Grants and philanthropy are subject to shifting policy priorities and cannot bridge every gap
I am from Guatemala.
Growing up, I heard stories, sometimes quiet, sometimes spoken openly, of families struggling to care for loved ones with severe mental illness. Not because they did not love them, but because they had no system to help them.
In many parts of the world, when mental health care is inaccessible, families are left with difficult choices. Families send their loved ones with severe mental illness to institutions where they may be confined, restrained, or even chained, often because families lack the resources to care for them safely. This reflects a broader pattern in places with no societal structures that support mental diseases.
In the United States, we point to hospitals, clinics, and publicly funded systems as evidence that we have solved this problem. And we have indeed made meaningful progress.
But it’s an ongoing effort. Caring for individuals with severe and persistent mental illness, severe substance use disorders, and recently incarcerated individuals transitioning back into the community is not a discrete intervention. It is not reducible to a visit or a prescription. It’s relational work that involves supporting families in crisis, managing chronic instability, navigating reintegration, and holding together care over years, not weeks.
Across community mental health systems, even those that are already publicly funded, there is growing pressure to expand third-party billing as grant funding becomes less stable and more uncertain. The intention is understandable. It is an attempt to create sustainability. But the model is misaligned.
I have worked in systems where this tension did not exist. In the Veterans Health Administration, the question was never whether veterans would receive care. That was already decided. The focus was on how to deliver better care, not whether it could be afforded.
For the populations we now serve, that same commitment has not been fully made.
Third-party reimbursement is built for defined, measurable interventions. It works well for procedures and time-limited care. It does not map onto chronic, relational, system-level work.
So the system adapts, not by redefining what is funded, but by shifting expectations onto the workforce. Clinicians are asked to produce revenue within a model that does not reflect the care they provide. Documentation expands. Time compresses. But the needs of patients and families do not shrink.
What cannot be billed does not disappear. It is absorbed by the clinician who stays late, by the therapist who carries emotional weight home, and by the team that stretches itself to hold together patients and families in crisis.
This has created a hidden economy, sustained not only by the unpaid emotional and relational labor of the workforce, but also by grants and philanthropy that attempt to fill the gaps. In the United States, major portions of care for individuals with severe mental illness are supported through federal block grants and targeted programs that are essential but often time-limited and vulnerable to shifting policy priorities.
At the same time, the workforce carrying this care is under increasing strain. Rising levels of burnout, depression, and moral distress among healthcare workers reflect a system where the demands of care are not aligned with how that care is funded.
This tension is not the result of any one organization’s decisions, but a broader structural reality facing community mental health systems nationwide. We are asking a critical system of care to operate on increasingly unstable ground.
We do not fund mental health care for the most vulnerable in the same way we fund other essential services. We do not ask police departments, fire services, or public utilities to justify their existence through billing codes that fail to capture the full scope of their work. We do not expect them to close funding gaps through productivity or temporary grants.
We fund them because we have collectively decided they are necessary.
Care for individuals with severe mental illness, substance use disorders, and those reintegrating after incarceration should be viewed the same way, not as a service that must continuously prove its financial worth, but as a system that must exist.
Because the question is not whether compassion exists. It is whether we are willing to build systems that can afford it.
I have seen what happens when systems do not exist. I have also seen what is possible when a system makes that commitment, when the question is no longer whether someone deserves care, but how to deliver it better, as I experienced in the VA system where I trained and worked.
The United States has built something extraordinary in its capacity to care for those with the most complex needs. But that progress is not guaranteed.
We need to support it. We need to protect it. And we need to ensure that it is not sustained by the quiet, uncompensated compassion of those who carry it every day.
References
- Human Rights Watch. Living in Chains: Shackling of People with Psychosocial Disabilities Worldwide (2020) https://www.hrw.org/report/2020/10/06/living-chains/shackling-people-psychosocial-disabilities-worldwide
- Substance Abuse and Mental Health Services Administration (SAMHSA). Serious Mental Illness Programs and Funding https://www.samhsa.gov/mental-health/serious-mental-illness
- American Medical Association. Statement on restoring federal grants for mental health and substance use care https://www.ama-assn.org/press-center/ama-press-releases/ama-statement-restoring-federal-grants-mental-health-and-sud-care
- U.S. Government Accountability Office. Health Care Workforce: Burnout, Behavioral Health, and Well-Being https://www.gao.gov/products/gao-26-107951
