Evolution of state variations in public mental health policymaking and its effect on access

The number of acute psychiatric inpatient beds has declined dramatically over the past decade, with corresponding declines in state-run long-term beds. State policies play an important role in both long-term bed supply and (through reimbursement) the financial viability of acute psychiatric beds. Historically, states were similar in public mental health funding approaches. However, with deinstitutionalization, state policies have diverged in both funding levels and the mechanisms and incentives built into the system. This has led to state differences in the viability of acute care inpatient beds, resulting in access difficulties in some states. The current research, part of a multiyear funded study, examines the relationships between state political factors and their ongoing policymaking with respect to public mental health services. All fifty states are included in this analysis. We classify states according to: generosity of funding; degree of funding centralization (county versus state); which entity risks cost overruns (e.g. county, state, or private entity); any existing Medicaid waivers; and the role of state long-term beds. We show that the above policies are significant predictors of the supply of private psychiatric beds. Furthermore, we model policy dimensions as a function of exogenous policymaking variables including: political party control; executive versus legislative control; socioeconomic evolution; and state regulation levels. We find that state public mental health policy has evolved in ways reflecting the state government structure; socioeconomic conditions; and elected officeholders. The structure of the government, in turn, determines the viability of public mental health care and access through policy implementation.