558,922 37,650
psychiatric beds · 1955 psychiatric beds · today
One Hundred Years of The Untreated
America closed its psychiatric hospitals. It never built what was supposed to replace them.
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One Hundred Years of

The Untreated

Where did the deinstitutionalized go? Five receiving systems absorbed 521,272 missing beds.
Report   06 / 10
Window   1900 — 2024
Beds lost
521,272
558,922 − 37,650
SMI in jails/prisons
383,000
10× more than in hospitals
Homeless with SMI
172,000
1 in 3 homeless adults
SMI untreated
5,000,000
40% of all SMI adults
Receiving systems 5 destinations

Where the untreated went

The 521,272 beds that disappeared represent people who, under 1955 ratios, would have been hospitalized. They went to five systems — none designed as psychiatric care.
The transfer thesis

Deinstitutionalization was not a failure of idea but of execution. The Community Mental Health Act of 1963 envisioned 2,000 community mental health centers. Fewer than half were ever built, and most were underfunded within a decade.

The IMD exclusion — a Medicaid provision barring federal payment for psychiatric hospitals with more than 16 beds — created a perverse incentive: states saved money by closing hospitals and shifting costs to jails, ERs, and the streets.

The result is a system of transinstitutionalization: patients moved not from institutions to communities, but from one form of institutional confinement to another. The three largest psychiatric facilities in the United States are now the Los Angeles County Jail, Cook County Jail, and Rikers Island.