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Bring Vision to Hochul’s Mental Health Plans

Stephen Eide

May 09, 2024

New York needs more psych beds —

New York needs more psych beds —

but just as badly, it needs a strategy.

Mental health policy provides one of the most striking differences between New York Gov. Kathy Hochul and her predecessor, Andrew Cuomo. While Cuomo prioritized cutting psychiatric hospital beds, Hochul has been adding them.

This is a welcome development that lends indispensable support to New York City Mayor Eric Adams’ own mental health agenda. But Hochul’s approach to psych beds is, as of yet, under-strategized. Cuomo was clear about his goal: the “transformation” of New York’s mental health system into one centered more around community-based programs, such as outpatient clinics and supportive housing, and less reliant on inpatient care. The Hochul administration still uses that “transformation” language in official documents and public statements. And top leadership at the Office of Mental Health is unchanged since Cuomo resigned in August 2021. 

But what, exactly, Hochul is trying to “transform,” and into what, begs clarification so that all the people and institutions involved in the complex mental health system understand where New York intends to head and why.

How many beds New York needs is an important and complex question that has to do with who the population is, where they live and what kind of care — short-term or long-term — they require. To be viable, answers must reflect practical considerations such as funding and the need to compromise with the advocacy community’s strongly held views on involuntary treatment. There’s no agreed-upon “right number,” but there’s no question in the mind of anyone serious about this issue that the current levels are much too low.

The Hochul record on psychiatric hospitals was discussed in a March report by state Comptroller Thomas DiNapoli. That analysis parsed trends in beds in state-run “Psychiatric Centers” (legacy mental institution campuses such as Creedmoor and Pilgrim State, that specialize in psychiatric care), on the one hand, and, on the other, trends in psych beds in general hospitals, which provide inpatient care among many other services, and are often run by private health systems. A portion of the latter stock of beds was repurposed during COVID to anticipate a surge in pandemic-related needs and has yet to return to its previous function as psychiatric care beds. 

With those beds, Hochul’s strategy is clear: She wants all the beds back and, to that end, has incentivized hospitals with boosts to Medicaid reimbursement rates and punished them with fines.

The critics are wrong to suggest that New York doesn’t need the beds; it does, because there are thousands of people with serious mental illness for whom they provide necessary services that community-based programs can’t offer.

She’s also increased the stock of beds in state-run Psychiatric Centers in two bursts: 150 during last year’s (FY 24) budget cycle, and then 200 during the recent (FY 25) cycle. These investments have restored only some of the roughly 770 beds Cuomo cut via his “transformation” push. But some advocates, who view inpatient programs as a wasteful diversion of resources from community-based treatment programs, have criticized Hochul’s bed investments as overreactions to tabloid coverage of subway chaos. 

The critics are wrong to suggest that New York doesn’t need the beds; it does. Community programs work best for those willing to engage in services on a voluntary basis. Many New Yorkers with serious mental illness won’t accept services on those terms. They will either receive treatment in a hospital setting, or no treatment at all. Equally important, inpatient mental health programs take the hardest cases off the hands of community programs, allowing the latter to serve the clients they’re best suited to serve.

But the critics are on to something when they characterize Hochul’s moves as reactive, not guided by long-term strategic vision. 

The head of the New York State Office of Mental Health is Dr. Ann Marie Sullivan. She has been at the helm since 2014. For years under Cuomo, Sullivan’s standard refrain was that the state mental health system’s “inpatient footprint has remained disproportionately large” and that New York was burdened by too many “unnecessary” beds. While some outside groups, such as the Treatment Advocacy Center, a national organization focused on reforming policy to benefit the seriously mentally ill, commended New York for boasting one of the highest per-capita psych bed rates among all states, the Cuomo OMH typically treated New York’s above-average bed capacity as a problem to be solved. As lieutenant governor, Hochul sympathized with this outlook. Between 2014 and Cuomo’s resignation, New York lost 11% of its psychiatric hospital beds, mostly as a result of the above-mentioned cuts in state-run programs.

The political winds shifted after COVID. Youth mental health disorders rose, which stoked demand for hospital-based treatment that, rhetoric about “unnecessary” beds notwithstanding, could not be met by existing system capacity. So the OMH, under Hochul, reversed course, boosting bed capacity in youth and adult hospital programs and reevaluating legal barriers to inpatient care. This coincided with a growing focus on the seriously mentally ill homeless adults in the subways and elsewhere — a problem that intensive inpatient care is a necessary part of the solution to. In February 2022, Sullivan issued “guidance” clarifying that, under state law, an “inability to meet basic living needs,” not just the narrower standard of dangerousness, can justify involuntary civil commitment.

Cutting psychiatric hospital beds, though always touted as a way to save money, does not do that when capacity falls too low.

These changes fit nicely with city-level developments. Mayor Adams has made a policy priority of early intervention with adults with untreated serious mental illness, to prevent deterioration and violence. And he’s simultaneously pressed to give the City stronger tools to involuntarily commit seriously mentally ill people who might be a danger to themselves or others. In contrast to his state counterparts’ flip flopping, and his own triage-style response to the migrant crisis, Adams has been a study in steadiness in mental health policy. He made a campaign promise and then moved after inauguration to hire relevant leadership, who then developed and rolled out a strategy to meet the mayor’s broad vision. The release of the Adams involuntary treatment plan in November 2022 was met with extensive national media coverage, much of it negative. But Adams has held firm.

As is the case with so many New York policy questions, though, while what the mayor does attracts most of the attention, what the governor does matters more. Only state policymakers, through their influence over Medicaid and the OMH system, can deliver the beds Adams needs for his plan to succeed.

Let’s be clear about what the problem is. Cutting psychiatric hospital beds, though always touted as a way to save money, does not do that when capacity falls too low. It just pushes costs onto other agencies, such as homeless services, transit, libraries, police and corrections. If we want to reduce the high rate of serious mental illness in jails and prisons, there’s no realistic way to do that without investing in psychiatric hospitals. Other states that have cut beds excessively have left themselves unable to meet the rights of mentally ill adults charged with crimes to be restored to “competency” before their case proceeds. This has exposed those states to lawsuits. New York State is home to many communities that are mental health deserts; a full 20 counties have not one psych bed. There, when someone needs inpatient treatment, they must be transported hours away. In urban and rural regions alike, when a bed isn’t available to someone in crisis, they wind up “boarded” in the ER. Some analyses have found New York’s boarding problem to be among the worst in the nation.

Hochul should be looking to expand bed capacity over and beyond the pre-COVID level, where, thanks to past administrations’ policies, it was inadequate.

What the Hochul administration needs to present is something like the typical New York City mayor’s housing plan, but for psych beds: Here’s how many beds are envisioned, here’s where they’ll be going, here’s how it’ll all be financed and here’s how long the build-out will take. The most important strategic question that begs an answer is how should state government and private hospital systems share responsibility over inpatient psychiatric care?

In the coming years, New York’s mental health system will not be able to lean on the private sector as much as it has in the past. Private systems have been cutting beds at an impressive rate. Since as far back as 10 years ago, according to the Independent Budget Office, NYC Health + Hospitals, a public agency, has been shouldering a disproportionate share of the growing demand for inpatient mental health in New York City. Local hospital systems describe inpatient psychiatric care as a “loss leader.” New York is not unique. A recent study by UCLA scholar Jill Horwitz and colleagues categorized psychiatric services as among the most “unprofitable” hospitals can provide.

Viewed against this backdrop, Hochul’s push to bring back the COVID beds back to 2019 levels looks like triage. She should be looking to expand bed capacity over and beyond the pre-COVID level, where, thanks to past administrations’ policies, it was inadequate.

The state Psychiatric Center network, at its peak, had 93,314 patients under its care. That number is now around 3,500. It probably won’t drop much farther. New York State seems to have finally hit rock bottom with respect to the deinstitutionalization of the mentally ill. We’ve learned that there’s a limit to how much we should expect out of community treatment, which can be just as blunt of an instrument as inpatient treatment. We’ve learned that overpromising what community-based treatment can do on its own leads to terrible consequences for families and that, when many of the communities in question struggle with high levels of drugs and crime, the risks of psychiatric deterioration run alarmingly high.