16 BED LIMIT

Medicaid · 42 U.S.C. §1396d · in force since 1965

Medicaid stops paying at 16 beds*.

Medicaid has refused to pay for adults in psychiatric institutions since it was created in 1965, and since 1988 the statute has drawn that line at 16 beds. If an adult between 21 and 64 is treated in a psychiatric or addiction facility with more than 16 beds, federal Medicaid pays nothing toward their care.

The average psychiatric hospital in the United States has 108 beds. So the rule does not fund small hospitals. It defunds almost all of them.

* The bar applies only to adults aged 21-64 treated in a facility that meets Medicaid’s statutory definition of an “institution for mental diseases” (IMD) — the 16-bed line quoted above is part of that definition, not a separate rule.

It is not absolute. States can route around it for some patients through a section 1115 waiver, a 15-day managed-care carve-in, and a 30-day substance-use-disorder option — see Waivers and Who decides — and IMDs can receive a separate, capped share of Medicaid disproportionate-share (DSH) payments under 42 U.S.C. §1396r-4(h), a different mechanism from the exclusion itself. Medicaid.gov, Disproportionate Share Hospital (DSH) Payments. Full statutory text: 42 U.S.C. §1396d(i) — Social Security Act §1905(i).

System readoutretrieved 2026-08-26

Federal bed limit

16

Unchanged since it entered the statute in 1988.

Average psychiatric hospital

108

Smaller than the average general hospital.

Hospitals under the limit

<8%

The rest cannot bill Medicaid for adult care.

State psychiatric beds

36,150

Down from 558,922 in 1955. A record low, in 2023.

FIG. 01

Two capacities, one country

State psychiatric hospital beds against the number of people held in state and federal prisons and in local jails, 1955 to the present. Points are census and survey years, and the line between them is a connector, not measured data. The series stop where the published figures stop: beds and prisons at 2023, jails at 2024. Everything to the right of that line is time we have no national count for yet, not a decline to zero.

Psychiatric hospital beds falling and prison population rising, 1955 to the presentState psychiatric hospital beds fall from 558,922 in 1955 to 36,150 in 2023. Over the same period the state and federal prison population rises from 185,780 in 1955 to a peak of 1,612,395 in 2010 and stands at 1,254,200 in 2023. Local jails held 657,500 people at midyear 2024. Medicaid was enacted with the institutions for mental diseases exclusion in 1965. The horizontal axis continues to the current year; no line is drawn past the last year each agency has published, which is 2023 for beds and prisons and 2024 for jails.195019601970198019902000201020202026published data ends 20241965 · Medicaid enacted, with the rule1955: 185,780 people in state and federal prison (sentenced basis) — BJS, Prisoners 1925-81, Table 11965: 210,895 people in state and federal prison (sentenced basis) — BJS, Prisoners 1925-81, Table 11980: 315,974 people in state and federal prison (sentenced basis) — BJS, Prisoners 1925-81, Table 11990: 773,919 people in state and federal prison (jurisdiction basis) — BJS, Prisoners in 1998, Table 12000: 1,381,892 people in state and federal prison (jurisdiction basis) — BJS, Prisoners in 20002010: 1,612,395 people in state and federal prison (jurisdiction basis) — BJS, Prisoners in 2010 (Revised)2023: 1,254,200 people in state and federal prison (jurisdiction basis) — BJS, Prisons Report Series: Preliminary Data Release, 20231990: 405,320 people in local jails — BJS, Prisoners in 1998, Table 11998: 592,462 people in local jails — BJS, Prisoners in 1998, Table 12013: 731,200 people in local jails — BJS, Jail Inmates in 20232023: 664,200 people in local jails — BJS, Jail Inmates in 20232024: 657,500 people in local jails — BJS, Jails Report Series: 2024 Preliminary Data Release (midyear 2024)1955: 558,922 state psychiatric hospital beds — APA Psychiatric Bed Crisis Report (citing Bockoven 1972)2010: 43,318 state psychiatric hospital beds — Treatment Advocacy Center, "Going, Going, Gone" (2016)2016: 37,679 state psychiatric hospital beds — Treatment Advocacy Center, "Going, Going, Gone" (2016)2023: 36,150 state psychiatric hospital beds — Treatment Advocacy Center, "Prevention Over Punishment" (2024)558,922 beds36,1501,254,200 in prison657,500 in jail

Both axes use a square-root scale so a collapse from 559,000 and a rise past 1.6 million stay readable in one frame. Point values are shown on hover and tap.

These two lines are not a causal claim. Incarceration in the United States rose for many reasons — sentencing law, drug policy, and policing changed enormously over the same period. What the chart shows is that the country reduced its psychiatric hospital capacity to almost nothing and expanded its correctional capacity enormously, and that a federal funding rule adopted in 1965 made the first of those two things cheaper for states to do.

Two BJS measures are stitched here. Figures through 1980 count sentenced prisoners in state and federal institutions; from 1990 they count prisoners under the jurisdiction of state and federal authorities. Local jails are a separate line and are not added into the prison figure.

If you want to do something about this

Tell Congress you support the billsSend records or your storyWho can actually change it

Or ask a question — the assistant answers only from the sources on this page:

01 — What the rule says

One sentence, written in 1965

Medicaid pays for almost every kind of medical care. There is one category of facility it will not pay for, and psychiatric hospitals are it.

a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services42 U.S.C. §1396d(i) — Social Security Act §1905(i)

That is the definition of an institution for mental diseases, or IMD. The exclusion itself is a second passage, which says Medicaid will not pay for

any such payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases42 U.S.C. §1396d(a), concluding paragraph, clause (B)
In plain language

If you are between 21 and 64, and you are a patient in a psychiatric or addiction treatment facility with more than 16 beds, Medicaid will not pay for your care. Not the psychiatric care, and not the ordinary medical care either. The bar follows you: it also covers treatment delivered outside the facility while you are a patient there. If you are 65 or older, or under 21, separate exceptions apply.

A note on citations. The exclusion sits in the flush language after the §1905(a) service list. That list now runs to paragraph (32), so older citations such as §1905(a)(30)(B) reflect earlier numbering. We link the current United States Code text so you can read it yourself: 42 U.S.C. §1396d.

Why 16?

This is the question everyone asks. Here is everything that is documented.

  • The ≤16-bed exception was added by the Medicare Catastrophic Coverage Act of 1988 (P.L. 100-360), which wrote the IMD definition into statute. CRS IF10222
  • A definition of “institution for mental diseases” already existed in regulation — but without any bed count. The 1978 rule turned on a facility’s “overall character.” The number 16 was added by the 1988 statute, and the regulation was edited to match it in 1991. 43 FR 45204 (1978)
  • The stated intent was to favor smaller settings over large institutions, which indicates Congress supported the use of smaller facilities. CRS IF10222
  • The regulations governing the IMD exclusion have not been updated since 1988. Legal Action Center
And here is what is not

None of the standard references explains why the number is 16 rather than 20, 30, or 50. There is no published cost model, bed-supply study, or clinical standard behind the figure in any source checked here. It has not moved in the 38 years since, while the average psychiatric hospital has settled at 108 beds.

The closest anyone comes

The closest thing to an official rationale is not about Medicaid at all. It is in the 1976 SSI rule that let people keep their benefits in small group homes, and it explains a purpose rather than a number: Congress, the agency wrote, "envisions a 16 resident capacity as an outer limit applicable to community residences" — a "small, free-standing, community-based living unit" meant as an alternative to a large institution. When a commenter asked the agency to count the threshold a different way, it refused, because that would not be consistent with the statute "and its legislative history." The agency treats 16 as given to it. It never says where the figure came from.

No document connects that 1976 SSI figure to the 1988 Medicaid one. They are the same number doing similar work twelve years apart, which is suggestive and is not evidence. Treat the link as an open question, not a finding.

43 FR 55379 (28 Nov 1978) →

Sources checked for a rationale: CRS IF10222 (read in full 2026-09-01 via a mirror, after congress.gov itself refused automated access); MACPAC; Manhattan Institute (2021 and 2025); Legal Action Center; American Psychiatric Association; National Association of Medicaid Directors; Mental Health America; Treatment Advocacy Center; Orchid Advocacy; SSA Ruling SSR 79-8; and the 1978 rulemaking at 43 FR 55379.

If you find a published rationale for the figure, we want it. Send it to hello@16bedlimit.com and this section will be corrected with the citation.

01b — The order and the statute

A 2025 executive order points at the beds. It does not mention the rule.

Executive Order 14321, Ending Crime and Disorder on America’s Streets, was signed 2025-07-24 and published at 90 FR 35817. Its stated policy is to move people into institutional treatment. Read it next to the sentence above.

Shifting homeless individuals into long-term institutional settings for humane treatment through the appropriate use of civil commitment will restore public order.Executive Order 14321, Section 1, Purpose and Policy
  • Sec. 2 — Restoring Civil Commitment. Directs the Attorney General, with HHS, to seek reversal of precedents and consent decrees that impede civil commitment, and at 2(a)(ii) to help states adopt “maximally flexible civil commitment, institutional treatment, and ‘step-down’ treatment standards”.
  • Sec. 3(b)(iii) — Fighting Vagrancy on America’s Streets. Directs the Attorney General to assess federal resources to determine whether they may be directed toward ensuring that detainees with serious mental illness “are not released into the public because of a lack of forensic bed capacity at appropriate local, State, and Federal jails or hospitals”.
  • Sec. 4(a) — Redirecting Federal Resources. Assigns HHS the mental-health work, and routes it through three things: discretionary grants issued by the Substance Abuse and Mental Health Services Administration, technical assistance to assisted-outpatient-treatment programs, and funds for Federally Qualified Health Centers and Certified Community Behavioral Health Clinics. Medicaid is not among them.

What the order says, counted

Counted in the order's operative text on 2026-09-02 — everything from “By the authority vested” to the signature, so the White House site's own menus are left out.

7civil commitment
1institutional treatment
1forensic bed capacity
0institution for mental diseases
0IMD
016 bed
0Medicaid

The three non-zero counts are the control: they prove the search could find what is there, so the zeros are about the document and not about the method. The one “Medicaid” string anywhere on that page is a headline in the site's navigation menu, not a word in the order.

Reading them together

The order points states and federal agencies toward institutional treatment. Medicaid is the largest payer for that treatment, and for an adult aged 21 to 64 the statute above forbids it in any facility with more than 16 beds. The order does not mention that bar, and an executive order could not lift it in any case: the bar is in the statute, and only Congress can change a statute. So the two documents describe the same population and answer different questions — one names a destination, the other decides who pays once a person arrives.

This is a comparison of two texts, and nothing more. It is not a claim that the order is unlawful, that its drafters overlooked the exclusion, or that repeal is anyone’s stated policy. Read both documents and draw your own conclusion; both are linked. Read the order at The White House or as published in the Federal Register, 90 FR 35817.

02 — The scale problem

Sixteen is not a small hospital. It is almost no hospital.

The number was meant to favor small community settings over large institutions. The effect is that nearly every psychiatric hospital in the country falls on the wrong side of it.

FIG. 02

Where the line falls

Every psychiatric hospital larger than 16 beds is an institution for mental diseases, and Medicaid will not pay for adult care inside it. These are the measured landmarks of the national bed-size distribution.

Psychiatric hospital size against the 16-bed Medicaid limitThe federal limit is 16 beds. The average United States psychiatric hospital has 108 beds. Ninety-five percent of psychiatric hospitals have fewer than 305 beds. Fewer than 8 percent have 16 beds or fewer.Fewer than 8% of psychiatric hospitals are at or below the 16-bed line.01650108150200250305beds in the facility16 — the statutory limiteligible108average hospital30595th percentileMedicaid will not pay for adults 21 to 64 in this range

Landmarks only. We do not have the full facility-by-facility distribution, so this is not drawn as a histogram. Source: Manhattan Institute, "U.S. Psychiatric Hospitals Under Medicaid's IMD Exclusion" (Aug 2025).

  • The average U.S. psychiatric hospital has 108 beds — smaller than the average general hospital.
  • 95% of psychiatric hospitals have fewer than 305 beds.
  • Less than 8% of psychiatric hospitals have 16 beds or fewer.
  • Redefining an IMD as a facility with more than 108 beds would make as many as 332 existing hospitals, holding more than 20,000 beds, eligible for Medicaid reimbursement.
03 — The workarounds

Most states have negotiated an exception

Because the rule is hard to live with, states ask the federal government for permission to ignore parts of it. That permission is a section 1115 demonstration waiver, and it is temporary, conditional, and narrower than it sounds.

FIG. 03

Who got a waiver

States can ask CMS for a section 1115 demonstration waiver to bill Medicaid for short IMD stays anyway. Most have one for addiction treatment. Far fewer have one for mental health. Every square is one state, sized equally.

Section 1115 IMD waiver status by stateA grid of all fifty states and the District of Columbia. 14 have approved section 1115 waivers for both substance use disorder and mental health treatment, 23 for addiction treatment only, 1 for mental health only, 3 have an application pending with CMS, and 10 have neither an approved waiver nor a pending application.AKAK: approved waiver for substance use disorder treatment onlyMEME: approved waiver for substance use disorder treatment onlyVTVT: approved waivers for both substance use disorder and mental health treatmentNHNH: approved waivers for both substance use disorder and mental health treatmentWIWI: approved waiver for substance use disorder treatment onlyMIMI: approved waiver for substance use disorder treatment onlyNYNY: approved waiver for substance use disorder treatment onlyMAMA: approved waiver for substance use disorder treatment onlyRIRI: approved waiver for substance use disorder treatment onlyIDID: approved waivers for both substance use disorder and mental health treatmentMTMT: approved waiver for substance use disorder treatment onlyNDND: no approved or pending IMD waiverMNMN: approved waiver for substance use disorder treatment onlyILIL: approved waiver for substance use disorder treatment onlyININ: approved waivers for both substance use disorder and mental health treatmentOHOH: approved waiver for substance use disorder treatment onlyPAPA: approved waiver for substance use disorder treatment onlyNJNJ: approved waiver for substance use disorder treatment onlyCTCT: approved waiver for substance use disorder treatment onlyWAWA: approved waivers for both substance use disorder and mental health treatmentWYWY: no approved or pending IMD waiverSDSD: no approved or pending IMD waiverIAIA: no approved or pending IMD waiverMOMO: approved waivers for both substance use disorder and mental health treatmentKYKY: approved waivers for both substance use disorder and mental health treatmentWVWV: approved waiver for substance use disorder treatment onlyVAVA: approved waiver for substance use disorder treatment onlyMDMD: approved waivers for both substance use disorder and mental health treatmentDEDE: approved waiver for substance use disorder treatment onlyOROR: approved waiver for substance use disorder treatment onlyNVNV: approved waiver for substance use disorder treatment onlyCOCO: approved waivers for both substance use disorder and mental health treatmentNENE: approved waiver for substance use disorder treatment onlyARAR: application pending with CMSTNTN: application pending with CMSNCNC: approved waiver for substance use disorder treatment onlySCSC: no approved or pending IMD waiverDCDC: approved waivers for both substance use disorder and mental health treatmentCACA: approved waivers for both substance use disorder and mental health treatmentUTUT: approved waivers for both substance use disorder and mental health treatmentNMNM: approved waivers for both substance use disorder and mental health treatmentKSKS: approved waiver for substance use disorder treatment onlyLALA: approved waiver for substance use disorder treatment onlyMSMS: no approved or pending IMD waiverALAL: approved waiver for mental health treatment onlyGAGA: no approved or pending IMD waiverHIHI: no approved or pending IMD waiverAZAZ: application pending with CMSOKOK: approved waivers for both substance use disorder and mental health treatmentTXTX: no approved or pending IMD waiverFLFL: no approved or pending IMD waiver
  • Both14
  • Addiction only23
  • Mental health only1
  • Pending3
  • None10

A waiver is a time-limited demonstration, not a change in the law. It usually covers only short stays and comes with CMS milestones the state has to hit.

Status as of 2025-01-14, from CRS IF10222, Table 1 (source: KFF Medicaid Waiver Tracker, Jan 14 2025). Waiver status changes; check the KFF tracker for the current picture. Separately, managed care plans may pay for stays of up to 15 days in a month, and a state plan option allows up to 30 days a year for substance use disorder treatment. This dataset is now part of the same automated freshness watch as the bed, prison and jail counts on this page: it checks weekly whether the KFF tracker above has changed and flags it for a person to re-read. Live status: /api/freshness.

04 — How it got here

Sixty years of narrow exceptions

Congress has amended around this rule repeatedly. It has never removed it.

  1. 1854
    Presidential veto

    Pierce vetoes the Bill for the Benefit of the Indigent Insane

    President Franklin Pierce vetoes federal land-grant funding for public mental institutions, reaffirming that paying for psychiatric care is a state responsibility. Later scholarship treats this as the ancestor of the IMD exclusion — but no primary document from 1935, 1950 or 1965 makes that connection, and the 1935 record cuts against it.

    Manhattan Institute →
  2. 1950
    P.L. 81-734

    The actual origin — fifteen years before Medicaid exists

    Section 303(a), 64 Stat. 549, creates federal “vendor payments” to medical providers and, in the same sentence, carves two categories back out: patients in institutions for tuberculosis or mental diseases. This is where mental institutions first enter federal law — as an exception to a liberalisation. The House adopted the conference report 373-1, with Republicans voting 137-1 in favour. Truman signed it.

    P.L. 81-734, 64 Stat. 477 →
  3. 1960
    P.L. 86-778

    The Senate votes to abolish it. A conference committee reverses that overnight.

    On 23 August the Senate adopts Sen. Russell Long’s amendment permitting federal matching of vendor payments to public mental and tuberculosis hospitals. On 24 August the conference committee accepts the Senate’s medical-care provisions “except for Senator Long’s amendment.” Reading the enacted statute confirms it: no such authority survives. This is the only moment in the whole history where the rule was genuinely contested, and it lasted a day.

    SSA legislative chronology, 1960 →
  4. 1965
    P.L. 89-97

    Medicaid inherits the exclusion — and narrows it

    Section 121(a), 79 Stat. 351-352, carries the 1950 sentence into the new Title XIX — so Medicaid does not invent this rule, it inherits it. 1965 is also the one year Congress narrowed it: §1905(a)(14) affirmatively covers people 65 and over in an IMD, which SSA’s own contemporaneous account describes as removing the exclusion for aged individuals. There was no under-21 carve-out yet; the exclusion hit everyone under 65, and the 21-64 band arrives in 1972.

    P.L. 89-97, 79 Stat. 286 →
  5. 1972
    P.L. 92-603

    "Psych under 21" carve-out

    Congress creates an optional benefit letting states cover inpatient psychiatric services for people under 21. Because an EPSDT screen can find the care medically necessary, every state now covers it.

    CRS IF10222 →
  6. 1988
    P.L. 100-360

    The number 16 enters the statute

    The Medicare Catastrophic Coverage Act writes the IMD definition into law and adds the piece that had not been there before: facilities of 16 beds or fewer are exempt. It arrives at §411(k)(14)(A), under a heading reading TECHNICAL CORRECTIONS TO CERTAIN HEALTH CARE PROVISIONS, sitting between a schools provision and an eligibility-paperwork fix. CRS records the intent as favouring small settings over large institutions; the enacted text itself gives no rationale, and there was no bed count in the regulation for it to be correcting. The number has not moved since.

    P.L. 100-360, 102 Stat. 683 →
  7. 2015
    CMS guidance

    Section 1115 waivers open for addiction treatment

    CMS tells states it will approve §1115 demonstration waivers covering short-term IMD stays for substance use disorder treatment. Updated November 2017.

    CRS IF10222 →
  8. 2016
    42 CFR managed care rule

    The 15-day managed-care workaround

    CMS regulation lets states pay managed care plans for enrollees aged 21-64 in an IMD as an "in lieu of" service, capped at 15 days in the payment month. The SUPPORT Act later writes this into statute.

    MACPAC →
  9. 2018
    SMD 18-011 (per P.L. 114-255 §12003)

    Waivers extended to serious mental illness

    Acting on a mandate in the 21st Century Cures Act, CMS issues guidance letting states seek §1115 waivers for short-term IMD stays for adults with serious mental illness and children with serious emotional disturbance.

    CMS →
  10. 2018
    P.L. 115-271 (SUPPORT Act)

    A 30-day state plan option, and a fix for pregnant patients

    §5052 adds a state plan option under SSA §1915(l) covering adults 21-64 with a substance use disorder in an eligible IMD for up to 30 days in a 12-month period. §1012 stops states denying federal match for non-IMD services delivered to pregnant and postpartum patients receiving SUD care in an IMD. §1013 codifies the 15-day managed care rule.

    CRS IF10222 →
  11. 2025
    H.R. 5462 / H.R. 6727

    Two live bills, two different answers

    The Michelle Alyssa Go Act would raise the threshold from 16 beds to 36. The Repealing the IMD Exclusion Act would strike the exclusion outright. Both are in committee.

    CRS IF10222 →
04b — What the record shows

Nobody ever voted on the 16-bed limit

Every roll call of the 89th Congress was read, along with the Statutes at Large, the Federal Register and CBO's cost estimates. The rule was never debated on a floor, never amended on a floor, and never voted on by itself. Here is what the record does say.

First, precisely what the rule does

Medicaid does fund mental health care — outpatient treatment, and psychiatric units inside general hospitals. What the exclusion bars is federal Medicaid payment for an adult aged 21 to 64 who is a patient in a facility primarily engaged in treating mental disease with more than 16 beds. That is narrower than “Medicaid won’t pay for psychiatric care” — and devastating exactly where inpatient beds live, because almost no psychiatric hospital has 16 beds or fewer.

  1. 1

    Nobody ever voted on it.

    All 394 House and 497 Senate roll calls of the 89th Congress were enumerated. Exactly 16 touched H.R. 6675, and the House took only three recorded votes on the bill — none of them on an amendment. Every Title XIX provision dealing with institutions for mental diseases (Senate amendments 255, 262-263, 275, 276 and 279) was a committee amendment. Not one reached the floor.

    Voteview roll-call data →
  2. 2

    Medicaid inherited the rule. It did not create it.

    The exclusion dates to 1950, not 1965. P.L. 81-734 §303(a), 64 Stat. 549, created federal vendor payments and carved tuberculosis and mental-disease institutions back out of them in the same sentence. The 1935 Social Security Act rule was about an "inmate of a public institution" — an almshouse rule. The words "insane" and "asylum" appear zero times in the 1935 Ways and Means report or in the Committee on Economic Security report. In 1965 Congress actually narrowed the exclusion, by adding coverage for people 65 and over.

    P.L. 81-734, 64 Stat. 477 →
  3. 3

    The Senate voted to abolish it in 1960. A conference committee killed it overnight.

    On 23 August 1960 the Senate adopted an amendment by Sen. Russell Long (D-LA) permitting federal matching of vendor payments to public mental and tuberculosis hospitals. On 24 August the conference committee agreed to the Senate’s medical-care provisions "except for Senator Long’s amendment." That is the one moment in the record where the rule was genuinely contested, and it lasted a day.

    SSA legislative chronology, 1960 →
  4. 4

    The number 16 was enacted as a technical correction.

    It entered the statute at P.L. 100-360 §411(k)(14)(A), 102 Stat. 798-799, under the heading "SEC. 411. TECHNICAL CORRECTIONS TO CERTAIN HEALTH CARE PROVISIONS", subheading "(k) CORRECTIONS TO SUBTITLE B OF TITLE IV (RELATING TO MEDICAID)", paragraph "(14) CLARIFICATION OF TERM ‘INSTITUTION FOR MENTAL DISEASES’". It sits between a provision on educationally related services and a technical correction about eligibility verification.

    P.L. 100-360, 102 Stat. 683 →
  5. 5

    The statute came first. The regulation copied it.

    The intuitive story — that regulators invented the number and Congress ratified it — is the wrong way round. The 1978 rule at 43 FR 45204 defined an institution for mental diseases by its "overall character" and set no bed count at all. HCFA put Congress’s number into the Code of Federal Regulations at 56 FR 8854 on 1 March 1991, in a rule titled "OBRA ’87 Conforming Amendments" — two years and eight months after the statute.

    43 FR 45204 (29 Sept 1978) →
  6. 6

    Congress fixed this for tuberculosis and not for mental illness.

    Both conditions were excluded in the same 1965 clause. §2335(f) of the Deficit Reduction Act of 1984 (P.L. 98-369) struck the words "tuberculosis or" and left the psychiatric half of the sentence standing. Forty-two years later it has not been revisited.

    P.L. 89-97, 79 Stat. 286 →
  7. 7

    In 2023 the House voted 386-37 to lift part of it. The Senate never took it up.

    Section 304 of H.R. 4531 in the 118th Congress was titled "LIFTING THE IMD EXCLUSION FOR SUBSTANCE USE DISORDER". It cleared subcommittee 49-0 and full committee 29-3, then passed the House 386-37 on 12 December 2023 — Republicans 190-26, Democrats 196-11. It went to the Senate HELP Committee the next day and has not moved since: no hearing, no vote, and no member on record against it.

    Voteview roll-call data →
  8. 8

    What keeps it alive is the price tag.

    CBO scored the options in April 2023. Over 2024-2033 the narrow state-plan option for substance use disorder costs $155-560 million in net federal Medicaid spending — and that is the one Congress enacted. Repeal for substance use disorder costs $7.7 billion, repeal for mental illness $33.5 billion, and full repeal $38.4 billion. Everything ever enacted sits on the cheap side of that line. Every repeal bill sits on the expensive side, and none has left committee.

    CBO Publication 59071 (April 2023) →

The real lineage

The chain runs thirty years before Medicaid. Each step was verified against the enacted statute, not against a summary of it.

  1. 1935

    The Social Security Act — and it is not about mental illness

    Title I bars aid to anyone who “is not an inmate of a public institution.” That is a poorhouse rule, aimed at almshouses. The words insane and asylum appear zero times in the House Ways and Means report or in the Committee on Economic Security’s report to the President. Aid to Dependent Children carried no such clause, which makes the exclusion an adult-category rule from birth.

    P.L. 74-271, 49 Stat. 620 →
  2. 1950

    The actual origin point

    P.L. 81-734 §303(a), 64 Stat. 549, creates federal “vendor payments” to medical providers — and then carves two categories back out of them. Mental institutions enter federal law here, as an exception to a liberalisation.

    …but does not include any such payments to or care in behalf of any individual who is an inmate of a public institution (except as a patient in a medical institution) or any individual (a) who is a patient in an institution for tuberculosis or mental diseases…P.L. 81-734 §303(a), 64 Stat. 549

    House conference report 373–1, with Republicans 137–1 in favour. Senate 82–2. Signed by Truman.

    P.L. 81-734, 64 Stat. 477 →
  3. 1960

    The one time it was nearly killed

    From the Social Security Administration’s own legislative chronology, two consecutive days:

    August 23, 1960 — “An amendment introduced by Senator Long to permit Federal matching of vendor payments… to public mental and tuberculosis hospitals was adopted.” · August 24, 1960 — “The Conference Committee agreed to the medical care provisions added by the Senate, except for Senator Long’s amendment.”SSA legislative chronology, 1960

    The Senate voted to end this rule, and a conference committee reversed it in a single day. Corroborated by reading the enacted statute: no provision authorising such matching survives in P.L. 86-778, only a 42-day allowance for general-hospital care. If you want one identifiable decision point in the whole history, this is it.

    SSA legislative chronology, 1960 →
  4. 1965

    Medicaid inherits it — and narrows it

    P.L. 89-97 §121(a), 79 Stat. 351–352, carries the 1950 sentence into the new Title XIX, now bounded by age, while §1905(a)(14) affirmatively covers people 65 and over in an IMD. SSA’s own contemporaneous account describes this as removing the exclusion with respect to payments for aged individuals.

    “(B) any such payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an institution for tuberculosis or mental diseases.”P.L. 89-97 §121(a), 79 Stat. 351–352

    Sixty-one years later those words are unchanged, except that “tuberculosis or” is gone. In 1965 there was no under-21 carve-out either — the exclusion hit everyone under 65. The 21–64 band was created in 1972.

    P.L. 89-97, 79 Stat. 286 →

Where the number 16 came from

  1. 1976

    A group-home rule

    SSI law exempts “a publicly operated community residence which serves no more than 16 residents.” This is the earliest 16 in this corner of federal law.

  2. 1978

    The IMD rule has no number

    43 FR 45204 defines an institution for mental diseases by its “overall character” — no bed count anywhere in it. The figure 16 appears in that same rule only for community residences.

  3. 1988

    16 becomes a wall

    OBRA ’87 had just emptied §1905(i). A 1988 “clarification” fills it with “more than 16 beds.”

  4. 1991

    The regulation catches up

    56 FR 8854 edits the rule to match: “‘an institution’ is changed to ‘a hospital, nursing facility, or other institution of more than 16 beds’.” Two years and eight months after the statute.

A hypothesis this research killed

The intuitive story — that career regulators invented 16 and Congress later rubber-stamped it — is wrong, and the paper trail runs the other way. Congress wrote the number in July 1988. HCFA copied it into the Code of Federal Regulations in March 1991, in a rule expressly titled “OBRA ’87 Conforming Amendments.” The agency was conforming to Congress, not the reverse. So the “technical correction” that carried the number was not correcting anything: there was nothing yet to correct.

Where it sits in the 1988 law
  • SEC. 411. TECHNICAL CORRECTIONS TO CERTAIN HEALTH CARE PROVISIONS
  • (k) CORRECTIONS TO SUBTITLE B OF TITLE IV (RELATING TO MEDICAID)
  • (13) TREATMENT OF EDUCATIONALLY-RELATED SERVICES
  • (14) CLARIFICATION OF TERM “INSTITUTION FOR MENTAL DISEASES”
  • (15) ELIGIBILITY VERIFICATION TECHNICAL CORRECTION

Sandwiched between a schools provision and a paperwork fix. The 1976 → 1988 link is a documented structural parallel, not a documented causal chain — no paper trail says Congress borrowed the SSI figure. What is established: the number did not come from the IMD regulation, and no clinical or empirical basis for it appears anywhere in the record searched.

P.L. 100-360, 102 Stat. 683 →

The votes that did happen

Reconstructed from the Voteview congressional-votes database and SSA's own tallies. The House Clerk publishes no roll calls before 1990, so these are the authoritative machine-readable record.

YearChamberMeasureTallyDemRep
1950HouseConference report, P.L. 81-734 — origin of the carve-out373-1233-0137-1
1960SenatePassage, Kerr-Mills (P.L. 86-778)74-1143-1031-1
1965HousePassage, H.R. 6675313-115248-4265-73
1965SenatePassage, H.R. 667568-2155-713-14
1972HouseConference report, P.L. 92-603 — psych under 21305-1176-0129-1
1984HouseConference report, P.L. 98-369268-155192-6976-86
1988HouseConference report, P.L. 100-360328-72230-998-63
1988SenateConference report, P.L. 100-36086-1152-034-11
2023HousePassage, H.R. 4531386-37196-11190-26
Why none of these is "a vote for the 16-bed limit"

Every row is a vote on an omnibus. A member voting yes in April 1965 was voting to create Medicare; a member voting no was voting against Medicare, not for the exclusion — the Republican substitute would not have removed it either. In sixty-one years the exclusion has never once been put to a standalone recorded vote. That is the finding, not a hole in it.

How that negative was measured

“There was no vote” is a claim about a complete set, so the set was enumerated. All 394 House and 497 Senate roll calls of the 89th Congress were pulled and filtered to H.R. 6675: exactly 16 roll calls, every description read. The House took only three recorded votes on the bill in its entire life — recommit, passage, conference report — and none on any amendment at all. Then the amendments themselves: all 513 Senate amendments were read from the official conference print. Every Title XIX provision touching institutions for mental diseases — amendments 255, 262–263, 275, 276 and 279 — is labelled a Committee amendment. Not one reached the floor.

Positive control: the same method surfaced 13 Senate roll calls on other specific 1965 provisions, including a 26–64 vote to strike Medicare Parts A and B outright, and it did flag Senator McCarthy’s psychiatric-exclusion amendment (which concerned Medicare and drew no roll call). An instrument that found those found zero for the Medicaid IMD exclusion.

Document gate: that 32-page conference print is a pure image scan with no text layer. A keyword search would have returned zero and meant nothing, so it was read page by page.

Who the record names

  • Rep. Wilbur D. Mills (D-AR) — Sponsored H.R. 6675 and chaired Ways and Means, where the Medicaid title was written.
  • Sen. Harry F. Byrd Sr. (D-VA) — Chaired Senate Finance and reported the bill out 12-5, while joining four Republicans in voting against it.
  • Sen. Russell Long (D-LA) — The only member on record who tried to end the rule. His 1960 amendment passed the Senate and died in conference.
  • Rep. Fortney "Pete" Stark (D-CA) — Sponsored the 1988 bill that carried the 16-bed paragraph. There is no evidence he wrote that paragraph.
  • Rep. Brett Guthrie (R-KY) — Sponsored H.R. 4531, the 2023 bill the House passed 386-37.
And who it does not
  • The 1988 drafter (Author of the 16-bed paragraph) — Not identifiable in the published record.
  • The 1960 conferees (Killed the Long amendment) — Not individually recorded in the chronology.

Who drafted the 16-bed paragraph in 1988 is not recoverable from the published record, and neither is any rationale for that particular figure. The conferees who struck Senator Long’s amendment in 1960 are not named in the chronology either. These are gaps in the record, not gaps in the research, and they are stated here rather than filled in.

Why it is still here

This is the part that actually answers the question. Congressional Budget Office, April 2023, Publication 59071 — net increase in federal Medicaid spending, 2024 through 2033.

$0.2–0.6B

Extend the narrow addiction option

✓ Congress passed this

$7.7B

Repeal for addiction

Passed House, died in Senate

$33.5B

Repeal for mental illness

Never voted on

$38.4B

Full repeal

Never scored in a bill

Every IMD change that has ever become law sits on the cheap side of that line. Every repeal bill sits on the expensive side, and not one has ever been reported out of committee, scored, or given a vote in any Congress. The gap between what passes and what does not is roughly 70× to 250×.

2023: the closest it has ever come

H.R. 4531 in the 118th Congress carried a section titled, verbatim, LIFTING THE IMD EXCLUSION FOR SUBSTANCE USE DISORDER. It cleared subcommittee 49–0 and full committee 29–3, then passed the House 386–37 on 12 December 2023 — Republicans 190–26, Democrats 196–11. It went to the Senate HELP Committee the next day and never moved again: no hearing, no markup, no vote, and no recorded opponent. The substance was rescued three months later inside an appropriations bill, which made the narrow 30-day addiction option permanent. The broader relief was not.

Six bills in the 119th Congress would change this rule, and all six are sitting in the same committee. Not one of them has a Senate companion — the Michelle Alyssa Go Act has now been introduced in three consecutive Congresses without ever getting one, and its cosponsor count and its bipartisanship have both gone down since the 118th. No CBO score exists for any of the six; a bill has to leave committee to get one.

So which party did this?

The voting record does not support a partisan answer. Every enactment carrying this exclusion passed with majority Republican support, under Democratic and Republican presidents alike.

  • 1950, when mental institutions were first carved out: House Republicans voted 137–1 in favour.
  • 1960, the one contested moment: the amendment to abolish it was killed by a conference committee, not a party. More Democrats than Republicans opposed the underlying bill.
  • 1984: a Democratic House and a Republican Senate together deleted the tuberculosis half and kept the psychiatric half. Nobody in either party moved to delete both.
  • 1988: the number 16 rode in on a conference report backed by 98 Republicans and 230 Democrats, and was signed by Ronald Reagan.
  • 2023: the House voted to lift part of it 386–37, with overwhelming majorities of both parties. It still died.

If you are looking for someone who destroyed this, the record refuses to give you one. What it gives you is worse and more useful: a 1950 cost-allocation decision between the states and Washington that nobody has ever had to defend on a floor, because nobody has ever been made to vote on it — protected now by a $38.4 billion price tag and a constituency too sick and too poor to hire lobbyists. It survives on procedure and arithmetic, not ideology. That is why it has outlasted every majority of the last sixty-one years.

What the record does not contain

Measured absences, not assumptions. Every row was searched with a method proven to find comparable material first — the control column is what makes the zero mean something.

SearchedForResultControl
1935 Ways and Means report + CES report to the PresidentAny mention of insanity or asylumsZeroAll 10 “institution” hits found
1935, 1950 and 1965 statutes + contemporaneous SSA accountsAny stated reason for the exclusionNone at any stepRule itself located in each
43 FR 45204, first 400 pages“16 beds” in the 1978 IMD definitionZeroPage 45204 confirmed present in the extract
Every CFR amendment to the IMD definition, 1978–1996When the regulation acquired the number1991 — after the statuteAmendment chain read in full
Pre-1978 regulation (45 CFR 248.60)Whether any earlier bed count existedNot searched — no CFR before 1996 is online—
All 394 House + 497 Senate roll calls, 89th Congress; all 513 Senate amendmentsAny vote on the IMD exclusionZero13 other amendment roll calls found
MACPAC Report to Congress on IMDs (128 pages)Any rationale for the figure 162 mentions, both descriptive“beds” → 15 hits
2025 SUPPORT Act reauthorisation, all six text versionsAny IMD or Medicaid provisionZero“opioid” → 36 hits
CRS report IF10222 · congress.govCongressional intent for the thresholdUnmeasured — bot wall, not bypassed—
One correction worth stating plainly

The familiar story — that Congress excluded asylums because President Pierce established in 1854 that they are a state responsibility — is a reconstruction by later scholars. Pierce’s veto is real and says what it is quoted as saying. But no 1935, 1950 or 1965 primary document reached here connects the two, and the 1935 record actively cuts against it: those drafters were legislating about almshouses and never mentioned insanity at all.

Caveats. Stated so you can discount them yourself. Vote sourcing: GovTrack draws its pre-1990 roll calls from Voteview, so they are one lineage, not two. The 1965 totals and the two conference-report party splits are independently confirmed by SSA’s official tally page; the 1965 passage-vote party splits rest on the Voteview lineage alone. Voteview’s member-level file and its own summary field also disagree by one vote on several 1965 and 1972 roll calls — official tallies are shown throughout. Bill status: congress.gov is bot-walled, so this came from GovInfo BILLSTATUS, the same Library of Congress feed, with as-of dates between November 2025 and June 2026; very recent committee action would not appear. Not established: no document connects the 1976 SSI 16-resident figure to the 1988 Medicaid number — that remains a hypothesis. The pre-1978 regulation was never searched, because no CFR earlier than 1996 is online; nor were the 1966 Handbook of Public Assistance Administration, the 1975–76 field instructions, or the 1982 State Medicaid Manual, each of which MACPAC records as carrying an IMD definition. So “16 had no regulatory predecessor” is proven for 1978–1991 and unmeasured before that. Sponsorship of the 1950 and 1972 bills is single-sourced.

The same research as a document

Everything above is also published as a 15-page report with the statutory text set as it appears in the Statutes at Large. Download the PDF (806 KB). The page you are reading is the whole of it — the PDF is for citing and printing, not for the parts the page left out.

05 — Where people go instead

The capacity did not disappear. It moved.

When a hospital bed is not available or not payable, the person in crisis still exists. They turn up somewhere, and the somewhere is usually an emergency department, a jail, or the street.

About half

forensic

Of the state hospital beds still in service in 2016, close to half — roughly 5.5 of the 11.7 beds per 100,000 people — were occupied by forensic patients, meaning people charged with or convicted of a crime. By 2023 a majority of state hospital beds were forensic.

Treatment Advocacy Center →
+76%

forensic

Forensic patients in state hospitals rose 76% between 1999 and 2014, from about 13,394 on a given day to more than 23,574 across 37 reporting states — while the total number of psychiatric beds kept falling.

Manhattan Institute (2025) →
60 days

incarceration

Across 26 states, people in jail wait a median of 60 days for a bed to restore their competency to stand trial. At least 12 states have been sued for failing to provide that care in time.

Manhattan Institute (2025), citing Treatment Advocacy Center →
14% / 8%

incarceration

About 14% of people in state prison and 8% in federal prison met the threshold for serious psychological distress in the past 30 days — several times the rate in the general adult population.

Bureau of Justice Statistics, Survey of Prison Inmates 2016 →
37% / 44%

incarceration

Thirty-seven percent of people in prison and 44% of people in jail had previously been told by a mental health professional that they had a mental disorder.

Bureau of Justice Statistics, National Inmate Survey 2011-12 →
770,000+

homelessness

More than 770,000 people were experiencing homelessness on a single night in January 2024 — the highest count HUD has recorded. Serious mental illness is heavily overrepresented in this population.

HUD 2024 Annual Homelessness Assessment Report (Point-in-Time count) →
3×

emergency

Patients in psychiatric crisis wait up to three times as long as other patients to move from an emergency department to an inpatient bed. In San Francisco, 87% of people with 18 or more ED visits a year had a mental illness or substance use disorder.

Manhattan Institute (2025) →

Who this rule reaches

14.6 million

prevalence

U.S. adults live with a serious mental illness.

Manhattan Institute (2025) →
10%

prevalence

Of non-elderly adult Medicaid enrollees have a serious mental illness.

Manhattan Institute (2025) →
90% more likely

prevalence

Medicaid enrollees are 90% more likely to have a serious mental illness than privately insured Americans.

Manhattan Institute (2025) →

What this site actually argues for

Enforce Olmstead. Fund community care. Repeal the age bar. These are not in tension — Olmstead bars unnecessary institutionalization; §1905(a) decides whether Medicaid pays for the institutional care a person’s own clinicians say is necessary. Repeal the age bar in §1905(a) — not the bed count in §1905(i) — and attach conditions to it. That combination is the preferred fix; raising the bed threshold to 36, which H.R. 5462 does, is a bridge worth supporting while the larger repeal is stuck, not a substitute for it.

  • Medical necessity: the standing rule that federal money follows a clinical decision to admit, not a facility’s size or a diagnosis category.
  • Community-care investment kept whole: a maintenance-of-effort requirement on non-federal community spending, so federal inpatient dollars cannot quietly replace state community dollars. §1915(l)(3) is the existing model.
  • A community-capacity requirement, on the model H.R. 4022 already uses: each state plans for, and reports annually on, outpatient and crisis capacity.
  • Adequate rates and workforce capacity: repeal does not answer for itself if the community system it is supposed to strengthen cannot staff or afford the care it is asked to deliver.
  • Discharge continuity: a person leaving an IMD has a documented, funded path into community treatment, not just a payment authorization that ends at the hospital door.
  • Quality reporting on outcomes, not just spending, so a bill’s effect can be measured after enactment rather than assumed.
  • An explicit ADA Title II / Rehabilitation Act §504 most-integrated-setting condition, rather than assuming Medicaid compliance already carries it — the exact gap HHS itself has identified.
The 36-bed bill is a bridge, not the fix

H.R. 5462 raises the bed threshold to 36. That still excludes the average U.S. psychiatric hospital, which has 108 beds — so it helps whichever facilities happen to fall under the new line, while removing the age bar does not depend on facility size at all. Worth passing now; not the reform this site is asking for.

The case for each approach, made in full, with the strongest objection and how a bill can answer it: Bills and Debate.

06 — What is moving in Congress

Six bills, five different answers

All six are in the 119th Congress. All six are in committee. They disagree about whether to move the line, erase it, let it expire, or erase it and require something in its place.

H.R. 4022Repeal, with a duty attached

Increasing Behavioral Health Treatment Act

Sponsor: Salud Carbajal (D-CA-24)
Introduced: 2025-06-17
Cosponsors: 7 (5 D, 2 R)

Strikes the age-bar clause and makes the conforming changes, then adds a new §1902(a)(20)(D) requiring each state to have a plan — and to report on it annually — for increasing outpatient and community-based behavioral health care, crisis call centers, mobile crisis units, coordinated crisis response, and data sharing between physical health, mental health and addiction providers. It is the only one of the six that pairs the repeal with a community-capacity obligation.

Status: Introduced; referred to committee
Congress.gov
H.R. 5462Raise the threshold

Michelle Alyssa Go Act

Sponsor: Dan Goldman (D-NY-10)
Introduced: 2025-09-18
Cosponsors: 14 (10 D, 4 R)
Earlier version: H.R. 8575 (118th Congress)

Redefines an institution for mental diseases to exclude facilities of 36 beds or fewer, if they meet certain standards. Facilities up to 36 beds could bill Medicaid.

Status: Introduced; referred to committee
Congress.gov
H.R. 5662Clean repeal

Improving Access to Institutional Mental Health Care Act

Sponsor: Shri Thanedar (D-MI-13)
Introduced: 2025-09-30

Strikes the age-bar clause from the concluding language of §1905(a), and strikes “65 years of age or older” and “65 years of age or over” wherever they appear in §1902(a)(20) and (21), §1905(a)(14) and §1919(e)(7)(B)(i)(I). Nothing else.

Status: Introduced; referred to committee
Congress.gov
H.R. 5944Let the bar expire

Restoring Inpatient Mental Health Access Act of 2025

Sponsor: Brad Finstad (R-MN-1)
Introduced: 2025-11-07
Cosponsors: 3 (2 R, 1 D)

The most surgical drafting of the six. It removes the “other than services in an institution for mental diseases” parentheticals from §1905(a)(1), (a)(4)(A) and (a)(15), repeals (a)(14) as spent, and — instead of deleting the age-bar clause — inserts “furnished before January 1, 2027” into it, so the bar expires rather than being struck. The state-plan option for addiction treatment at §1915(l) is given the same end date.

Status: Introduced; referred to committee
Congress.gov
H.R. 6727Full repeal

Repealing the IMD Exclusion Act

Sponsor: Ritchie Torres (D-NY-15)
Introduced: 2025-12-15
Earlier version: H.R. 10266 (118th Congress)

Strikes the exclusion from Title XIX entirely, so Medicaid could cover services for eligible patients in an IMD regardless of age, where the facility meets required care and staffing standards.

Status: Introduced; referred to committee
Congress.gov
H.R. 8095Carve out one group

Ensuring Medicaid Continuity for Children in Foster Care Act of 2026

Sponsor: Gus Bilirakis (R-FL-12)
Introduced: 2026-03-26
Cosponsors: 1 (1 D)

The narrowest of the six, and the only one written for a named group. It leaves the age bar standing and adds an exception to it: a child in foster care placed in a qualified residential treatment program, as that term is defined at §472(k)(4), stays covered. Everyone else the bar reaches is unaffected. Like H.R. 5944 it edits the clause by position rather than by paragraph number — “the matter designated as subdivision (B) following the last numbered paragraph” — which is the drafting that survives the next renumbering of §1905(a).

Status: Introduced; referred to committee
Congress.gov
What the set shows

All six went to the same place — the House Committee on Energy and Commerce — and none has left it. Not one has had a hearing, a markup, a vote or a CBO score. None of the six has a Senate companion; the Senate has no vehicle for this at all. The sponsorship is bipartisan across the set rather than within each bill: two of the six are sponsored by Republicans, and three of the six carry Republican cosponsors. Between them they hold 25 cosponsors. They also disagree with each other about the remedy, which is five different answers competing for the same committee slot.

Sponsor, party, district, introduction date, cosponsor counts and status were read from GovInfo BILLSTATUS on 2026-09-02, and each bill's described effect was read from its introduced text. Follow the Congress.gov links for the current record, which is authoritative.

The sentence that has to change is the age bar, not the bed count

The site is named for the number, because the number is what people hear about. But the number is in the definition. It is a different sentence that does the denying.

  • The “more than 16 beds” figure lives in the definition of an institution for mental diseases at §1905(i). On its own it denies nobody anything; it only decides which buildings the label attaches to.
  • The denial is the clause quoted at the top of this page — the flush subdivision (B) following the last numbered paragraph of §1905(a), which bars payment for a patient “who has not attained 65 years of age”.
  • People 65 and over are affirmatively covered by §1905(a)(14). People under 21 are affirmatively covered by §1905(a)(16)(A), effective January 1973. Subtract those two and the excluded class is adults aged 21 through 64, and nobody else.
  • So raising the bed threshold moves the line and striking the age bar removes it. The two are not smaller and larger versions of the same reform; they are different reforms.

A threshold of 36 beds would still exclude the average psychiatric hospital, which has 108 beds. Raising the number helps whichever facilities happen to fall under the new line; removing the age bar does not depend on facility size at all.

An inference from the text, not a published finding

There may also be a reason to leave §1905(i) alone. The definition is used elsewhere in Medicaid, including in Community First Choice at 42 U.S.C. §1396n(k), where attendant services must be furnished “in a home or community setting, which does not include a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded.” Widening the definition so that facilities of 36 beds or fewer are no longer institutions for mental diseases would, on the face of that sentence, also widen what counts as a home or community setting there. Repealing the age bar and leaving the definition untouched would not.

This is our own reading of the statutory text on 2026-09-02, not a claim about what any sponsor intended and not something we found stated in a CRS, MACPAC or CBO document. Anyone drafting from it should confirm it with legislative counsel.

42 U.S.C. §1396n(k) →

Say you support them

Both bills are stuck in the House Energy and Commerce Committee. Both bills were referred here and neither has moved. A bill that is never scheduled never gets a vote, so this is the committee that decides whether either one is considered at all.

Members of the House do not publish email addresses. Every office below takes messages through its own web form, so there is no address to click — pick a draft, copy it, then open the form and paste it in. Change it before you send: identical form letters get counted once.

Support H.R. 5462 (raise the limit to 36 beds)

SubjectPlease support H.R. 5462, the Michelle Alyssa Go Act

I am writing to ask you to support H.R. 5462, the Michelle Alyssa Go Act.

Medicaid will not pay for adults aged 21 to 64 who are treated in a psychiatric or addiction facility with more than 16 beds. The average psychiatric hospital in this country has 108 beds, so the rule reaches almost all of them. H.R. 5462 would raise that threshold to 36 beds for facilities that meet the standards in the bill.

The bill is sitting in the Energy and Commerce Committee and has not moved.

[If you have a personal reason for writing — a family member who could not get a bed, or work you do in this system — put it here in your own words. It is the part staff actually read.]

Thank you for your time.

Support H.R. 6727 (repeal the exclusion)

SubjectPlease support H.R. 6727, Repealing the IMD Exclusion Act

I am writing to ask you to support H.R. 6727, the Repealing the IMD Exclusion Act.

Medicaid currently pays nothing toward care for adults aged 21 to 64 in a psychiatric or addiction facility with more than 16 beds. H.R. 6727 would strike that exclusion from Title XIX, so coverage would follow the patient rather than the size of the building.

The bill is sitting in the Energy and Commerce Committee and has not moved.

[If you have a personal reason for writing, put it here in your own words. It is the part staff actually read.]

Thank you for your time.

Ask my own representative to back both

SubjectThe Medicaid 16-bed rule — H.R. 5462 and H.R. 6727

I am a constituent, and I am writing about the Medicaid rule that stops federal payment for adults aged 21 to 64 in psychiatric facilities with more than 16 beds.

Two bills would change it. H.R. 5462 would raise the threshold to 36 beds. H.R. 6727 would repeal the exclusion entirely. Both are in the Energy and Commerce Committee and neither has moved.

I would like to know your position on each, and whether you will cosponsor either one.

[Add your own reason for caring about this — it matters more than anything else in this message.]

Thank you.

Where to send it

  • Rep. Dan Goldman

    Sponsor, H.R. 5462 — New York’s 10th district

    He introduced the bill that would raise the limit from 16 beds to 36. Messages of support to a sponsor are counted by their staff and cited when they ask leadership for a hearing.

    Web form. Asks for a district address first — if you live elsewhere, write to your own representative below instead.

    Open the contact form

  • Rep. Ritchie Torres

    Sponsor, H.R. 6727 — New York’s 15th district

    He introduced the bill that would repeal the exclusion outright rather than move the threshold.

    Web form.

    Open the contact form

  • Rep. Salud Carbajal

    Sponsor, H.R. 4022 — California’s 24th district

    His is the only one of the six bills that pairs repeal with a duty on states to build outpatient and crisis capacity, which is the drafting that answers the main objection to repeal.

    Web form.

    Open the contact form

  • Rep. Shri Thanedar

    Sponsor, H.R. 5662 — Michigan’s 13th district

    He introduced the shortest of the repeal bills, and it has no cosponsors at all. A bill with no cosponsors is the one where a message costs an office the least to notice.

    Web form.

    Open the contact form

  • Rep. Brad Finstad

    Sponsor, H.R. 5944 — Minnesota’s 1st district

    One of the two Republican sponsors in the set. Anything that moves in this committee needs support on both sides of it, so this office is where a bipartisan hearing request would have to start.

    Web form.

    Open the contact form

  • Rep. Gus Bilirakis

    Sponsor, H.R. 8095 — Florida’s 12th district

    The other Republican sponsor, and the one already on Energy and Commerce. His bill is the narrow version — it protects foster children in residential treatment and leaves the bar standing for everyone else — so his office is the one to ask why the same sentence should not be fixed for the rest of the people it reaches.

    Web form.

    Open the contact form

  • Your own representative

    Whoever holds your district

    This is the message that carries the most weight, because offices weigh their own constituents. If your representative sits on Energy and Commerce, it counts for more still.

    Enter your address, then use the contact form on your member’s own site.

    Open the contact form

  • Your two senators

    Statewide

    These particular bills are in the House, so a senator cannot vote on them yet. Writing anyway matters because any repeal or threshold change ultimately needs the Senate, and companion bills start with senators who already hear about it.

    Pick your state, then use each senator’s own form.

    Open the contact form

  • House Energy and Commerce Committee

    Where both bills are waiting

    If one of these members represents you, that is the single most useful message on this page. Committee members decide what gets a hearing.

    Members list — find yours, then use that member's own contact form.

    See the committee's members

Every link above was fetched and confirmed working on 2026-08-26. If one has since moved, tell us at hello@16bedlimit.com and it gets fixed.

07 — The disagreement

This is genuinely contested

People who work on this in good faith disagree about whether the rule should go. Both cases are set out here as their proponents make them.

The case for changing it

  • The exclusion discourages states from investing in inpatient care, so people who need a hospital end up boarded in emergency departments, on the street, or in jail.
  • It singles out one category of illness for worse fiscal treatment than any other. In almost every other setting the federal government pays at least half the cost.
  • The population of public psychiatric hospitals is already a small fraction of what it was before deinstitutionalization, so a return to mass institutionalization is not the realistic risk.
  • Legal protections that did not exist in 1965 now exist, most importantly the integration mandate of the Supreme Court's Olmstead decision, which requires community placement where appropriate.
Manhattan Institute, "Medicaid's IMD Exclusion: The Case for Repeal" (2021) →

The case for keeping it

  • The original purpose was to stop states shifting the cost of their asylums to the federal government. Remove it and the same incentive returns.
  • The exclusion pushed money toward community-based care rather than large institutions. Critics of repeal argue that is a feature, not a bug.
  • Congress has repeatedly chosen narrow exceptions — 1972, 1988, 2016, 2018 — rather than repeal, which reflects sustained concern about the cost and the institutional-care precedent.
  • A full repeal has an unscored federal cost. Every workaround to date has been deliberately time-limited or capped.
CRS IF10222 (legislative history and stated congressional intent) →

The strongest objection, in the objector’s own words

The four points above are our paraphrase. This is the sentence itself, from a comment letter to HHS that was read in full on 2026-09-02. The first half of the footnote is quoted too, because it changes how the second half reads: the exclusion is being defended in passing, while objecting to something else.

We appreciate that California has decided to limit its FFP proposal to facilities under 17 beds and are not seeking to undermine Medicaid’s “institutions for mental diseases” exclusion (IMD exclusion). The IMD exclusion is essential to ensuring that states are incentivized to invest in community-based services rather than services in IMD settings, where FFP is not permitted.Judge David L. Bazelon Center for Mental Health Law, comments to HHS on California’s BH-CONNECT demonstration addendum, 30 August 2024, footnote 14.
  • The Americans with Disabilities Act and Olmstead v. L.C., 527 U.S. 581 (1999), require that people be served in the most integrated setting appropriate and not unnecessarily given institutional care. Cited in the comment alongside 45 C.F.R. §84.76(b).
  • Meeting Medicaid’s rules is not the same as meeting civil-rights obligations. HHS has said so directly: “the civil rights obligations created by section 504 are separate and distinct from the requirements of Medicaid and the Social Security Act. Compliance with Medicaid requirements does not necessarily mean a recipient has met the obligations of section 504.” 89 Fed. Reg. 40066, 40119.
  • The “linear continuum of care” — moving people through successively less restrictive congregate placements before independent housing — was called “archaic” by one court expert and “outdated” by another in DAI v. Paterson, 653 F. Supp. 2d 184 (E.D.N.Y. 2009). Both experts are quoted at length in the comment.
  • The comment reports outcome figures for two community programs: New York’s Nathaniel Project, a 70% reduction in arrests within two years of admission; and Chicago’s Thresholds, an 89% reduction in arrests, an 86% decrease in jail time, and a 76% reduction in hospitalizations. Stated in the comment without a citation of its own, so these are reported as the Bazelon Center’s figures rather than confirmed here.
Bazelon Center comment on CA BH-CONNECT (PDF, 6 pages) →

What a bill would have to say to answer it

The objection lands against long-term custodial placement used as a substitute for housing. It does not land against every version of the reform, and the versions it does not land against are ones that can be written down.

  • Repeal the age bar and leave the §1905(i) definition intact, so the definition keeps doing its integration-protective work in the other places Medicaid uses it.
  • Attach a maintenance-of-effort requirement on non-federal community spending, so federal money for inpatient care cannot quietly replace state money for community care. §1915(l)(3) is the existing model.
  • Attach a community-capacity requirement. H.R. 4022 already does this: it makes each state plan for, and report annually on, outpatient and crisis capacity.
  • Make compliance with the most-integrated-setting obligations of ADA Title II and section 504 an explicit condition, rather than assuming Medicaid compliance carries it — which is the exact point HHS made in the passage quoted above.
What repeal does not change

One thing the reform does not reach in either direction: repealing the exclusion changes who pays for care, not who can be committed. Civil commitment is state law, and Title XIX does not touch it.

07b — Who can change it

Four offices, three different kinds of power

Only Congress can change the statute. CMS cannot repeal it — but CMS approves the waivers that let a state work around it, which is the faster lever and the one a state official or provider can actually move. Writing the wrong ask to the right office is a wasted letter, so each entry says what that office can and cannot do.

  • House Energy and Commerce — Health Subcommittee

    Holds Medicaid jurisdiction in the House, and is where both H.R. 5462 and H.R. 6727 were referred. Nothing reaches a floor vote without moving through here first.

    The askAsk them to schedule a hearing or markup on the two bills by number.

    Subcommittee members

  • Senate Finance Committee

    Medicaid jurisdiction in the Senate. Any repeal or threshold change ultimately needs a Senate vehicle, and it starts here.

    The askAsk whether a Senate companion to H.R. 5462 or H.R. 6727 is being drafted.

    Committee membership

  • CMS — Centers for Medicare and Medicaid Services

    Cannot repeal the exclusion; it is written into the statute. CMS does approve the section 1115 waivers that let a state get around it, which is why 37 states have an addiction-treatment waiver and only 15 have one for mental health.

    The askA waiver question, not a repeal question — whether your state has applied, where an application stands, or what a state would need to submit. Asking CMS to repeal the rule is asking the wrong agency.

    Medicaid.gov contact

  • HHS — Office of Intergovernmental and External Affairs

    CMS sits inside HHS, and this is the office that handles outside stakeholders. It sets the direction CMS applies when it weighs waiver applications.

    The askPolicy direction on behavioral-health waivers, rather than an individual case.

    HHS IEA

None of these offices publishes an email address; each link opens its own contact page or member list. All four were fetched and confirmed working on 2026-08-26.

08 — Get in touch

Send records, ask who is working on this, or help fund it

Every message goes to hello@16bedlimit.com. Each button below opens your email app with the subject and prompts already filled in.

Before you send anything

Do not email unredacted medical records. Remove or black out names, dates of birth, home addresses, case or docket numbers, Social Security numbers, and any other identifying information before you send a document — send only redacted copies. This site is not a patient-care portal and cannot provide medical or legal advice; nothing sent here creates a provider or attorney relationship. In crisis, call or text 988.

Send records or documents

Denial letters, state waiver correspondence, hospital transfer records, competency-restoration wait letters. Redact what you need to.

Compose email

Ask who is working on this

Which organizations, committees, and offices are actively moving on the IMD exclusion, and how to reach them.

Compose email

Share what happened to you

If you or someone you care about could not get a bed, that is the evidence this argument runs on.

Compose email

Fund or support this work

Foundations, donors, and advocacy organizations — see the funding routes below.

Compose email

How work like this gets funded

People often ask which vehicle is the right one for pushing on a federal funding rule. The honest answer is that it depends what you want to do, because each one permits different activity. This is a description of the rules, not legal advice.

VehicleWhat it can doWhat it cannot doAuthority
501(c)(3) public charityResearch, public education, and a limited amount of direct lobbying. Donations are tax-deductible.No campaign intervention for or against any candidate. Lobbying must stay within an insubstantial part of activities, or within the §501(h) expenditure limits if that election is made.IRS — Lobbying by 501(c)(3) organizations
501(c)(4) social welfare organizationUnlimited lobbying on the IMD exclusion as its primary activity, plus some political activity as a secondary purpose.Donations are not tax-deductible. Political activity cannot be the primary activity.IRS — Social welfare organizations
Super PAC (independent expenditure-only committee)Raise and spend unlimited sums from individuals, corporations, and unions on independent expenditures supporting or opposing federal candidates.May not contribute to, or coordinate with, a candidate or party committee. Must register and report to the FEC.FEC — Independent expenditure-only committees
Registered lobbyingDirect advocacy to Members of Congress and their staff on H.R. 5462, H.R. 6727, or any successor.Above statutory thresholds, registration and quarterly disclosure under the Lobbying Disclosure Act are mandatory.Congress — Lobbying Disclosure Act filings
09 — Where every number came from

Sources

Nothing on this page is estimated or recalled. Each figure was fetched from the source below on 2026-08-26, and the legislative-record sources on 2026-09-01. The same data is available as JSON at /api.

This list is also the assistant's entire memory

The question box on this page runs on these 30 sources and nothing else. It has no web access and is instructed not to answer from general knowledge, so if you ask it something these sources do not cover, it will tell you that instead of inventing an answer. Anything it tells you can be checked against the original, one link away.

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