By Chris Adams

Dr. Brian Hepburn has seen the transformation of America’s mental health system up close.

When he was young, two of his aunts worked at a state psychiatric hospital in Michigan, one as a head nurse and the second as an assistant head nurse. One of those aunts lived in the hospital’s training center, so he would be there for birthdays and holidays and other visits.

“We used to go to tea parties with the patients at the hospital,” he said. “That was at a time that people rarely ever left. We interacted with them fairly easily.”

He worked at the hospital himself, and his mother was sometimes a patient there, so he came to know it well.

But that was in the 1950 and 1960s, and since then behavioral health treatment has changed substantially. In a session at the National Press Foundation, Hepburn – now executive director of the National Association of State Mental Health Program Directors – described the arc of treatment settings over past decades.

That encompassed a major overhaul in how people are treated. Just one example: Over four decades, state mental health expenditures for psychiatric hospitals and those for community-based outpatient services flipped, with the hospital portion moving from two-thirds of spending to less than one-third.

Hepburn described some of the other changes, including the growth of community health models in the 1970s and 1980s; the move into managed care in the 1980s and 1990s; the innovations brought by the New Freedom Commission during the 2000s; and the impact of the Affordable Care Act in the 2010s.

Two of those key ACA impacts were the mandates that children could stay on their parents’ health insurance until age 26 and that insurers couldn’t turn down people with pre-existing conditions.

That’s key in mental health, Hepburn said. “Behavioral health issues are issues of the young,” he said.