Privatizing North Carolina’s state mental hospitals is a bad idea

Our public mental health system has struggled mightily to adequately serve the people of North Carolina. A cornerstone of that system is our three state hospitals.

Legislatively-mandated public mental health reforms in the early 2000’s ended government operation of county-based outpatient mental health programs, and critically cut the bed capacity of state hospitals by half, creating crippling logjams in admissions. In recent years, even that diminished bed capacity has been further over-burdened by court referrals of persons lacking the capacity to stand trial and in need of treatment to restore their capacity.

In addition, these hospitals have struggled to hire and retain nursing staff, leading to chronic bed closures. All told, 50% or fewer state hospital beds at a given time are available for civil patients not there by criminal court order.

What is a state legislature to do with such a set of seemingly intractable problems? It appears the NC General Assembly is nearly ready to hand the problem off to a private company or possibly a university. In either case, it’s a bad idea.

Evidence of the support for state hospital privatization is a provision in the newly enacted H1104 that calls for study of “the feasibility of the change of operation or administration of state-operated psychiatric hospitals.”

Since Dorothea Dix persuaded the state to develop its state hospitals in the mid-1800s, these state hospitals have been a critical safety net for indigent and complex patients and, moreover, critical training grounds for our state’s mental health workforce — a struggling workforce in shortage to this day.

The privatization of our public outpatient mental health programs in the 2000s greatly reduced the opportunities for mental health workforce training, so state hospitals are an even more important lifeline for training and our behavioral health training programs critically depend on them. Privatization of state hospitals would threaten their current training missions under a privatized mission of operational efficiency and profitability. Similarly, clinical research now conducted at all three facilities would likely be squeezed out, threatening cutting-edge treatment advances.

What are the risks of privatizing our state hospitals? A recent Stanford University study found that access to hospital beds significantly declines under privatization, and low-income residents are hit the hardest by the cutbacks in available beds and other levels of care. Reduced access for vulnerable patients is also accompanied by lower staffing levels and poorer quality of care.

Another recent review also concluded that privatization may reduce costs, but at the expense of quality of care. Public oversight and accountability of privatized hospitals is clearly weakened when hospitals come under private control, which is a particular concern given the historic mission of state mental hospitals to care for our most vulnerable patients.

Rather than furthering the divestiture of our public mental health programs, we should buckle down and give state government more time to develop effective solutions. These include freeing up beds by diverting patients incompetent to stand trial to other less expensive treatment options, growing the capacity of outpatient programs to treat patients with severe conditions outside state hospitals ,and developing new staffing initiatives to fill state hospital personnel vacancies.

Once we privatize our state hospitals, it will be nearly impossible to undo it. We will have dug a far deeper hole for our public mental health system. Despite our impatience, we need to give state government time to find public-minded solutions.

Marvin Swartz MD is a professor of psychiatry at the Duke University School of Medicine Department of Psychiatry and Behavioral Science and a faculty affiliate of the Wilson Center for Science and Justice at the Duke University School of Law. The views expressed are his alone and not that of Duke University.