. . . man behind the myth
For the next twelve months, the Ronald Reagan image machine will be turning out countless vignettes of the nation's 40th president, the man neighbors called "Dutch." He will be described as no-nonsense yet kindly, remote but avuncular, a movies-star-turned-politician, and remembered as a local lifeguard rescuing people in troubled waters. With dashing good looks, a sonorous tone that became the voice of General Electric, and an affable smile, even those who disagreed with his policies will say he was genuinely kind-hearted.
So what did this mean practically for policies about mental health? Here we need to ask how the image departs from the reality.
Contrary to the spin about trimming government, which he called "the problem," we all know he oversaw increases in federal spending that exploded the national debt, and grew the size of the government he impugned. Another part of the reality, rarely the image, is how he attempted to savage the entitlement system and roll back supports for people with a mental illness.
When Ronald Reagan arrived in Washington, he inherited the Mental Health Systems Act of 1980. One of the last achievements of Pres. Jimmy Carter, this was passed by the House 277 to 15, in the Senate, 93 to 3. With as many critics as there were special interests, it was far from perfect. Yet it expanded the federal government's commitment to services, to research, to training professionals, and to patient rights. It identified stigma as an impediment to seeking and receiving services. It established parity in Medicaid and Medicare. It recognized the link between physical health and mental health. And it dedicated $800 million over 4 years to redress the gross neglect of the commitment to mental health in earlier administrations. In short, it moved an agenda that minimized homelessness, the reliance on expensive nursing homes, jails and prisons, and one that to more hopeful choices for those who needed help.
The Mental Health Systems Act was a milestone. It came on the heels of four years of hearings and a presidential task force benefiting from First Lady Rosalynn Carter's active involvement. Philosophically it affirmed Pres. John F. Kennedy's Community Mental Health Centers, an attempt to thwart hospitalizations. It fit into the safety-net values championed by Pres. Lyndon B. Johnson with the passage of Medicaid and Medicare.
Still, by 1980 the nation needed more for those with a chronic illness. Many failures accompanied the attempts to close the miserable hospitals, often little more than warehouses, to help patients succeed in the community. The neglect of government support conspired to form a patchwork system with notable gaping holes. A 1977 GAO report said, "Government needs to do more." Congressional hearings in 1979 re-affirmed the need to strengthen impoverished services and the failed policies.
Although not perfect, the Mental Health Systems Act responded to these problems. For the first time since the National Institute of Mental Health became part of NIH in 1949, mental health was front and center in federal policy.
Then came Ronald Reagan. Within a month, the Office of Management Budget announced it would curtail the budget of the National Institute of Mental Health (NIMH), phase out training of clinicians, interrupt research, and eliminate services. Cutbacks to staff followed; chaos ensued. Experienced people left, others remained in government service but were forced into menial jobs. Trained professionals were reassigned to labs to dissect dead rats; science writers were reassigned to typing pools. The Mental Health Systems Act would be disappear. Instead, the Omnibus Budget Reconciliation Act (1982) would merge money for mental health programs into block grants, and with fewer dollars going to the states. They had the discretion to use them however they saw fit, often to perpetuate programs already deemed problematic. The pretense for all this was the president's concept of a "new federalism."
"Many of our dreams were gone," wrote Rosalynn Carter in Helping Someone with Mental Illness. "It was a bitter loss."
This could have been enough, but it was not. Pres. Reagan attempted to restrict criteria for determining eligibility for SSI, thought to be a safety-net. Nearly 2.6 million people were receiving insurance because their disability prevented them from working. New evaluations for eligibility led to widespread terminations. Of those who were terminated, about half appealed, and in two-thirds of the cases, administrative law judges reversed the decision. The process took nearly a year, during which time they, and their families, were deprived of promised help.
About 340,000 people would lose their insurance before public outcry and courts halted the process. Sen. John Heinz, a liberal Republican from Pennsylvania, told the New York Times the policy was a "meat grinder." Sen. Carl Levin, Michigan Democrat, said the reviews caused "unconscionable suffering." In June 1983 HHS Secretary Margaret Heckler announced she would halt suspending about 135,000 people until the government could improve standards for "functional psychotic disorders."
By then, however, the nation was doubting the president's kindness. A1982 Louis Harris survey found nearly three-quarters of the respondents said the president was hard-hearted toward the poor.
These are the facts. And they add up to a roll-back of opportunities for people already struggling with a psychiatric illness. Whatever spin accompanies the birthday celebrations for Ronald Reagan, we should not create yet another mythic figure, larger than life, more pure than Ivory soap, or with qualities he did not have. He may have portrayed himself as everybody's lifeguard, but he seemed willing to let people with a psychiatric illness sink.