To the Congress of the United States:
I am today submitting to Congress the Mental Health Systems Act. This proposed legislation establishes a new partnership between the federal government and the states in the planning 'and provision of mental health services. It seeks to assure that the chronically mentally ill no longer face the cruel alternative of unnecessary institutionalization or inadequate care in the community. It provides local communities with more flexible federal support for mental health services and places a new emphasis on the prevention of mental illness.
I am deeply committed to reducing the tragic toll which mental illness exacts from our citizens and our country. Less than one month after entering office I signed an Executive Order creating the President's Commission on Mental Health with Rosalynn Carter as Honorary Chairperson. I directed the Commission to undertake an intensive study of the mental health needs of our nation and to recommend appropriate ways of meeting these needs.
During our years in Georgia, both Rosalynn and I became keenly aware of the unmet needs of people in our state who suffered from mental and emotional disabilities. Those with chronic mental illness were too often locked away in isolated institutions far from family and friends. Children and adults with signs of developing mental and emotional problems did not have access to early detection and prevention programs. Community-based care was beginning to develop but was constantly stripped of its full potential by inflexible program models designed for the "average" community, rather than for the particular needs of a given locale or state. Special populations such as the elderly, children, and racial and ethnic minorities were not receiving care designed to meet their special needs. For those who required hospitalization there were almost no alternatives to large state mental hospitals. Aftercare was almost non-existent for patients released from those hospitals who returned to their home communities.
While I am proud of what we accomplished in Georgia to begin to solve these problems, my concern that similar problems exist throughout the nation prompted me to establish the Commission and to ask it to report back to me in one year with its findings and recommendations. The excellent final report of the Commission presented to me last April made clear that the past 30 years had seen tremendous achievement on behalf of our mentally ill population. Not only had there been a dramatic shift of emphasis from inpatient care to community-based care, but great strides had been made in mental health related research, and thousands of mental health personnel had been trained. However, the report also contained unmistakable evidence that there are unmet needs in every region of our country.
Some of the key Commission findings dramatically illustrated the challenges this nation faces in meeting the needs of the mentally ill:
—According to the most recent estimates, between ten and fifteen percent of the population—20-32 million Americans-need some form of mental health services at any one time.
—Substantial numbers of Americans do not have access to mental health care of high quality and at reasonable cost. For many, this is because of where they live; for others, it is because of who they are-their race, age, or sex; for still others, it is because of their particular disability or economic circumstance.
—There are approximately 1.5 million chronically mentally disabled adults in mental hospitals, nursing homes and other residential facilities. Many of these individuals could lead better lives in less restrictive settings if mental health and supporting services were available in their communities. The problem is that for them—and for the hundreds of thousands of patients who have been returned to their communities from large institutions over the past few years—such support services are seldom readily available. As a result, evidence indicates that half the people released from large state mental hospitals are readmitted within a year of discharge.
—There is insufficient emphasis at federal, state, and local levels on prevention and early detection of mental disorders. Infants and children would especially benefit from expanded prevention efforts, since early intervention with problems in physical, emotional and cognitive development can prevent more serious mental and emotional problems in the future.
—Conflicting policy objectives in various Federal health and mental health programs and between federal and state programs often lead to confusion, fragmentation of services, and a lack of continuity of care for those with mental and emotional problems. In addition, diverse federal planning requirements and poorly developed planning capabilities at the state and local levels have perpetuated the lack of integrated planning necessary to build a nationwide network of accessible public and private mental health services.
—The lack of flexibility in Federal funding of community-based services has prevented some communities from providing services to their underserved populations. Although over 700 Community Mental Health Centers provide services to almost 3 million patients annually, this model of organizing services cannot fit the needs of all people and all communities. Therefore, varying approaches to developing comprehensive community mental health services should be encouraged.
—About two-thirds of all mentally ill persons being treated in this country every year are receiving care in the general health care system. Nevertheless, cooperative working arrangements between general health care settings and community mental health programs are rare.
—Over the past several years, there has been a marked increase in the number of professional and paraprofessional mental health practitioners. However, rural areas, small towns, and poor urban areas still have only a fraction of the personnel they need. Many mental health facilities have a shortage of trained personnel. The mental health professions still have too few minority members, and there is a shortage of specialists trained to work with children, adolescents, and the elderly.
—Since 1969, our national mental health research capacity has undergone substantial erosion and our investment in mental health research is now so low that the development of new knowledge is jeopardized.
To deal with these and other problems in the mental health arena, the Commission developed a series of recommendations for bold new action to improve our nation's mental health. Many of these recommendations served as a blueprint for the proposed Mental Health Systems Act.
The proposed Act charts a new course for mental health care which promises comprehensiveness, flexibility and innovation. For the first time in the history of federal involvement with mental health care, a true, performance-based partnership would be created between the federal and state governments. Special emphasis is placed on the chronically mentally ill. Recognizing that this population has long been the most neglected of any mentally ill group, the proposed Act provides support to states which are phasing down large state hospitals, upgrading the quality of services in remaining institutions, and providing quality alternatives to institutionalization. I believe that these provisions of the Act will encourage the development of a comprehensive, integrated system of care designed to best serve the needs of chronically mentally ill adults and children.
Another innovation is the proposed Act's emphasis on prevention. States and localities are awarded grants to develop preventive and mental health promotion programs through public and professional education and demonstration projects. Such programs, I believe, will lay the foundation for the future in mental health care as we learn how to prevent mental illness before it occurs.
The proposed legislation gives a new and much needed flexibility to community mental health programs. It authorizes funds for one or more mental health services without requiring that a comprehensive package be developed as a prerequisite for financial assistance. This new flexibility will enable communities to provide services to their most underserved populations—whether the chronically mentally ill, children, the elderly, racial and ethnic minorities, the poor, rural residents, or other groups—and build toward a comprehensive system of care for the entire community over time. In addition, by providing financial incentives for closer coordination between ambulatory health care providers and mental health care providers, the Act takes an important step toward assuring that appropriate mental health care is available for all who need help.
The Act also guarantees increased availability of mental health personnel in underserved areas by requiring that mental health professionals who receive federal support for training work in an area with a shortage of mental health personnel for a period equal to the length of the support.
It is, of course, impossible for any one piece of legislation to meet all the mental health needs of the nation. The federal government has already sought to implement many of the recommendations of the Commission in other ways:
—To increase the development of new knowledge about mental illness, the 1980 budget provides additional funding for research into disabling mental illness, and for determining ways to improve the delivery of mental health care.
—To increase the availability of mental health services for the elderly, changes have been proposed increasing the Medicare reimbursement ceiling for outpatient mental health services and decreasing the beneficiary's co-payment requirement. Also, the Child Health Assurance Program will mandate that states provide mental health services for Medicaid-eligible children.
—To assist the chronically mentally ill to function effectively outside of institutions, the Departments of Health, Education, and Welfare and Housing and Urban Development have initiated a joint demonstration project which provides both housing and support services.
—To promote protection of the rights of the mentally ill, the Administration is funding demonstration projects which deliver advocacy services to the mentally ill and is studying existing advocacy programs to determine the appropriate role for the federal government in this area.
I am convinced that these actions and the passage of the Mental Health Systems Act will reduce the number of Americans robbed of vital and satisfying lives by mental illness. I ask the Congress to join with me in developing a new system of mental health care designed to deal more effectively with our nation's unmet mental health needs.
The White House,
May 15, 1979.