Beyond Deinstitutionalization: Mental Health Reform in Michigan

Shhh! There's a quiet revolution underway in mental health service delivery in Michigan.

Unlike the highly publicized closure of Detroit's Lafayette Clinic and nine other state hospitals and living centers in 1991 and 1992, these changes don't promise the sort of sensational confrontation that sells newspapers and makes for shocking television news coverage. They are, however, no less profound. To put the continuing reform effort in context, let's consider where Michigan was in the past and where it is today.

By 1970, a national movement to end the warehousing of the mentally ill in latter-day asylums and integrate them into the broader society had largely succeeded. In Michigan, the legislature passed a bill to provide more compassionate and supportive services based in local communities where patients' families live. Unfortunately, this recognition of the dignity of the mentally ill and developmentally disabled has often been saddled with the term, "deinstitutionalization," and used to explain away a host of society's ills, from crime to homelessness.

Studies document the therapeutic advantages of community-based care for all but the most severely ill. Through the involvement and support of parents and family, educational opportunities, job training, and supported employment, the mentally ill and developmentally disabled can achieve greater independence and stronger feelings of self-worth than can be obtained in an institutional setting.

By 1993, the legislature's 1974 goal of a statewide system of community health boards responsive to local needs had become a reality. Fifty-five boards serve all 83 Michigan counties, managing such services as assertive community treatment teams, outpatient counseling, and inpatient care. In 1993, the community programs served over 170,000 people. State financial support to local programs has increased from $165.8 million in 1980 to $1 billion in 1993. This dramatic increase in state support for community mental health was made possible by closing state hospitals that cost as much as $500,000 per bed per year.

From 1980 to 1990, 14 state hospitals and centers were closed, and the adult psychiatric patient population in state facilities shrunk by 32 percent. Since 1990, the population has declined another 33 percent. Now, only 10 percent of adult mental health patients are admitted to state psychiatric facilities, with the remainder being cared for in community hospitals and other local residential facilities. The numbers of children and adults receiving state inpatient treatment for developmental disabilities have also declined by similar proportions.

This is not the end of reform. Draft revisions to the state Mental Health Code are being circulated by the state Department of Mental Health (DMH) to allow community mental health boards to carry money forward, own property, issue bonds, and engage in new types of services appropriate to meet local client needs. This would allow boards to become less dependent on county governments, already strapped for cash, for financial support.

The most dramatic aspect of DMH's proposed changes would end the subsidy of private health insurers from the state and community mental health system. Current law says that anyone who is diagnosed as having a chronic mental illness becomes the responsibility of the public system, shifting the cost from health insurers to state taxpayers. DMH, instead, would like to turn this upside down, converting a public liability into a community asset- whereby private insurers pay competitive, locally-based providers to do the best job for those who require care. The objective of all these reforms to provide a seamless service delivery system for mental health, public health, substance abuse treatment, and social welfare delivery, ending turf disputes and cost-shifting between agencies.

Vilified during the highly visible and controversial closure of the Lafayette Clinic, state Mental Health Director James Haveman has emerged as one of the nation's senior mental health administrators. In other states where governors avoid controversy and let overstaffed, underpopulated hospitals that benefit from influential legislative favor continue to operate rather than seek compassionate, community-based alternatives, turnover among mental health directors is high.

Mental health policy makers in other states and in the nation's capital are watching reform efforts in Michigan closely. More and more of them are looking at our state as a model for the rest of the country.