In considering how to improve the mental health system, the question that needs to be asked is, “Who should be responsible?” If no one is responsible, no one can be blamed; consequently, there is no leverage to improve the system. Before 1963, the responsibility for the treatment of persons with serious mental illness was a state responsibility; thus, the governor and the state Legislature could be held accountable.

With the passage of the 1963 Community Mental Health Act, followed by federal funding through Medicaid, Medicare, Supplemental Security Income and Social Security Disability Insurance, the funding of the mental health system effectively shifted from the states to the federal government. But who is ultimately responsible? Medicaid funds are essentially driving the system, but we don’t hold the head of the Medicaid program responsible. In fact, no one is responsible. States and counties deliver the services, but their decisions are constrained by federal guidelines regarding what can and what cannot be funded. The funding of the mental health services in the U.S. is more thought-disordered than any of the thought-disordered patients it is meant to serve.

The logical answer is to give the responsibility — and the federal funds currently supporting mental health services — back to the states and hold them accountable. The experiment in federalizing these services, begun in 1963, has been a clear and continuing failure. We tried, and it did not work. State governors and state Legislatures should assume responsibility for all mental health services and substance abuse services and then be held accountable.

Mark Jacobson

Winona