Four million Americans have serious untreated mental health illnesses. Credit: Getty
Donald Trump is a master at disrupting stale bipartisan orthodoxies and remaking the politics of familiar issues. He did so with free trade and industrial policy in his first term, forcing even the Biden administration to adopt his views. This time around, his tough stance on the border, which helped him win in November, may form the next consensus. America’s mental-health crisis — recently highlighted by a string of horrific attacks in the New York subway system — presents another such opportunity.
That crisis consists of the four million or so adults with untreated serious mental illnesses, such as bipolar disorder and schizophrenia. The result is homelessness, mass shootings, random subway violence, and incarceration, especially in Democratic areas that shifted sharply to the Right in the 2024 election. Trump can disrupt and realign the status quo — provided he ignores small-government zealots in his own camp.
The mental-health crisis stems more from partisan agreement than disagreement. In his hit 2023 book, The Best Minds, author Jonathan Rosen noted that “Left and Right often met at the gates of the asylum.” He was referring to how, back in the 1960s, the deinstitutionalisation of the mentally ill was a joint effort of fiscal conservatives and progressive civil libertarians: the former shuttering mental hospitals in the name of austerity, the latter for autonomy’s sake. In the six decades that followed, the number of psychiatric beds nationally dropped to 35,000 down from 560,000.
That coalition still controls mental health-policy six decades later. Reformers and relatives of the seriously mentally ill have long called for allowing Medicaid, America’s public-insurance programme for the poor, to fund care in specialised psychiatric hospitals. Yet the move has long been opposed by a coalition of Republicans, who believe it would cost too much money, and Democrats, who worry that it would risk mass re-institutionalisation.
Enter Trump, whose first term mental-health agenda was underrated. Trump appointed a dedicated change agent as his mental health czar and weakened (if not removed) restrictions on the use of Medicaid for psychiatric hospitalisation. A second Trump administration raises hopes of further progress.
One reason to be optimistic about mental health is that the Trump-led GOP is less fiscally conservative than previous iterations. Greenlighting Medicaid funding for more adult beds in specialised psychiatric hospitals would cost $3 billion to $4 billion a year. This cost should be owned up to. Yes, savings could be realised from reduced spending on jails and homeless services and a serious reform agenda would slash funding for the numerous and pointless wellness programmes within the federal mental health budget.
Yet to DOGE-ify the discourse on mental health would risk repeating the mistakes of the past. One of the original sins of deinstitutionalisation was the belief that serious mental illness could be treated on the cheap. We learned the hard way that it wasn’t enough to offer meds and benefits to former asylum patients and expect them to take matters in hand from there. Schizophrenia is a chronic condition, characterised by episodic emergencies that necessitate extended supervision. Real reform will require a bigger mental-health budget. Hospitalisation, particularly, is an expensive intervention if we want to ensure high standards of care.
Sometimes things have to get worse before they can get better. As blue-city voters complain and the data show, public transit and street conditions have recently worsened. In last November’s election cycle, some high profile progressive prosecutors were voted out of office, and Californians passed Proposition 36, which strengthened penalties for low-level crimes. The proposition’s nearly 40-point pass margin signals that the politics of law and order are almost as popular in California as Donald Trump is in West Virginia.
Treating serious mental disorders and fighting crime are different government functions. But the reality is that a Democrat who votes to crack down against retail theft will likely also support a more paternalistic turn in mental health. Paternalism needn’t, and almost surely won’t, mean the return of the asylum order. Every Western nation deinstitutionalised its mentally ill, and none has brought back former asylum systems.
Community-based mental health will remain central, but nestled within that system must be a more robust stock of psych beds than is currently available to the seriously mentally ill Americans. And many forms of paternalism stop short of hospitalisation, such as programmes that mandate outpatient treatment programs, such as mental-health courts and New York’s Kendra’s Law, which gives judges the power to order people to receive care.
Bipartisan policymaking used to be more common in America. It was dealt a fatal blow by Democrats, 15 years ago, when they overrode traditional legislative norms to ram through ObamaCare. We’ve forgotten the old model’s two attractions: bipartisan reforms give cover to politicians facing competitive reelection races — and they’re more sustainable in the long term. When the backbench party wins power, it won’t immediately set itself to undoing the previous administration or Congress’s achievements, because their fingerprints are on those achievements, or some of them.
The framing is crucial. Untreated serious mental illness tends to be seen as an “urban” problem, in a way that harms the chances of federal-level reform. New York City plays a large role in this conception because of its media profile and the fact that most everyone uses public transit, thus bringing the broader population into direct contact with the unsheltered homeless in all their untreated acuity.
In most of the country, where private transportation is the norm, the crisis of mental illness is more hidden. But it strikes rich families, such as Sam Altman’s, as well as the poor, and those in rural America, where housing may be cheaper but psychiatrists and other specialists are practically non-existent.
Families are one group for whom the mental-health crisis is not at all hidden. The community-based system in many respects is really a family-based system. Government assigns to families supervisory functions that, in decades past, were handled by massive asylum programmes.
Caring for an adult schizophrenic child entails interminable fights over taking meds and not taking street drugs. They’re prone to paranoia but also to trusting too much, making them easy prey for malefactors such as drug dealers and financial scammers. They can be irrationally risk-prone or overcautious to an extreme. The strange hours, hoarding, atrocious hygiene habits, and property damage: mental illness overwhelms family caregivers. It also sometimes makes them victims of violence. One 2016 study estimated that the seriously mentally ill commit more than 1,000 family homicides each year. Most matricides and patricides involve serious mental illness.
To promote reform, we should frame untreated serious mental illness as more of a family problem than an urban one. Thinking about how government may best support family caregivers is the most coherent way to build an effective mental-health system, one that anticipates crises before tragedy strikes.
Perhaps that framing may also build more support among Republicans, the party of family values. In terms of the policy, a realignment on mental health should be structured around more spending on services for the seriously mentally ill and more paternalism. New York and other major cities would benefit. But they would be far from the only beneficiaries.
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SubscribeAlmost everything in this article also applies to the UK where mental health provision, both in the community and in hospitals is chaotic and underfunded.
Most people with bipolar and a significant proportion of those suffering from schizophrenia can, with support and some medication, not just live successfully in the community, but hold down jobs, pursue careers, have families and pay taxes.
There’s a lot of historical myopia among journalists and commentators who romanticize past conditions and political policies as remedies for the present. I’m an advocate for learning what we can from our past and using it to gain knowledge about ourselves that may help make good decisions in the present, but not this romanticizing lens of some lost golden age. If we’re going to learn from history, let’s not forget that things just don’t happen randomly. The why’s of history are just as important as the how, when, where, and who and often more instructive.
In other words, it bears remembering why the dismantling of the asylum system was such a bipartisan effort that encountered so little public outcry. One of the major factors that prompted the people of the 60’s and 70’s to close these institutions was the atrocious conditions of the facilities and the abuses of patients that occurred there. They were closed because they were government run institutions that were about as efficient and well run as any other. The conditions were not much better or even worse than prisons and the patients were often victims of abuse and experimentation. One can understand why taxpayers objected to paying for an abusive system that wasn’t helping the people it was supposed to help. Let’s realize that what talking about is the de facto incarceration of people who may or may not have committed any crimes. They object, as most anyone would, to being jailed for some hypothetical crime they might commit and taxpayers have a right and duty to object to their tax dollars being spent to jail people who might never commit any crime.
Let’s also keep in mind that the stories of the mentally ill committing crimes are a case of the squeaky wheel. We here about these high profile cases and see them in the news, but we don’t see the vast majority of people who are mentally ill but do not commit crimes and often suffer more from crime than the general population. It has been well established that the mentally ill are more likely to be victims of crime than perpetrators. How justified is it to spend massive amounts of money on these low probability outcomes, considering that the mentally ill who actually commit crimes will face arrest and prosecution as much as anyone else. Mental illness is seldom accepted as a defense by judges or juries.
The grim reality is that mental illness poses inescapable problems in those who suffer from them. There’s only so much that can be done, and putting people in prison-like conditions for things they might do certainly isn’t helpful to them. The argument really is one of public security, and it’s hard to justify a new initiative when the criminal justice system is already overburdened to the point that minor crimes get very light sentences or are just ignored altogether. How many of the mentally ill commit minor crimes at first but later escalate their criminal behavior after getting slapped on the wrist?
These are complex problems with only imperfect solutions. Politicians have to balance the costs of institutionalization against the costs of criminal behavior and balance both against the Constitutionally protected rights of citizens. Previous generations dealt with the problem by essentially sweeping the problem under the rug, sending the mentally ill off to poorly funded institutions where they lived in prison like conditions so people wouldn’t have to deal with them. It was an expedient, but expensive, solution and it enabled a lot of abuse to take place. Progressives protested the awful conditions of these institutions, the abuse, and the denial of civil rights. Small government conservatives objected to the fact that all this was occurring at the expense of taxpayers. The people who closed the psychiatric institutions had good reason to do so. When we examine history, let’s not forget to ask why.
Everything you say is true. I am embittered brother who helps my elderly father in caretaking for my brother. My brother’s illness caused him to be a selfish, shameless, and neglectful man. Lives were maimed due to sacrifices, shame, and burden. I choose not to runaway because it would be the tragic death to my father to whom my brother offers no paternal or elder respect or deference. Families are ostracized due to the ugliness of a mentally ill child, nobody wants crazy around children.
I want the asylums returned. They won’t be Bedlam nor Medfield with proper oversight and modern treatment. Most Families don’t have the resources, training, nor opportunity to care for a disabled human. It’s brutally hard to make a living in America
First off, if there’s domestic abuse, document it and report it to the proper authorities. There are institutions within the prison system to deal with those whose mental illness leads to criminal behavior. Domestic abuse shouldn’t be tolerated out of sympathy or familial loyalty. That’s enabling. Is this person intelligent and aware enough that he could be held competent to stand trial in court? If the answer is yes, then the abuse should be prosecuted, and the justice system allowed to do its job.
If the behavior falls short of criminality, then there are basically two scenarios. If this person is aware and responsible enough to be held responsible in court, the only option is probably for your father to just throw him out. If the father refuses out of sympathy or duty, he’s still made a choice and he’s still enabling this behavior. If the person requires constant care just to perform basic daily functions like eating, dressing himself, etc, then yes, there should be institutions for that. It’s the most humane thing we can do. If families have no option but to suspend their lives to care for a disabled person, then I’ll agree that this is a pretty serious oversight that needs to be corrected.
First and foremost, looking down on the mentally ill is childish. Anyone can be at risk of developing a mental illness—whether from a car accident, an infection, or really bad decision, or other factors that cause neurological damage. Mental illness is universal and isn’t going away, as there are countless social and biological factors that contribute to it.
I won’t go into the reasons why asylums were closed because, with a bit of critical thinking, it should already be obvious—even without knowing the full history.
The solution shouldn’t be another institutional approach but something more advanced. The government should start with housing.
Mental health is often about the lack of safety—both internally and externally. People are scared because they have nothing; they live in fear. They are exposed, and they are hungry. But if people had stable housing—if they were given free housing—mental health issues would largely take care of themselves, especially for those who are on the fringe (less chronic). And those at risk are, more often than not, the majority—people dealing with trauma, childhood issues, or circumstances beyond their control can gain some resemblance of normality for themselves!
Severe mental illness would be far less common if people didn’t have to constantly worry about where they’ll live for safety. And those who do need support could be cared for in their own homes, rather than being placed in institutions where authority figures monitor them constantly, like in a panopticon-style system (As Foucault observed not different than being in prison). That kind of surveillance alone could drive even a healthy person insane.
That’s just my personal opinion. But when I say housing, I mean real housing—not shared spaces, but private units with their own bedroom, bathroom, and kitchen (if able to cook). If people had that, I believe the mental health crisis would be significantly reduced to manageable industry.
I have been in psychiatric hospitals time and time again. They are cruel places, where staff hold you down and sedate you, and shout at you. They don’t do anything except give you sedatives, which can easily be taken at home. In my experience these places just keep you locked up, and in one place, because family, especially mothers, find it troubling to see their children behave differently.
Everyone here blithely talks about asylums as if they are safe. These places are the locale of some of the worst tortures and human rights abuses in the West. You should be ashamed of yourselves that you would be content to see this return to the society you live in.
One final note, I know lots of people who have been in modern day ‘asylums’ and we are decent human beings. If people commit murder they are murderers, and no amount of mental health problems can change that. I am nothing to do with those abysmal people, and in all my time I haven’t met any of those people either. They should be in prison. That law that says ‘lunacy’ somehow means the criminal can evade prison is outdated and causes prejudice to the majority of us who have a diagnosis and are not murderers.
The comments here are so old fashioned and conservative. Caging innocent people? You are from the stone age!!
Shuttering of mental health asylums was never primarily or significantly a “small government” initiative. It was rooted deep in the long-running movement to reform mental health care generally, which by the 1960s and 70s had overstepped logical bounds. Remember “One Flew Over the Cuckoo’s Nest”? Ken Kesey was no small-government conservative. Ending custodial care was a typical liberal-left feel-good initiative determined to ignore the obvious tragic results of leaving very ill people to fall through the easily predictable cracks in “community care.”
It was both. The anti-psychiatry movement, for example, appealed to both progressives and libertarians.
In fairness, the author does mention in the first couple paragraphs that progressives worked in concert with small government libertarians to dismantle the asylum system. He then focuses on small government types because the conservative Republicans who usually advocate for small government are in power, and progressive Democrats are not. He’s basically saying that with Republicans, there exists an opportunity for reform in this area if Trump can break with the more libertarian leaning members of his party. I think that will be difficult as that faction of the party embraced Trump earlier than most and became important in ousting the old guard. They’ve also demonstrated the ability and the willingness to obstruct any legislation they don’t approve of. They are generally from rural districts whose voters likely will see this as one of the reasons they don’t like the city and don’t live in one. In other words, their attitude is likely to be that it’s city people’s problem that they cause by electing progressives and we don’t want to pay for their stupidity.
I remember when it started in the UK in 1979. I was working at a mental hospital at the time.
I thought then it was an unholy alliance between a Conservative government who saw the opportunity for savings and a group of almost deluded wishful thinkers who imagined that pretty much unlimited resources would be made available for their vision of care in the community.
For a lot of patients those institutions were a place of sanctuary and they were always going to suffer, sometime terribly so, in the community
Small govt is not the same as no govt at all, so please stop with the straw men. It wasn’t small govt advocates who took issue with institutionalization, it was the likes of the ACLU.
Small govt means not having 100 federal anti poverty programs, because that’s what we have. It means not squandering billions on someone else’s winnable war. It means not believing that govt knows best about all things. And it means focusing the bulk of resources on the things govt SHOULD do: public safety, criminal justice, infrastructure, and a few other things.
Agree 100%. The burden placed on families to care is immense in time, money, and sacrifices
It’s also important to remember that, while psychiatric care has advanced greatly (mainly due to drug discoveries), many kinds and/or intensities of mental illness remain intractable. Many beds for those who are now beyond treatment will be needed, resulting in warehousing, This fact will require that the impact of those individuals on their community will have to be weighed on a par with their individual rights. Such thinking is anathema to many.
For a realistic description of what a family living with mental illness is like, I recommend reading ‘Hidden Valley Road’ (a rather obscure title) and watching the documentary ‘Six Schizophrenic Brothers: The Gavin Family’.
The major flaw in this is that the Community doesn’t care.
The most salient point in this short and shallow missive on “the mental health crisis “ is that it is first and foremost a family issue. Untreated mental illness creates behaviors that only a mother (or father, or sibling, or grandparent) could love. One of the most heartwarming calls I made during my working years was to a family member hundreds of miles away at 2:00 AM answered with “she’s been missing for over a year, how can we get her home?” Often in government the amount of money isn’t the problem, it’s how it’s spent. DOGE just might provide a path to prioritized spending, which would certainly make improved mental health care within reach.
Small government is never the answer to any question that presupposes a claim for state spending. That doesn’t mean it’s the wrong thing to do.
I’m a small government libertarian and I don’t make the absurd claim that the government could get better results for less money (this is actually true in a limited number of cases but not in general). The point is that there are many things the government does which it should simply not do at all.
The case for small government is simply that high taxes and spending are so colossally damaging to wider society and the economy that cutting the size of government is worth it even though the disadvantages will be considerable.
.. your point being?