GRADING THE STATES ON MENTAL HEALTH | Behavioral Healthcare Executive Skip to content Skip to navigation


April 1, 2006
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NAMI's landmark report highlights the important work ahead

On March 1, NAMI, the National Alliance on Mental Illness, released Grading the States: A Report on America's Health Care System for Serious Mental Illness. This report represents one of the most important projects in our organization's 26-year history. Without question, the report will serve as the backbone for NAMI advocacy efforts for years to come.

The report's findings do not paint a positive picture of the American mental health system. The national average was a “D.” No state received an “A,” and eight states received an “F.” (For a map of how each state scored, see This report comes on the heels of the President's New Freedom Commission on Mental Health Report, the Surgeon General's 1999 report on mental health, and the Institute of Medicine's 2005 report, all of which point to a system in “shambles” with significant gaps between promise and performance. NAMI's Grading the States provides further evidence of these failings.

Our state mental health systems are too frequently held together by rubber bands and bailing wire. Common themes found in the report include chronically inadequate funding, workforce concerns for people living with mental illness, and failure to promote and implement proven treatment practices. The report also documents breakdowns in the development of comprehensive community systems of care. From lack of available healthcare workers, to inadequate capacity for short-term hospitalizations, systems of care often are fragmented and have no long-term vision for recovery.

Despite the overall gloominess of the report, there are examples of gradual improvements that are noteworthy and should be replicated nationwide. New Mexico's Behavioral Health Purchasing Collaborative, Missouri's prescriber education initiative, and New Jersey's renaissance in mental health provide hope. However, these bright spots are too far and few in between.

NAMI has issued five specific policy recommendations to address the many shortcomings identified in the report. Advocates will be working diligently with state legislatures, governor offices, and administrative agencies to influence policy to bring these recommendations into practice. The five identified areas of emphasis are:

  1. Increase funding tied to performance and outcomes.

  2. Invest in evidence-based and emerging best practices.

  3. Improve data collection, reporting, and transparency of information.

  4. Involve consumers and families in all aspects of the system.

  5. Eliminate discrimination.

NAMI performed similar reviews in the late 1980s and 1990. Although very different in methodology, the earlier reports provided valuable background information that spurred modest changes in the mental health landscape. However, our state governments forgot the criticism and recommendations of the earlier reports; hopefully, the lessons of 2006 will not be so short lived.

It is important to point out that the report was not developed through a subjective lens. Rather, the report represents a structured, methodologic approach to gathering information on the systems of care for people living with mental illness from each of our 50 states and the District of Columbia. The authors took extraordinary steps to incorporate data from numerous credible sources, including family and consumer experiences, state system surveys, reviews of similar studies and reports, and measures of activity against best-practice standards. State administration leaders, NAMI members, and advocates were contacted for input and clarification. Each state mental health authority was asked to self-report information to ensure accuracy. NAMI also engaged a nationally recognized research agency to consult on methodology protocols and used “masked” graders to screen responses. These measures were taken to make the end product both unbiased and accurate.

The release of the report has garnered significant national attention. Within one week of release, the report had received more than 3.3 million print media impressions, had reached a national TV audience of more than 7 million, and had been discussed on 500 radio stations nationwide. The broad exposure of this report has contributed to an environment that is ripe for advocacy efforts to improve our nation's mental healthcare system.

In many states, the report already has created positive momentum. Governors, legislative leaders, and agency officials have used the report to justify greater investment and serious efforts at system reform. There have been a few isolated incidents in which public officials have attempted to distance themselves from the findings, but these have been the exception.

Since the release of the report, many are asking “so what next?” A valuable lesson learned from years in the trenches fighting for mental health parity is that wholesale movement takes time—sometimes months but, more frequently, years. For advocates interested in improving the quality of mental health services, many long hours of educating legislators await. Undoubtedly, frustration and resistance will surface. However, the promise of an improved system of care is worth the fight. Grading the States is only one tool in this urgent call for system change, but it is a very powerful one.

Steven L. Buck is Director of State Policy for NAMI.