Episode 20: Why There Are So Few Psychiatric Beds
Why Are There So Few Long-Term Psychiatric Beds?
I work with a lot of families of people living with serious mental illness. One question comes up over and over again:
“My loved one has been struggling for years. He keeps cycling between jail, psychiatric hospitals, and homelessness. He’s clearly unable to care for himself. Why can’t I find a long-term facility where he can stay?”
It’s not just families asking this question. Mental health providers, medical staff, law enforcement officers, and correctional workers often ask some version of the same thing. Most people instinctively assume that there must be long-term psychiatric facilities for people who are chronically disabled by severe mental illness. What surprises them is how difficult those facilities are to access—and how few of them actually exist.
The short answer is that America has dramatically reduced its long-term psychiatric treatment capacity over the last several decades, and we have never replaced it with anything capable of meeting the need.
The Small Group of Patients Who Need More Than Outpatient Care
Most mental health conditions can be treated successfully with therapy, medication, or a combination of both.
However, there is a smaller group of patients for whom that isn’t enough. Some repeatedly stop taking medications that are necessary to keep them safe. Others remain unable to care for themselves even when treatment is available. Mental health professionals often refer to these individuals as being gravely disabled by their illness.
People who become dangerous or incapable of functioning when they are not receiving treatment typically require regular supervision. In practice, that means a facility with around-the-clock care and some mechanism to prevent patients from simply walking away when they are too ill to make safe decisions.
Community psychiatric hospitals provide this type of care—but only temporarily.
The reason is simple: insurance companies, including Medicaid, generally limit how many days they will pay for psychiatric hospitalization. Once coverage runs out, pressure builds to discharge the patient, whether or not the underlying problem has truly been resolved.
The Facilities We Need Already Exist—Sort Of
The closest thing we have to a long-term psychiatric treatment system is the state psychiatric hospital.
These facilities are designed to serve people with severe mental illness who are not responding to treatment in the community. Unlike community hospitals, they are not intended to operate on a strict timetable. Patients can remain there for extended periods if necessary.
At least in theory.
In practice, there are several major problems.
1. We Don’t Have Enough Beds
The United States has lost roughly 95% of its state psychiatric hospital beds since the deinstitutionalization movement began in the 1950s.
The result is exactly what you would expect: demand far exceeds supply.
Recent research suggests that the United States would need to at least double its state psychiatric bed capacity to meet current needs. Because there are so few beds available, wait times can stretch for months. In some areas, waiting four or five months for a state hospital bed is not unusual.
When families ask why their loved one cannot be admitted to a state hospital, the answer is often frustratingly simple: there is no room.
2. Hospitals Face Pressure to Discharge Patients Quickly
State psychiatric hospitals do not impose strict time limits on treatment, but that does not mean patients can stay indefinitely.
There are important legal safeguards. Courts regularly review cases and require hospitals to justify continued hospitalization. Patients also have opportunities to challenge their commitment if they believe they are ready for discharge.
Those protections are necessary.
The more significant issue is the pressure created by bed shortages.
When dozens—or hundreds—of people are waiting for admission, administrators and treatment teams face constant pressure to move patients through the system. Every occupied bed is a bed that cannot be offered to someone else.
As a result, some patients are discharged before they are truly ready to live independently in the community. I’ve seen this happen multiple times. If more beds were available, treatment teams could focus solely on clinical readiness instead of balancing patient needs against lengthy waiting lists.
3. Psychiatric Beds Are Increasingly Occupied by Forensic Patients
State hospitals do not serve only civil psychiatric patients.
They also house individuals who have been found incompetent to stand trial.
The Constitution prohibits criminal prosecution of someone who cannot understand the charges against them or assist in their own defense. When that happens, courts often order the person to a state psychiatric hospital for competency restoration treatment.
These patients receive treatment and education designed to help them understand the legal process well enough to participate in their case.
The problem is that competency restoration patients are competing for the same limited bed space as people with severe mental illness in the community.
According to a 2024 report from the Treatment Advocacy Center, forensic patients now occupy more than half of all state psychiatric beds nationwide. In my state, the figure is closer to 75%.
That means community mental health patients are competing against court-ordered referrals for an already scarce resource.
The Problem Is Not Complicated
At its core, the psychiatric bed shortage is a supply problem.
We have more people who need long-term psychiatric care than we have places to put them.
There are two obvious solutions:
Build more state psychiatric hospitals or expand existing ones.
Change insurance regulations so patients can remain in community psychiatric hospitals for as long as treatment is medically necessary.
Most people agree these ideas make sense.
The obstacle is not conceptual. It’s political.
Why Haven’t We Fixed This?
Like many public policy problems, the answer comes down to incentives.
Expanding psychiatric treatment capacity costs money. Not an enormous amount by federal budget standards—but enough that someone has to decide to pay for it.
A recent estimate suggested that the United States could largely solve this problem by increasing annual spending on state psychiatric hospitals by roughly $14 billion per year.
For most people, $14 billion sounds enormous. In the context of a federal budget measured in trillions, it is relatively modest.
It’s also worth considering the costs we already absorb when people with serious mental illness do not receive adequate treatment. Jails, emergency rooms, homeless service systems, law enforcement agencies, and families all end up carrying part of that burden.
The question is not whether we pay for untreated mental illness. We already do.
The question is whether we want to pay for treatment instead.
The Politics of Mental Health Funding
Most legislators want to remain in office. Their decisions are heavily influenced by what they believe voters will support.
Public opinion creates a difficult balancing act.
Surveys consistently show that Americans believe the country is experiencing a mental health crisis. Large majorities support improving mental health services.
At the same time, large majorities also believe their taxes are already too high.
This creates a familiar problem: people want better services, but they often oppose the mechanisms required to fund those services.
As a result, broad tax increases are politically difficult. Any effort to expand psychiatric bed capacity would likely require either reallocating money from other parts of the budget or creating a targeted funding source.
Both options come with political challenges.
Military spending, healthcare spending, correctional spending, and other large budget categories all have powerful constituencies that resist reductions.
One Possible Funding Approach
One potential solution would be targeted taxes on alcohol and, in states where it is legal, cannabis products.
Based on current sales figures, even a relatively modest tax could generate enough revenue to substantially expand psychiatric bed capacity nationwide.
There is also a policy argument for linking funding to these products. Alcohol and cannabis can contribute to addiction and mental health problems for some users, creating costs that are ultimately borne by taxpayers through healthcare, social services, and the criminal justice system.
Critics would correctly point out that these taxes are regressive, meaning they place a proportionally larger burden on lower-income individuals.
If the goal is a progressive funding mechanism, we could simply tax wealth, as I have repeatedly suggested in previous articles. I won’t get back on that soapbox today.
The Bottom Line
America’s psychiatric bed shortage is not a mystery.
We dramatically reduced long-term psychiatric capacity over several decades. The remaining facilities are overwhelmed. Many of their beds are occupied by forensic patients, and the system lacks the resources needed to meet current demand.
The result is a revolving door that many families know all too well: psychiatric crisis, hospitalization, discharge, homelessness, arrest, jail, hospitalization again.
The solutions are not especially complicated. We know how to build psychiatric hospitals. We know how to fund healthcare systems. We know how to expand treatment capacity.
The challenge is deciding that the problem matters enough to invest in solving it.
Until we do, families, hospitals, jails, and communities will continue to bear the consequences of a mental health system that simply does not have enough places for its sickest patients to go.