For 60 years Washington has been wrong in prohibiting Medicaid payment for care provided in “institutions for mental disease,” defined as psychiatric hospitals or other treatment facilities with more than 16 beds. That terrible rule, the IMD exclusion, has been in place since Medicaid’s enactment in 1965, and it prevents the feds from covering the cost of medically necessary care simply because of the type of care and where it happens to be delivered.
The result has left untold New Yorkers languishing without care, compounding the risk on the streets.
In 2022, Rep. Carolyn Maloney wrote in these pages that the rule “was created as part of a noble effort at de-institutionalization, one that has saved countless people experiencing mental illness from suffering in hospitals that were ill-equipped to handle their needs. However, an unintended consequence of the IMD exclusion is that people who need long-term treatment often cannot receive it because they have no way to pay for it.”
Maloney authored the Michelle Go Act removing the arbitrary cap. Michelle Go was pushed to her death on the Times Square subway tracks in January 2022 by a destitute homeless man battling schizophrenia who may never have spiraled downward had someone been able to put him in a psychiatric hospital on the government dime.
The bill didn’t pass then — but now it’s back in amended form, reintroduced by Reps. Dan Goldman of Manhattan and Nicole Malliotakis of Staten Island. He’s a Democrat, she’s a Republican, but both see the self-destructiveness of prohibiting the federal government’s health-care program serving the poor from covering the inpatient care that seriously mentally ill people need most.
Importantly, the new version of the bill doesn’t end the IMD exclusion entirely. It instead increases the cap from 16 to 36 beds, consistent with a proposal from mental health advocate Cheryl Roberts, who wrote in these pages that such a compromise might strike the right balance by alleviating fears that, should broader reforms pass, America might slide back into an era of large-scale asylums.
We’d rather see the exclusion done away with entirely; a 50- or 100-person mental health facility could well be best suited to serve many people in crying need. But if a legislative increase from 16 to 36 beds is the best way to break a logjam and substantially increase the number of psychiatric beds, we’ll take it.
New York badly needs more places to treat people who are struggling with serious mental illness. As is, they languish on the subways and in the streets, never getting or sticking to treatment. The vast majority are no danger to themselves or others, but a fraction are — and it’s almost impossible to know when a psychotic break may come.
With a push on the subway tracks, Kendra Webdale was killed by such a man in 1999; a law in her name gave courts the power, still underutilized, to require that unwell people enter outpatient treatment. Michelle Go’s 2022 murder should prompt a new law, this time in Go’s name, to close another aching gap. Seriously mentally ill New Yorkers cut off from society need treatment, and the rest of us deserve assurances that government is doing everything reasonable in its power to protect society from the possibility that they may hurt others.
