Trump's plan to bring back mental institutions

Driving the news: "When I am back in the White House, we will use every tool, lever, and authority to get the homeless off our streets," Trump said in a video posted on his campaign site in August, saying that he'll work with states to ban urban camping.

• Trump said his administration would offer treatment and other resources for people who are "just temporarily down on their luck" or have less severe mental health issues.
• "And for those who are severely mentally ill and deeply disturbed, we will bring them back to mental institutions, where they belong," he said, "with the goal of reintegrating them back into society once they are well enough to manage."

The big picture: Large psychiatric hospitals lost credibility in part because they ended up simply warehousing people, rather than doing much to treat them. Facilities that want to receive federal Medicaid money are now capped at a certain size.

• There's a push in some academic and policy circles to lift or even remove that cap, allowing facilities to take in and treat more patients.
• But that's different from committing people against their will — an approach that some Democrats, including New York City Mayor Eric Adams, also want to expand

Trump was also interested in similar plans while he was in office, but they were upended by the coronavirus pandemic, said Joe Grogan, the former director of Trump's Domestic Policy Council.

• "We were spending a lot of time on it, and we had plans for commissioned corps appointments, for intake at homeless encampments, we were trying to figure out where we could remove people to and give them shelter to get them off the city streets," Grogan told Axios.
• Those plans included lifting the cap on mental health facilities' size.

"The fact that we did a terrible job on this 50, 60, 100 years ago shouldn't freeze us into thinking we have to let people rot on the streets," Grogan said. "It's going to be expensive, but I think Trump was willing to invest the money."

The administration wanted to find a city to partner with, to move people out of encampments "and get them into a place that was built and maintained with law and order, to get the people stabilized and moved into institutions if possible and moved on to other care," Grogan said.

• "We weren't going to invade a municipality and take control of the homeless situation. We'd have to have a mayor who would say, 'You're right, I'm at a breaking point, we need help,'" he added, and the administration was "having significant discussions with a couple mayors in California."
• The Trump campaign did not respond to a request for more detail about future plans.

Reality check: Most homeless people are not mentally ill.

• "We need to separate the homeless from the mental health problems," said Zeke Emanuel, who co-authored a 2015 JAMA article — controversial at the time, he said — calling for a return to using asylums for some people.
• Of Trump's agenda, he said: "Like everything the man does, it conflates so many different things that I don't even know what we're really supposed to understand except, get them off our streets."

Between the lines: Experts who are supportive of expanded longer-term inpatient hospitalization emphasize that they don't want a return to last century's approach.

• "If you could combine modern psychiatric medication and some techniques, behavioral techniques that we've perfected, with a setting … I have this romantic vision with animals and a farm, and people could be productive," said Sally Satel, a psychiatrist and a senior fellow at the American Enterprise Institute. "It would be a very easy environment to negotiate, and it would be pretty long-term."

What they're saying: Civil rights groups have opposed the expanded use of involuntary commitment.

• "Making it easier to commit people against their will would repeat one of the great wrongs of the last 150 years," the ACLU wrote in 2019. "It will rob innocent people of their most basic civil liberty: the day-to-day freedom to live on your own and make your own decisions about whether and what kind of medical treatment to receive."

By the numbers: Around 1 in 20 U.S. adults experienced serious mental illness in 2021, and about two-thirds of the 14.1 million adults with a serious mental illness received some kind of mental health service, according to a report by the Substance Abuse and Mental Health Services Administration.

• A large portion of this population is "riding this institutional circuit between streets and jail and very short-term commitments, and then back on the street," said Stephen Eide, a senior fellow at the Manhattan Institute.
• "Particularly if you're talking about incarcerated seriously mentally ill people, it seems to me that if we are really concerned that jail is not the best place for people with schizophrenia, expanding our stock of inpatient psychiatric beds is going to have to be part of the solution to that."

The bottom line: Although it's unclear exactly what Trump's vision is, those calling for more mental hospitals say there would be fundamental differences from the prior system.

• "We're never going back to the old way," Eide said. "Adjusted for population, you'd be talking about over a million people involuntarily confined to mental institutions, oftentimes for a long time — years, even decades."