Two behavioral health bookends define the past half century. They are President John Kennedy’s Community Mental Health Act of 1963 (CMHA) and President Barack Obama’s Affordable Care Act of 2010 (ACA). These two Acts are very similar in key respects: badly needed when enacted; basically beneficial for behavioral health; broadly promising for the future. Yet, these two monumental Acts also occurred in very different eras. The early 1960s were a period of exceptional growth and promise: people believed that everything was getting better! By contrast, the early 2010s are a period of much doubt and cut back: many people are fearful of the future! Because of these similarities and differences, we must learn from our 50-year response to the CMHA in order to help us plan effectively for the coming ACA era.
Clearly, the past half-century has been very uneven terrain for those directing mental health and substance use services, especially county directors of these programs, who are on the front lines of care. We have gone from soaring heights to sinking depths several times during the 50 year period between 1963 and 2013. The peaks include the CMHA, passage of the Mental Health Systems Act of 1980, President Clinton’s efforts to pass the Health Security Act in 1993; the Surgeon General’s first-ever Report on Mental Health in 1999; the President’s New Freedom Commission on Mental Health in 2003; and the remarkable growth of the consumer movement, which has brought us the crystal clear promise of recovery.
Arguably, the valleys include obvious failures of deinstitutionalization in the 1970s and 1980s, which resulted in many adult mentally ill persons becoming homeless or incarcerated; the repeal of the Mental Health Systems Act in 1981, which delayed by a quarter century our organized response for adults with serious mental illness; elimination of substance use as a source of disability for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) in 1998, which resulted in considerable pent-up demand for substance use services; and much angst over organizational and provider reimbursement, as states instituted managed care, and as budgets tightened in the 2000s, especially after 2008, with the onset of the Great Recession.
What have we learned from all of these ups and downs? Here, I will cite several different things that strike me as very important learnings for the future. These items are suggestive rather than exhaustive. You may want to think about this issue and add your own items to my list.