Straight to the point

Donald Trump is a master at disrupting stale bipartisan orthodoxies and remaking the politics of familiar issues. He did so with free trade and industrial policy in his first term, forcing even the Biden administration to adopt his views. This time around, his tough stance on the border, which helped him win in November, may form the next consensus. America’s mental-health crisis — recently highlighted by a string of horrific attacks in the New York subway system — presents another such opportunity.

That crisis consists of the four million or so adults with untreated serious mental illnesses, such as bipolar disorder and schizophrenia. The result is homelessness, mass shootings, random subway violence, and incarceration, especially in Democratic areas that shifted sharply to the Right in the 2024 election. Trump can disrupt and realign the status quo — provided he ignores small-government zealots in his own camp. 

The mental-health crisis stems more from partisan agreement than disagreement. In his hit 2023 book, The Best Minds, author Jonathan Rosen noted that “Left and Right often met at the gates of the asylum.” He was referring to how, back in the 1960s, the deinstitutionalisation of the mentally ill was a joint effort of fiscal conservatives and progressive civil libertarians: the former shuttering mental hospitals in the name of austerity, the latter for autonomy’s sake. In the six decades that followed, the number of psychiatric beds nationally dropped to 35,000 down from 560,000.

That coalition still controls mental health-policy six decades later. Reformers and relatives of the seriously mentally ill have long called for allowing Medicaid, America’s public-insurance programme for the poor, to fund care in specialised psychiatric hospitals. Yet the move has long been opposed by a coalition of Republicans, who believe it would cost too much money, and Democrats, who worry that it would risk mass re-institutionalisation.

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Enter Trump, whose first term mental-health agenda was underrated. Trump appointed a dedicated change agent as his mental health czar and weakened (if not removed) restrictions on the use of Medicaid for psychiatric hospitalisation. A second Trump administration raises hopes of further progress.

One reason to be optimistic about mental health is that the Trump-led GOP is less fiscally conservative than previous iterations. Greenlighting Medicaid funding for more adult beds in specialised psychiatric hospitals would cost $3 billion to $4 billion a year. This cost should be owned up to. Yes, savings could be realised from reduced spending on jails and homeless services and a serious reform agenda would slash funding for the numerous and pointless wellness programmes within the federal mental health budget.

Yet to DOGE-ify the discourse on mental health would risk repeating the mistakes of the past. One of the original sins of deinstitutionalization was the belief that serious mental illness could be treated on the cheap. We learned the hard way that it wasn’t enough to offer meds and benefits to former asylum patients and expect them to take matters in hand from there. Schizophrenia is a chronic condition, characterised by episodic emergencies that necessitate extended supervision. Real reform will require a bigger mental-health budget. Hospitalisation, particularly, is an expensive intervention if we want to ensure high standards of care.

Sometimes things have to get worse before they can get better. As blue-city voters complain and the data show, public transit and street conditions have recently worsened. In last November’s election cycle, some high profile progressive prosecutors were voted out of office, and Californians passed Proposition 36, which strengthened penalties for low-level crimes. The proposition’s nearly 40-point pass margin signals that the politics of law and order are almost as popular in California as Donald Trump is in West Virginia.

Treating serious mental disorders and fighting crime are different government functions. But the reality is that a Democrat who votes to crack down against retail theft will likely also support a more paternalistic turn in mental health. Paternalism needn’t, and almost surely won’t, mean the return of the asylum order. Every Western nation deinstitutionalised its mentally ill, and none has brought back former asylum systems.

Community-based mental health will remain central, but nestled within that system must be a more robust stock of psych beds than is currently available to the seriously mentally ill Americans. And many forms of paternalism stop short of hospitalisation, such as programmes that mandate outpatient treatment programs, such as mental-health courts and New York’s Kendra’s Law, which gives judges the power to order people to receive care.

Bipartisan policymaking used to be more common in America. It was dealt a fatal blow by Democrats, 15 years ago, when they overrode traditional legislative norms to ram through ObamaCare. We’ve forgotten the old model’s two attractions: bipartisan reforms give cover to politicians facing competitive reelection races — and they’re more sustainable in the long term. When the backbench party wins power, it won’t immediately set itself to undoing the previous administration or Congress’s achievements, because their fingerprints are on those achievements, or some of them.

The framing is crucial. Untreated serious mental illness tends to be seen as an “urban” problem, in a way that harms the chances of federal-level reform. New York City plays a large role in this conception because of its media profile and the fact that most everyone uses public transit, thus bringing the broader population into direct contact with the unsheltered homeless in all their untreated acuity.

In most of the country, where private transportation is the norm, the crisis of mental illness is more hidden. But it strikes rich families, such as Sam Altman’s, as well as the poor, and those in rural America, where housing may be cheaper but psychiatrists and other specialists are practically non-existent.

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Families are one group for whom the mental-health crisis is not at all hidden. The community-based system in many respects is really a family-based system. Government assigns to families supervisory functions that, in decades past, were handled by massive asylum programmes.

Caring for an adult schizophrenic child entails interminable fights over taking meds and not taking street drugs. They’re prone to paranoia but also to trusting too much, making them easy prey for malefactors such as drug dealers and financial scammers. They can be irrationally risk-prone or overcautious to an extreme. The strange hours, hoarding, atrocious hygiene habits, and property damage: mental illness overwhelms family caregivers. It also sometimes makes them victims of violence. One 2016 study estimated that the seriously mentally ill commit more than 1,000 family homicides each year. Most matricides and patricides involve serious mental illness.

To promote reform, we should frame untreated serious mental illness as more of a family problem than an urban one. Thinking about how government may best support family caregivers is the most coherent way to build an effective mental-health system, one that anticipates crises before tragedy strikes.

Perhaps that framing may also build more support among Republicans, the party of family values. In terms of the policy, a realignment on mental health should be structured around more spending on services for the seriously mentally ill and more paternalism. New York and other major cities would benefit. But they would be far from the only beneficiaries.