Abstract
In a little less than a week, President Joe Biden and Vice President Kamala Harris will begin to launch a broad array of new policy initiatives that we hope will include a signature focus on reducing the use of institutions in our nation. The deadly impact of the COVID‐19 pandemic makes especially clear why this should be one of their top priorities.
In a little less than a week, President Joe Biden and Vice President Kamala Harris will begin to launch a broad array of new policy initiatives that we hope will include a signature focus on reducing the use of institutions in our nation. The deadly impact of the COVID‐19 pandemic makes especially clear why this should be one of their top priorities.
Approximately 40% of COVID‐19‐related deaths nationally have involved individuals in congregate care facilities, including nursing homes, psychiatric hospitals, assisted living facilities and adult and group homes. While these facilities have typically been a dead end for millions, they have now become deadly incubators for the virus.
Despite all of our efforts to advance community inclusion and integration, far too many individuals languish in institutions but for the lack of community‐based housing and supports and for opportunities to live meaningful lives pursuing their employment, educational and social goals.
Here are just a few actions the new administration and federal agencies should take to address this longtime crisis:
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1)
The Substance Abuse and Mental Health Services Administration (SAMHSA) must put in place leadership and policies that return that agency to making recovery and resilience and a life in the most integrated settings of choice the expectation not the exception, especially for those labeled the “seriously mentally ill.” People with lived experience should play central leadership roles. SAMHSA must also return to being a champion for effective, non‐coercive engagement and support strategies that are often driven by peer supporters and community health workers. This would represent a course correction from recent policies to weaken rights and privacy protections and incentivize states to create or expand involuntary “assisted” outpatient treatment initiatives that only serve to drive people away from needed public services and supports.
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The Department of Housing and Urban Development (HUD) should work with state and local governments and private developers to rehabilitate dilapidated and abandoned housing and to convert vacant properties into mixed‐use affordable housing. HUD should also exponentially increase the number of and funding level for Section 8 housing choice vouchers.
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The Social Security Administration, Department of Labor and HUD should collaborate to remove barriers to employment, allowing people with disabilities to hold onto 100% of their SSI benefits and their housing vouchers for up to one year while they achieve job stability. The Centers for Medicare & Medicaid Services (CMS) and state Medicaid authorities must ramp up Medicaid buy‐in programs to ensure that people with disabilities don't lose their health care upon returning to work.
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The CMS should permit an expansion in Medicaid's capacity to pay for home‐ and community‐based services and self‐direction Medicaid waivers, rather than permit an expansion of institutional hospital beds by increasing opportunities to waive the Institutions for Mental Disease exclusion. In a value‐based payment environment, it should hasten to define and financially incentivize strong housing and employment outcomes and reductions in incarceration.
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The CMS should also increase Medicaid rates that will allow agencies to better recruit and retain a quality workforce, especially in the face of huge increases in demand due to the impact of COVID‐19‐related trauma. It should also institute a national policy to restart Medicaid 30 days before jail and prison discharges to promote successful reentry into the community.
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The Department of Justice should restore policies that strictly enforce Olmstead requirements that people live and work in the most integrated community settings of choice.
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One in every five state and federal prisoners in the United States has tested positive for COVID‐19, a rate more than four times as high as the general population. In some states, more than half of prisoners have been infected. At the same time, Blacks, Indigenous and people of color (BIPOC) are more likely incarcerated, serve longer sentences and placed in solitary confinement. The DOJ and states must commit themselves to rooting out systemic racism, in part by ensuring the BIPOC communities are offered culturally appropriate engagement and service offerings and cracking down on incompetent, if not fatal, police actions.
Finally, it should support the creation of mental health peer and emergency medical technician first responder teams and other diversion initiatives, increase peer and family supports for those involved in the criminal justice system and eliminate solitary confinement for those with mental health or addiction problems in prisons and jails.
We look forward to supporting the administration's efforts to take major steps to end the use of outmoded and harmful institutional models, ramp up community‐focused and rights‐based approaches and to address systemic racism to create a broad range of policies that support meaningful and successful lives in the community for all.
Harvey Rosenthal is the CEO of the New York Association of Psychiatric Rehabilitation Services Inc.