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decade earlier had been comparatively highly regarded. The results have included the closure of almost all public psychiatric beds; jails and prisons filled with mentally ill prisoners; an increase in mentally ill homeless persons; emergency rooms overflowing with mentally ill individuals waiting for nonexistent beds; board-and-care homes with thousands of largely untreated patients; and a predictable series of homicides and other tragedies attributed to individuals with untreated severe mental illnesses. Since 2003, no state has more aggressively privatized its mental health services than North Carolina, and no state has had its services deteriorate more dramatically. 35
A more recent example is Pierce County, Washington, which in 2009 contracted for public mental health services with a for-profit company, OptumHealth. The outcome has been a massive overcrowding of the county jail with seriously mentally ill individuals, a 30% increase in mental illness-related calls to the county Fire and Rescue, and an increase in violent episodes, such as the shooting of three shoppers in August 2012 by Laura Sorensen, who was suffering from inadequately treated paranoid schizophrenia. One should never underestimate the ability of the for-profit sector to take responsibility for easy-to-treat patients and discard those who are difficult to treat, and thus more expensive, to the streets, jails, and prisons.
Scull has astutely pointed out that the for-profit privatization of mental health services currently underway in the United States is a repeat of what happened in England and, to a lesser extent in this country, during the early nineteenth century. At that time, local towns and counties turned mentally ill persons over to the highest bidders, usually private madhouses, for safe-keeping:
In an age that saw the triumph of laissez-faire capitalism, the insane enjoyed the dubious privilege of being among the first souls (other than slaves) to have their fate heavily determined by the marketplace. The experiment was not, on the whole, adjudged a success—save perhaps by the madhouse keepers themselves, whose business was often lucrative. Indeed, it was precisely the abuses to which a profit-oriented system was prone that led to a campaign for “reform” and to the establishment of those very state asylums against which the decarceration movement is now directed.
    We have thus come full circle, having emptied the asylums, which were built to reform the abuses of the for-profit system, and are again turning mentally ill persons over to the highest bidders. As Aldous Huxley noted, “That men do not learn very much from the lessons of history is the most important of all the lessons that history has to teach.” 36
7. For-profit funding of public mental illness services has been tried and does not work.
Another lesson that has emerged from a half-century of disjointed funding of mental health services is that it is essential to prioritize the patients for such services. As previously noted, studies have consistently shown that a relatively small subset of seriously mentally ill individuals are the ones who are repeatedly rehospitalized, become homeless, are regularly victimized, and end up in jails and prisons. One estimate of this subset is that approximately 10% of all seriously mentally ill individuals account for most of these problems. If services were to be prioritized for the 10% subset of individuals who are problematic, then most of the tragic consequences resulting from non-treatment would be avoided. 37
Recent studies support the necessity for such prioritization. In Philadelphia 2,703 individuals were identified who were chronically homeless. Researchers calculated the cost of their medical, psychiatric, social services, public shelter, and jail costs for a year and reported that 20% of them accounted for 60% of the total group costs. Among the 20% of high users, almost all (81%) had schizophrenia or a major affective disorder.