Most of the world has state funding in some method for mental health. Many would argue that it is unjust to compel a person to seek treatment and then charge for it. Historically, such coercion occurred in asylums and psychiatric hospitals, run by local authorities or the crown, and funded variably.
After these places closed, there has been a need for community care to be funded. How this happens varies: in New Zealand the state funds district health who must provide community care, but primary health care is partially subsidized with a co-payment for around fifty dollars (forty euros).
Some, if not most psychiatric patients, do not have GPs. The natural experiment in Holland indicates that part payment in mental health will not work. People need to eat, and 100 euros cuts into the food budget.
In 2012, the Dutch national government instituted a new co-payment of €100 (US$113) for visits to mental health care specialists, with a second payment of €100 (US$113) at the 100-minute mark of treatment. This payment was in addition to an increase in the deductible for all health services from €170 to €220 (US$192 to US$248), increasing total potential out-of-pocket prices for a new episode of treatment to as much as €420 (US$474).
The study by Ravesteijn et al5 in this issue of JAMA Psychiatry examines the consequences of this new mental health care cost-sharing requirement. This quasi-experimental study examined changes during the following year in outpatient mental health service use, involuntary commitment, acute care services, and costs. The difference-in-differences design compared changes between adults, who were subject to these new requirements, and youth aged 15 to 17 years, who were not. This analytic approach made it possible to isolate the influence of the new policy and to control for other unmeasured trends that could have occurred during the study period.
The findings are troubling. During the year after the cost-sharing policy was introduced, there was a decrease in new mental health treatment episodes of 13.4%, an increase in acute care treatment of 25.3%, and an increase in involuntary commitments of 96.8%. The reduction in demand for mental health services was greater in low-income than in high-income neighborhoods and was no different for less serious than more serious disorders.
Funding matters. Acute care is expensive. There needs to be some form of shelter and care for those incapable of funding their own. Many psychiatric patients are alienated from their families, for good or ill. But this I know. You can judge the social progress of a society by the safety of the religious and odd, and the care of the mad.
By that criteria, we are failing.