As states struggle to meet the needs of people with serious mental illness, some are signing on to a federal pilot project that’s funneling new funding into institutional care.

Danny Pasquini has managed to keep his drug use and schizophrenia mostly in check the last six years. He has a girlfriend. He feels safe.

“We got our Danny back,” his mother Teresa says.

It took nearly 30 years to get here.

The 43-year old has cycled through more than 40 different locked psychiatric institutions over the last three decades.

Danny’s stability today is bittersweet, says Teresa, who is now 70. “I just think back to all those years ago,” she says, shaking her head. What if, she asks, Danny had gotten “the right care at the right time in the right place”?

Federal health officials hope a pilot project can improve care for more of the country’s 14 million adults with serious mental illness. California, where Pasquini lives, recently joined this effort, alongside Medicaid programs in 15 other states plus Washington, D.C. 

The Centers for Medicare and Medicaid Services (CMS) are sending these states hundreds of millions of dollars to expand and improve short-term care in mental hospitals and other facilities dedicated to 24/7 psychiatric care. States must also invest in community services such as employment support and mobile crisis teams that can help avoid institutionalization in the first place.  

This effort, which began during President Trump’s first term, is unfolding amidst uncertainty about the future of America’s mental health care system. While Republicans in Washington slash Medicaid — the country’s single largest source of mental health coverage — they are also elevating mental institutions as a solution to America’s mental health crisis.

A controversial fix with a loaded past

People with serious mental illness across the U.S. languish in places that offer little help. North of 100,000 people with intense mental health needs live on the streets or in homeless shelters, and close to half of all state prison inmates report mental health issues.

This federal experiment aims to open up beds in settings more specialized in care for people experiencing a mental health crisis. When run well and used for short stints, University of California, Davis psychiatry professor Ruth Shim says, a good psychiatric facility can work the way a hospital does to help people who have chronic physical ailments. 

“Most people who have diabetes can manage their [condition],” Shim says. “But every now and then you might have a severe flare-up of your symptoms that requires you to go into the hospital for stabilizing.”

This type of stabilizing care, Shim notes, has become far too hard for people to find.

The cause of that scarcity can, in part, be traced back to a decision in 1965 by Congress to ban Medicaid, which now covers about 1 in 4 people with serious mental illness, from using federal money to pay for most inpatient psychiatric care. Lawmakers worried about costs spiraling out of control. States — and in some cases, counties — have largely been left to fund this level of care on their own, leaving them little incentive to add beds or improve services.

Federal policymakers, however, have made a growing number of exceptions, including most recently this pilot project. The experiment is doling out more than $500 million a year in Medicaid funding for institutional care. Supporters hope this move helps cement support in Washington for modern mental institutions, which have evolved considerably — downsizing from thousands of beds to hundreds, embracing newer treatments and abiding by stronger patient protections. 

Some experts remain wary of the risks that this expensive and restrictive level of care can pose. “The evidence to back up this model of institutional psychiatric care is surprisingly thin, given how much money is going into it,” says New York University sociology professor Alex Barnard. 

Critics point to the dark and troubled past of patients being abused, neglected and warehoused inside large state mental hospitals. They also highlight evidence that even some modern-day mental institutions — especially a climbing number of for-profit facilities — are still prone to waste and abuse. Disability rights advocates in North Dakota have even mounted multiple campaigns to prevent that state from joining the CMS pilot project.

“There’s always been a group of people that says, ‘We just need [more] institutional care,’ and there’s also a group of people that says, ‘But if we make that too easy … we’ll just sock people away and forget about them,’ ” says Joe Parks, medical director for the National Council for Mental Wellbeing. “There are truths on both sides.”

Given the spectrum of concerns, and the vulnerable population caught in the middle, CMS has designed this experiment with an eye towards rightsizing the role of institutional care in today’s modern mental health care system. Participating states must walk a tight rope to both improve care inside the facilities and build up meaningful community services for people leaving institutions — or hoping to avoid them altogether.

An uphill climb to improve care inside institutions

California’s Medicaid director Tyler Sadwith has just begun to walk this path. California is the largest state to participate in this experiment, and plans to draw more than $200 million in federal funding in its first year, alone.

”Historically speaking, people with mental illness have been neglected by the medical establishment and warehoused away from society,” Sadwith says. California’s plan, dubbed BH Connect, aims to avoid those mistakes. “We’re talking about making sure people are not staying in institutions unnecessarily, or longer than they need to.”

Psychiatric treatment facilities across California could receive up to $1 billion in federal, state and county funding over this five-year experiment — if they meet certain licensing and accreditation criteria. The state also requires every participating facility to assess patients’ medical and social needs in ways aimed at improving the transition after discharge. To discourage any warehousing, the federal government only funds stays up to 60 days.

Still, several former state and federal health officials told Tradeoffs they believe states struggle to ensure patients receive high-quality care in these settings. Reporting by the New York Times and San Francisco Chronicle, as well as academic research, has uncovered problems including understaffing, assaults of patients by staff and keeping patients confined longer than medically necessary, just to increase revenue.

Teresa Pasquini witnessed the serious damage a poor quality of care can inflict when her son landed in his late 20s at a large mental hospital that she describes as “dingy, dark and disrespectful.” The mismanagement of her son Danny’s medications there, she believes, led him to spiral and, ultimately, assault a fellow patient. Danny spent the next four years awaiting trial — cycling between jails and state hospitals — experiencing several traumatizing bouts of solitary confinement before his pending criminal charges were dropped. 

Improvements to community-based care needed, too

California also aims to raise the bar outside of institutions — by doubling down on evidence-based services that help people live more independently. 

Counties, which in this state run Medicaid mental health insurance plans, that want to tap into this new federal pool of money for institutional care must also commit to making a robust menu of supports available in the community. Those services include, for example, helping patients get and keep jobs or sending social workers and psychiatrists to their homes to help them manage their physical health, mental health and the day-to-day tasks of life.

Sending teams of mental health professionals on house calls, a model known as assertive community treatment (ACT), is backed by decades of rigorous studies. “We know that it leads to fewer emergency department visits, fewer inpatient hospital and psychiatric facility admissions,” Sadwith says. “Our goal with these services is to make a reality in our communities what we know to be possible through the literature.” 

The state’s plan also includes other services not traditionally covered by Medicaid such as temporary help with rent payments.

New bipartisan bill underscores need for more evidence on what works best

Seven years into the CMS pilot project, it’s unclear if care is improving.

Interim data published by states show a mixed bag. Some states, like Indiana, have boosted the number of people on Medicaid who have received institutional care. Others have not. And it remains unclear if inpatient stays are making people safer or healthier long term.

A CMS spokesperson tells Tradeoffs the agency expects to publish more data later this year.

Those data will be valuable with five more states ready to join the project, and a new bipartisan bill in the House of Representatives that would unleash even more federal funding for institutional care across the country. A prior analysis by the nonpartisan Congressional Budget Office projected that a policy similar to the current bill under consideration would cost taxpayers roughly $3 billion a year. 

With that much money — and the health and safety of so many vulnerable people on the line — more evidence on what works is sorely needed, says John O’Brien, who served as a senior health official during the Obama administration.

“Whether you’re talking about physical health or behavioral health,” O’Brien says, “if I’m going to get a service, I want to make sure that it’s pretty good.” Without stronger evidence on the value of this institutional level of care, O’Brien warns, neither states nor the federal government truly “know what they’re buying.” 

‘It’s the cruelest thing we do’

While Teresa Pasquini supports the House bill — and has supported similar efforts in the past — she also wants to see more investment in community services. She thinks her son Danny revolved in and out of locked settings so many times because he lacked the right support waiting for him on the outside.

Teresa remembers one independent living program that promised Danny “around-the-clock support” including access to a 24/7 help line. “Whatever it takes,” the provider assured her.  

Three weeks after he had moved into his new apartment, Danny’s then-girlfriend called Teresa. Danny had a knife to his throat. And, nobody had answered the helpline. 

Teresa immediately hung up and dialed 911. Police arrived and tased Danny and took him to the hospital where he was assigned another stint at an inpatient psychiatric facility.

“I think it’s the cruelest thing we do,” Teresa Pasquini says. “Take away someone’s rights, lock them up, get them into the best shape ever … and then let them fall off the cliff again.”

Episode Transcript and Resources

Episode Transcript

Dan Gorenstein (DG): Hey, it’s Dan — a quick heads up that today’s show discusses mental health and self harm. 

If you or someone you know is in crisis, you can call or text 9-8-8 to reach the Suicide & Crisis Lifeline. 

DG: Everyone agrees: America is failing a whole lot of the some 14 million adults who have serious mental illness. Too many of them end up in places that offer little help.

News clip: A vicious cycle takes ill people from the streets to the hospital to jail and back again.

DG: It’s expensive, ineffective and often inhumane.

News clip: Criminally ill defendants sitting in jail waiting for treatment. Emergency rooms are ground zero in our country’s growing mental health crisis. 

DG: The federal government is testing out one controversial fix, pouring lots of money into locked psychiatric facilities where they hope people can stabilize and quickly get back into their communities.

But critics warn these sorts of places have a long history of bad care.

Today, what role should modern-day mental institutions play in America?

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

*****

DG:  We’re telling today’s story with help from senior producer Leslie Walker. Leslie, hello! 

Leslie Walker (LW): Hey Dan. How’s it going? 

DG: So, Leslie. As we laid out at the top of the show, the United States has really struggled to care for people with serious mental illness.

And many experts and advocates believe that one big reason why is we just don’t have enough good places for people to go when they’re in crisis to get the meaningful help that they need.

So policymakers, with this federal experiment, are testing some ways to try to change that. Leslie, you’ve been reporting on this for several months now. Can you tell us more?

LW: Yeah so, this is a project actually started under President Trump during his first term but it’s picked up more steam recently.

We’ve now got Medicaid programs in 16 states — red and blue — plus Washington, D.C. on board.

And while the effort, Dan, has a few different elements to it, the bulk of the hundreds of millions of dollars the feds are doling out here is for the most intensive kind of mental health care around.

DG: We’re talking locked inpatient and residential facilities.

LW: That’s right — places dedicated to 24/7 care for people with serious mental illness. Primarily we’re talking about mental hospitals but also some nursing homes and other residential or rehab type facilities.

And experts like UC Davis psychiatrist Ruth Shim see this kind of care as essential for some folks who are really spiraling.

Ruth Shim: In some ways I think of it as the same as any type of physical condition. Most people who have diabetes can manage their diabetes not in the hospital, but every now and then you might have a severe flare up that would require you to go into the hospital for stabilizing

LW: Instead of people struggling on the street or ending up in jail — which can happen — people could do a stint at one of these inpatient mental health facilities.

DG: Somewhere to find their footing for a week or two, see some doctors, sort out their meds.

LW: Exactly. Right now, though, it’s really hard to find a bed in these places. 

And so with this experiment, the federal government is sending state Medicaid programs all this money to help them build out their capacity.

Now at the same time, Dan, everybody wants to be super careful. 

First, this kind of care is super expensive. We’re talking like hospital-level thousand-dollar-a-day stays, often for weeks.

And it’s very restrictive. People are sometimes sent to these places involuntarily. They are held behind locked doors. Staff can physically restrain them — even give them drugs against their will.

DG: Right. While this experiment is built on the idea that we can have modern-day inpatient facilities be part of the solution, part of a more robust mental health care system.

It sounds like, Leslie, you are also saying the architects of this plan are very aware of the risks these places can pose.

LW: Yeah. The people behind this experiment appreciate that our country has turned to mental hospitals as a solution before and that turned out pretty ugly.

Soundbite from “Final Asylum” documentary: The first state superintendent described Byberry as a medieval pest house. 

LW: By the 1960s…

Soundbite from “Any Place But Here” documentary: Nobody can know the despair of coming into a place like this.

LW: The situation for many of our political leaders had become intolerable.

President John F. Kennedy: Our chief aim is to get people out of state custodial institutions and back into their communities and homes without hardship or danger.

LW: President John F. Kennedy in a 1963 speech basically said we should abolish these places. 

Facilities were short-staffed. Investigations revealed sprawling state hospitals had cut corners. People were being warehoused. It was a disgrace. 

Kennedy: Today nearly one-fifth of the 279 state mental institutions are fire and health hazards. Three-fourths of them were open before World War II. 

LW: Not long after JFK gave that speech, Dan, Congress banned Medicaid from paying for care inside most inpatient facilities. Around then, state mental hospitals started to send tens of thousands of patients out — some even shut down.

DG: So the pendulum, in effect, swung pretty far in the other direction — away from institutional care.

LW: That’s right and what’s interesting — and tricky — to me about this federal experiment happening now is it’s part of this more recent effort by health officials to find some kind of middle ground.

They are saying look, we leaned too hard on mental hospitals before. That was a disaster.

But choking off Medicaid funding has been bad too. It’s left us relying too much on jails and other places less equipped to help people.

So this pilot project is an effort in some ways to find a rightsized role for this institutional care in today’s mental health care system.

DG: Got it and just to be here clear, Leslie, we’re not talking about reviving those World War II- era state hospitals, right? These ‘institutions’ of today look pretty different.

LW: Yeah, that’s a great point, Dan. A lot of these places are now owned by private companies. They’re much smaller — we’re talking 100 beds instead of 1,000. And, of course, care has evolved a lot since the era of lobotomies.

DG: Alright, I get that. I hear that. But I also have to think that folks thought they had a nice reasonable plan for those mental hospitals that turned into these terrible, awful places with people being warehoused.

So what are the feds doing with this pilot project to avoid some of the problems of the past?

LW: Yeah, you read my mind here, Dan. They’ve basically attached two big strings to this money I want to tell you about.

One – states have to take steps to improve the quality of care happening behind these locked doors and take steps to shorten stays so that nobody stays longer than they need to 

And two – states also have to invest in other places in the community for people in crisis to go that are less restrictive and generally cheaper. 

We’re talking walk-in centers, mobile care teams to de-escalate situations in people’s homes or on the streets.

DG: Meaningful places for people to go when they leave these institutions. I’m guessing if those places are good enough, in theory, they should also keep more people out of these institutions in the first place — or at least keep their stays shorter.

LW: That’s right. Now that all sounds good of course. It all makes sense. But the big question here is: Will these two guardrails work? Or do these facilities become at best, some kind of expensive band-aid on a broken system?

DG: And at worst, something out of that JFK speech — real hazards to people’s health and their dignity.

When we come back, one state’s plan to head off those concerns and one family’s journey through America’s often ineffective mental health system.

BREAK

DG: Welcome back. 

With the help of senior producer Leslie Walker, we’re looking at a controversial experiment that’s opening a flood of federal funding for short-term stays in psychiatric institutions.

Leslie, for the second half of this show, I asked you to show us how one Medicaid program is taking on this opportunity and the challenges — the very real challenges — that come with it.

So, where are we headed?

LW: Well, I was actually thinking we could just stay in my backyard in the Golden State. California is one of the newest states to join this experiment. They’re also the biggest. 

Their plans for this entire five-year project could cost over $5 billion.

And one other thing, Dan: California’s Medicaid chief, Tyler Sadwith, is very open about the dark history hanging over this whole project. It’s one of the first things he mentioned when we spoke.

Tyler Sadwith (TS): We know that, historically speaking, you know, people with mental illness have been put in asylums, in sanitariums. People have been in facilities and institutions sort of warehoused away from society.

LW: Tyler told me that while he appreciates that this federal money can help open up institutional beds for people who need them, what he’s really excited about is the chance to improve care inside these facilities and, most importantly, to expand services out in the community. 

DG: Those are the two guardrails, or requirements, that Washington is putting on this money. 

LW: Right, Tyler believes that if the states get those two things right, then California might actually see fewer people needing to use this kind of inpatient care — and shorter stays when they do.

TS: That’s what we’re talking about is making sure people are able to be in the community and not be staying in institutions unnecessarily or longer than they need to be.

LW: That said, Dan, critics of this experiment tell me they are pretty skeptical California can pull this all off. And in my reporting, I met one local family whose experience I think helps capture why California — and so many other states, really — face such a steep hill to climb. 

Teresa Pasquini (TS): I am Teresa Pasquini. I’m 70 years old just recently.

LW: Teresa lives in Benicia, California. She’s a proud mom of two grown kids.

For almost half of her life, Teresa’s managed the care of her son Danny, who’s struggled with schizophrenia and drug use since his early teens.

He’s now 43 years old, and Teresa told me he’s seen the inside of locked psych facilities more than 40 times.

TP: You shouldn’t have to fail 40 times — and that happened to Danny over and over and over again.

DG: Ideally, Leslie, you’d hope after maybe a few stints Danny would have gotten the support he needed to stay safe, healthy, stable. But not 40!

LW: Yeah, you know Teresa thinks a big part of why Danny’s bounced around so much is because of those two issues California’s hoping to tackle — bad care inside of these institutions and not enough places to go on the outside

Teresa told me a story that helped me understand why getting bad quality care can be so damaging.

Back in 2012, Danny got sent to this facility that Teresa knew almost immediately was a bad fit. 

TP:  Dingy, dark. I just, I didn’t feel any, I didn’t feel any light.

LW: She kept trying to get him moved. Then one day, her phone rang.

TP: I got a phone call. Will you accept charges from Napa County Jail? 

LW: Danny had assaulted a patient on his unit. 

TP: It felt terrible that he was in danger and that he had harmed somebody else. 

LW: Danny spent the next four years awaiting trial cycling between jails and state hospitals, sometimes in solitary confinement. Ultimately, charges were dismissed. Teresa believes the facility had mismanaged Danny’s meds, isolated and restrained him, bad care that she says sent him spiraling. 

DG: I mean Leslie, that is obviously a terrible outcome. But it’s also just one story at one facility. Did you get a sense from your reporting of how common this kind of inadequate care is?

LW: Yeah, that’s a question that NYU professor Alex Barnard has looked into. He spoke to 300 folks involved at every level of California’s mental health care system for this book that he published about that system’s shortcomings.

Alex Barnard (AB): I think in some ways the stories that stuck with me the most were the people who really captured how superficial and pointless a lot of the services were.

LW: Superficial and pointless. You know, Dan, those two words really jumped out at me, so I asked Alex what he meant by that.

He did this one interview that really captured the spirit of what he heard again and again. It was this patient who was in a facility who was seen by a doctor once a month for 15 minutes.

AB: And he realized eventually that all the doctor wanted was for him to say, “Yes, I have schizophrenia. I can identify my voices and I will take my medication.”

LW: Once the patient repeated that enough times, they let him back into the community.

Almost immediately, he stopped taking his meds, wound up right back in the hospital. 

AB: Even though he was in a setting that cost hundreds of dollars a day for him to be there, and all he was getting was a med check in every month, and some groups that he thought treated him like a child.

LW: So Dan, to answer your question, based on research by Alex and others I’d say unfortunately this kind of subpar care is quite common.

DG: I’m curious too, Leslie, about safety. It sounds like a lot of people are getting mediocre care, but are these dangerous places to be?

LW: You know, the data here is really hard to come by, Dan. But the researcher who’s maybe doing more to unearth it than anyone else is Morgan Shields at Washington University in St. Louis.

Morgan Shields: Verbal abuse. Physical abuse. Almost a thousand complaints related to sexual abuse. 

LW: Morgan’s talking there about a first of its kind study that she authored looking at complaints in the kinds of big facilities we could see more of thanks to this pilot. 

She found that, compared to other types of psych settings, those big places had more than triple the rate of complaints.

Journalists have turned up other problems too — understaffing, violence, patients held longer than necessary just so these facilities can make more money.

DG: Ok, so step back here, Leslie. Hearing Danny’s story plus this research from Alex and Morgan it sounds like the care some people get inside these institutions can be anywhere from ineffectual to downright abusive.

You say that California wants to improve the quality of care in these facilities. How are they going to go do it?

LW: Well, let’s start with the safety concerns.

The state says it’s impossible to police entirely on their own. So they’re funneling this new federal money only to places that are licensed and accredited. Plus they’re counting on insurers to make sure their members get good care. 

Second, Dan, the state’s focusing on the beginning and the end of people’s stays. 

At the start — the intake — they’re requiring every facility to screen folks for not just mental illness, but also their physical health, addiction, their social stability. Do they have housing? 

And at the end — on the discharge — they want facilities to do more to make sure folks like Danny have somewhere meaningful to go.

DG: Yeah, I mean getting that transition right seems essential if you want to see more folks getting out of — and staying out of — these places for good.

LW: Absolutely.

DG: Alright, Leslie, so that’s what Tyler’s team is up to when it comes to the care happening inside of these facilities.

Let’s talk about what’s happening out in the community. You’ve mentioned several times that there are shortcomings here, too. What’s the issue? 

LW: Well, ever since the U.S. started that mass migration of folks out of mental hospitals back in the 1960s, we’ve really struggled as a country to get people the help they need to live on their own.

Teresa Pasquini told me this is what frustrates her most about the current system we have. Even if you do get great care inside one of these institutions, it’s not enough. 

TP: I think it’s the cruelest thing we do is to take away someone’s rights, lock them up, get them into the best shape ever, promise that they’re going to come back to the community and then, you know, let them fall off the cliff again.

LW: There was this one place Danny landed back when he was 27 — this is 16 years ago after another one of his stints in a locked facility — and it sounded perfect.

I mean, he’d get his own apartment. It came with all these services to help him stay safe, independent — “whatever it takes,” the provider told Teresa.

Three weeks later, she got a call from Danny’s girlfriend.

TP: Saying Danny’s been carving on his throat all night trying to kill himself

And she said, “We called the help number” — the number that they were told to call 24/7 — “and nobody answered.”

LW: Teresa immediately hung up and called 911 herself.

Police arrived. Danny got tased, sent to the hospital, ultimately wound right back up in another inpatient facility.

DG: These stories, Leslie, are really painting a picture for me of how the larger mental health system can fail people like Danny. Sometimes it’s the big, locked institutions. Other times it’s the services out in the community. 

What’s California’s plan to improve the community-based care?

LW: So the state is kind of dangling a financial incentive for insurance plans to cover services that evidence shows actually work to help people with serious mental illness live more independently. 

DG: Services like what?

LW: One item that jumped out to me: sending nurses, social workers and psychiatrists to people’s homes – or wherever they are – to help them manage their medical health, their mental health and their day-to-day lives.

Again here’s California state Medicaid Director Tyler Sadwith.

TS:  We know that it leads to fewer emergency department visits, fewer inpatient hospital and psychiatric facility admissions, increased participation in the community. Our goal with these services is to make a reality in our communities we know to be possible through the literature. 

LW: And it’s not just medical services either, Dan. The state knows that social services can be just as crucial to keeping folks stable.

Through the pilot, people can also get help finding and keeping a job — even, in some cases, help paying rent for a few months.  

DG: Leslie, California’s plan sure sounds good. But I also know from our other reporting that mental health providers are facing staffing shortages, budget crunches, plus major Medicaid cuts coming out of Washington, D.C.

LW: That’s absolutely right. There is a lot of uncertainty ahead here, Dan.

DG: So I’m curious, zooming out of California, which I know is very early in its journey, do we have any data yet on how this is playing out in other states who have been at this longer?

LW: Not as much as I thought we would, you know? There’s some interim data, Dan. It’s a very mixed bag so far. Some states like Indiana are seeing a lot more folks getting care in institutional settings. Others are not.

And it’s not at all clear if those stays are making people safer or healthier in the long run.

Federal health officials did tell me they plan to publish more data later this year, but this former Obama mental health official, John O’Brien, told me he’s not holding his breath. 

John O’Brien: I would still love to have data showing that this works, but you know, I’m not sure I’m going be able to see that in my lifetime.

LW: John and others said given the limited information being collected here, they doubt that this pilot project will answer the big questions that have long loomed over this kind of institutional care: Do these facilities actually improve people’s health? And do they keep people safe?

DG: And when you have this lack of evidence — this is something I’ve seen this throughout my career as a health care reporter — it’s basically impossible to know what or who is right.

In this case, like, sure we can guarantee these psychiatric institutions won’t be perfect. No health care provider is.

But will they be better than some of the places people end up now — in jail, on the streets?

LW: That’s right. Danny’s experience captures the breadth of what could happen: the time he was given too much independence too fast, the place that landed him in jail.

And now, he’s here. 

Danny Pasquini (DP): My name is Danny. I try my best to be a better friend and family [member].

LW: Trying, as he says, to be a better friend and family member. Danny lives in a kind of closely supervised residential community about 20 miles south of San Jose.

LW: What else do you want people to know?

DP: Well, I care for my friends. I care for my family. I care for people.

LW: “I care for my friends. I care for my family. I care for people,” says Danny. 

He ended up in this spot after a stabilizing stint in another one of those locked institutions. And Teresa says something finally clicked.

TP: To me, it’s about getting the right care at the right time in the right place. 

LW: Danny has lived in this community for six years now. He struggles to talk, but he told me that he feels safe. He’s got a girlfriend.

He does wish he had more freedom but he says he likes the staff. They take him to the corner store to get his Pepsis and Mountain Dews.

For his mom Teresa, Danny’s newfound stability is bittersweet.

TP:  I just think back all those years ago, it’s like, what if he would’ve gone there sooner? We have to have a system that’s like we have for every other illness. This is a chronic illness of the brain. You need to have all levels of care available when people need it. And you can’t depend on families or, you know, homeless shelters to be that system. It’s just wrong.

LW: The truth, Dan, is nobody can say with any certainty what’s worked for Danny this time or why. But even without that clear answer, policymakers see this problem as just too big to leave alone. 

DG: Leslie Walker, thanks for your reporting on this story.

LW: You’re welcome, Dan.

***

DG: In Washington, D.C. some officials want to go even bigger than this pilot project.

President Trump recently signed an executive order that could force more people into mental institutions against their will.

A bipartisan group of lawmakers introduced a bill in the House that would open up a whole bunch more Medicaid funding for these facilities. If that policy comes to pass, it could cost taxpayers roughly $3 billion a year.

Whether that would be money well spent, remains an open question.

I’m Dan Gorenstein. This is Tradeoffs.

Episode Resources

Additional Reporting and Resources on Inpatient Psychiatric Care and the IMD Exclusion:

Episode Credits

Guests:

  • Alex Barnard, Assistant Professor of Sociology, New York University
  • Danny Pasquini
  • Teresa Pasquini, Advocate
  • Tyler Sadwith, Medicaid Director, California Department of Health Care Services
  • Morgan Shields, Assistant Professor, Washington University in St. Louis
  • Ruth Shim, Professor of Clinical Psychiatry, UC Davis 

This episode was produced by Leslie Walker, edited by Dan Gorenstein and Deborah Franklin and mixed by Andrew Parrella.

The Tradeoffs theme song was composed by Ty Citerman. Additional music this episode from Blue Dot Sessions and Epidemic Sound.

Special thanks to Jaclyn Baucum, Carolyn Gorman, Stephen Eide, Samuel Jain, Lynda Kaufmann, Tonya Moore, Joe Parks, Ryan Quist and Jen Snow.

Tradeoffs reporting for this story was supported, in part, by the California Health Care Foundation and the Sozosei Foundation.

Leslie is a senior reporter and producer for Tradeoffs covering a wide range of health policy issues including prescription drugs and Medicare. Her story, “Inside Big Health Insurers’ Side Hustle,”...

Dan is the Founder and Executive Editor of Tradeoffs, setting the vision for the organization’s journalism and strategy. Before Tradeoffs, he was the senior health care reporter at Marketplace and spent...