For-Profit Mental Healthcare Companies and the Practice of Forced Confinement

Kathryn MacKenzie is a school social worker in Florida who moved to Tampa in 2020 to be with her mother. MacKenzie had previously been diagnosed with bipolar disorder, after suffering a breakdown when she was in college. Since then, though, she has consistently taken her medication, attended group therapy, and reached out when she needed help. 

When she moved to Tampa, MacKenzie was excited about her new job and being closer to her mother, but experienced a slight disconnect in healthcare, as she didn't immediately find a new doctor. As a result of this, as well as the stress of moving, MacKenzie’s mother began picking up on some troubling signs: rapid speech, mood swings, and sleeplessness. Motivated by worry for Kathryn, her mother and sister urged her to see a doctor, and she did.

MacKenzie drives herself to the hospital to meet with a physician about reassessing her bipolar medication–something that should be a quick appointment. However, the doctor refers her to another hospital, under the healthcare company Acadia (North Tampa Behavioral Health Hospital), to get a psychological evaluation. There, she completes the evaluation, responding clearly that she does not have plans of hurting herself or others, nor does she have thoughts of doing so. Nevertheless, she is held at the center, against her will, for days, and denied contact with family.

MacKenzie is not receiving treatment or any form of therapy in the center. Acadia, however, is charging $2,200 to her insurance company, per day she is in their care. Without contact with the outside world, a sense of when she’s getting out, or any form of mental health treatment, MacKenzie begins to spiral.

After her sister and mother hire a lawyer to get her out of North Tampa Behavioral, MacKenzie is finally released, after seven days of commitment. However, the effects of this stint are permanent; MacKenzie suffers night terrors from her stay, she’s intensely scared of seeking mental healthcare in that way again, and she is quickly diagnosed with PTSD. She sought help and care but received trauma and neglect. How did this happen?

About 1 in 5 people in the United States live with a mental illness. An important note to this, however, is that mentally ill people were (and are) disproportionately low-income. Hence, before the Affordable Care Act, also known as the ACA, they were simply priced out of insurance. Insurance companies were allowed to screen possible clients for their medical history, and use the information they acquired to raise premiums, enforce caps on mental health treatment, and deny coverage. As a result, millions of Americans living with mental illness were not able to receive treatment. 

The ACA changed this. It required the coverage of mental health care as well as substance abuse treatment by most insurance companies, and ensured that limits weren’t placed on these treatments. Further, the ACA also expanded provisions in the Mental Health Parity and Addiction Equity Act (MHPAEA), which guaranteed insurance companies couldn’t charge higher cost-sharing for mental health services in relation to other services. As a result, Americans with mental illnesses were both more likely to be insured and more likely to have access to treatment than before. 

Undoubtedly, the ACA improved the lives of millions of Americans, but it also had an unintended consequence: private, for-profit mental healthcare facilities exploiting the subsidized requirement for insurance companies to cover mental healthcare costs. These companies would routinely hold patients against their will in order to make money, charging thousands of dollars per day. This was the case with Acadia, the company that held MacKenzie for days against her will. 

Specific laws concerning involuntary psychiatric commitment vary state-by-state. However, there are basic federal laws that provide parameters for involuntary commitment, most of which are based on the 14th Amendment, and more specifically the due process clause. Medical facilities in Florida are allowed to hold patients involuntarily only for 72 hours, only if patients are found to be “a danger to others or incapable of surviving safely without institutional care,” as asserted in O’Connor v. Donaldson. So already, Acadia Healthcare violated the law in committing MacKenzie, since she fit neither condition.

The 14th Amendment asserts that an individual’s life, liberty, and/or property cannot be restricted without due process of law. In this context, this clause manifests in the form of court hearings. Once the time period for involuntary commitment (which varies between states) has passed, mental healthcare facilities can file a petition to hold the patient for longer. However, simply filing the petition allows healthcare facilities to hold a patient until the court date and bill the insurance company accordingly. In the case of North Tampa Behavioral, it was found that only 1% of the petitions were granted. Hence, the petitions served as a delaying tactic to get insurance companies to pay them more. 

The situation becomes more problematic when one looks at the state-by-state rights of patients who are involuntarily committed. While Florida affords patients the least rights, they still affirm that patients have the right to see a healthcare professional for an assessment (during commitment). MacKenzie was not given this option. 

Following a thorough review of patient rights in these scenarios, the stories of formerly held patients, and cases that establish what qualifies one for involuntary commitment, it is clear that, for one, what happened to Kathryn MacKenzie was illegal. It is also clear, however, that the laws pertaining to involuntary commitment must be amended to allow for basic rights including, but not limited to the right to call a relative, the right to appeal the commitment, and the right to know the reason for one’s commitment. Finally, the government must crack down on for-profit mental healthcare institutions, ideally starting with the prosecution of Acadia. If other for-profit companies observe Acadia’s policies and lucrative profit-making strategies, and simultaneously recognize their lack of legal repercussions, we may see this problem multiply.

Alice Kovarik is a first-year studying Economics and International and Public Affairs. She can be reached at alice_kovarik@brown.edu

Kourtney Beauvais is a junior studying International and Public Affairs and Applied Math - Economics. She can be reached at kourtney_beauvais@brown.edu.