campaign machinery was also in full swing at the time, doing its damage just after the Watergate break-in.  Had people known at the time all there was to know about the Nixon Administration, any viable Democrat probably could have beaten him.

But it was still a full year before the full nature of that Presidency would come to light in the Watergate hearings.  It was more than a year before Spiro Agnew would resign the Vice-Presidency over corruption, and two years before Nixon would resign the Presidency in disgrace.

So the focus was on McGovern, who was on the defensive politically.  “A” list politicians wanted to stay off of the McGovern ticket.  At the last minute, McGovern finally settled on Senator Thomas Eagleton – a respected Senator from Missouri.  When McGovern asked him if he had any skeletons in his closet, Eagleton answered “no” and accepted the nomination for vice-president.

Within days, there were rumors that Eagleton had a “complicated” medical history.  People didn’t talk much about “complicated” medical histories in those days, but the story bled out over the next two weeks. 

Several years earlier, on three occasions, Eagleton had been treated – ultimately successfully – for depression.

That was the sum total of Eagleton’s “complicated” medical history.

McGovern initially responded by supporting Eagleton – I remember when he declared that he was behind him “1,000 percent.”  But within days, fears began to grow in the media and among the public about whether Eagleton, with a history of mental illness, could be trusted with his “finger on the button.”  Bowing to this fear and prejudice, McGovern backed away from Eagleton’s candidacy, and Eagleton gave up the nomination just eighteen days after accepting it.

How might the course of our public policy history have changed if McGovern had kept Eagleton on the ticket?

Certainly, the discourse of the 1972 campaign would have been different.  Eagleton’s continued presence on the ticket might have stripped away at least some of our prejudices.  We all would have been educated about the nature of treatable mental illness.

And it would have shown an entire nation that mental illnesses were not to be feared, and did not need to prevent people from lives of amazing accomplishment.

It might have changed the course of actual public policy, too. 

If Senator Eagleton were more than just a quiet footnote to Presidential campaign history, would the Community Mental Health Centers Act still have been repealed back in 1981 and replaced with a block grant?

Would fewer people with serious mental illness today be in jail – a percentage that is three times greater than the prevalence in the general population and also three times greater than the prevalence among those incarcerated at the time of the 1972 campaign – and more have access to treatment?

I don’t know the answer to these questions, but I do know this.  Senator McGovern – whom I otherwise admired until his death – had just a moment on the stage when as a candidate for President he could have permanently altered the way we think about illness and disease.

And he squandered that opportunity.  

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