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Trump Aims For Return To Bad Days Of Mass Institutionalization Of People With Disabilities

Millions of people with developmental disabilities are thriving in group homes where they find companionship, acceptance and safety.

As of 2019, 7.4 million people in the U.S. had intellectual and/or developmental disabilities. The Residential Information Systems Project (RISP) reported the total number of people with intellectual or developmental disabilities living in non-family residential settings (including group homes) increased by 27 percent from 2001 to 2021 — from 423,485 to 538,452. By 2023, 8.4 million Americans were receiving home- and community-based services through Medicaid.

In the bad old days, before community placements were available, thousands of people were condemned to life in overcrowded institutions where they were abused and warehoused with inadequate care provided by poorly trained, overworked, underpaid staff.

The plight of disabled people condemned to life in unhealthy institutions made dramatic national headlines and prompted legislation after a 1972 television broadcast from the Willowbrook State School in Staten Island, N.Y., titled “Willowbrook: The Last Great Disgrace,” outraged the general public.

A lawsuit, *New York ARC v. Rockefeller*, was filed by parents of 5,000 residents at the Willowbrook State School. The suit claimed the institution had inhumane living conditions where residents were abused and neglected. The facility was severely overcrowded, understaffed, and unsanitary, with roughly one attendant for every 50 residents. Film footage showed naked patients living in filth, and enduring neglect and abuse

Three years later, a consent judgement was signed which committed New York state to improve community placement for the now designated “Willowbrook Class.” The Willowbrook State School was closed in 1987, and all but about 150 of the former Willowbrook residents were moved to group homes by 1992.

Treatment and care for Americans with severe developmental disabilities has evolved since the 18th century when people were cared for by families or were shackled and housed in poorhouses and jails.

The Quakers in Philadelphia opened one of the first organized facilities for people with disabilities in 1752. By the mid-19th century, overcrowding led to larger, custodial institutions, often with poor ventilation, inadequate food, and minimal therapeutic focus.

By 1890, every U.S. state had a public mental hospital, housing people with dementia, developemental disorders and psychiatric conditions. The demand for insitutionalization became severe and the number of facilities could not keep up with demand, resulting in overcrowded, underfunded facilities which were and segregated by race in some states.

Treatment was often punitive, with patients chained, subjected to ice baths, or placed in isolation. Before the development of effective anti-psychotic medications, somatic treatments like insulin coma therapy and lobotomies were used, sometimes with severe harm. The 1952 introduction of chlorpromazine revolutionized care by reducing the need for long-term institutionalization.

The deinstitutionalization movement began in the 1960s, driven by the advent of anti-psychotic medication and a growing belief that early treatment outside of a hospital could prevent severe disability. However, the discharge of patients to underfunded community mental health centers meant that many patients were discharged without adequate support, contributing to homelessness and incarceration.

The Community Support Reform era that began in the late 1970s and continues today shifted focus to supporting people with disabilities, providing integrating housing, case management, and education.

Cruelty of Trump

Trump’s massive cuts in Medicaid funds threaten a return to the bad old days. The reductions in aid are only part of the administration’s ongoing battle to cut costs and reduce the number of homeless people, at the expense of the most vulnerable people.

Federal and state funding for group homes for people with intellectual and developmental disabilities is primarily through Medicaid, state developmental disability programs, and targeted grants. Last year’s ludicrously named, “One Big Beautiful Bill Act,” passed by Congress and signed by trump, requires states to make deep cuts to services previously funded by Medicaid. A recent Justice Department memo permits states to cut localized supports and, instead, rely on more expensive institutionalization.

The One Big Beautiful Bill Act, signed into law on July 4, 2025, implements the largest reductions in Medicaid funding in U.S. history, totaling over $1 trillion over 10 years and potentially causing 11.8 million people to lose coverage by 2034. The cuts are phased in gradually, with the heaviest impacts expected from 2027 onward.

The law is projected to cut Medicaid spending by an estimated $886.8 billion over the next decade, largely because new work requirements will force people off the rolls. The Congressional Budget Office estimated that the cuts could boost the number of people without health insurance by a whopping, 7.5 million in 2034.

States will have to either pick up the lost federal money with state funds, reduce services or provide coverage to fewer people.

Hospital psychiatric care units are among the least profitable cost centers for hospitals. As the poor sister of hospital care, the psychiatric units will be the likely early targets to meet the Medicaid funding cuts. Fewer hospital psychiatric units will mean more crowded emergency rooms and jails, which are often the defacto treatment centers for people with severe mental health issues who cannot be treated in hospitals.

The tragic effects of Medicaid cuts were examined by the American Psychiatric Association which found that states that had expanded Medicaid eligibility saw smaller increases in suicide compared with non-expansion states: Medicaid expansion was associated with about 0.4 fewer suicides per 100,000 people yearly, the association found.

The latest action in an ongoing incremental battle by the trump administration involves a federal report on cutting back on community care and returning many people to institutions. The recommendation is tied to the policy where Medicaid funds are being drastically reduced, likely leading to fewer group homes and other kinds of community care.

The report by the Justice Department expands on trump’s executive order on July 24, 2025. The order was intended to make it easier for state and local governments to police homelessness through involuntary institutionalization.

“For those who are severely mentally ill and deeply disturbed, we will bring them back to mental institutions, where they belong,” trump pledged in a 2023 campaign video.

In his executive order, trump said that public order will be restored by “shifting homeless individuals into long-term institutional settings for humane treatment through the appropriate use of civil commitment.” In other words, get the homeless out of sight and out of mind and away from the elections.

Olmstead Attack

A recent Justice Department memo gives states permission to cut localized supports and, instead, rely on more expensive institutionalization. The recommendation is reflected in a memo issued in June by the Justice Department regarding the 1999 Supreme Court case of Olmstead v L.C. The case is considered to be the most important disability rights decision since the Americans with Disabilities Act (ADA) was signed into law by President George H.W. Bush on July 26, 1990.

The 1999 decision established the “Olmstead mandate” which said that people with disabilities have the right to receive services and supports in community settings rather than being unnecessarily isolated in institutions. Since 1999, Olmstead has been used to expand access to community living, integrated employment, and inclusive services for people with disabilities across the United States.

For nearly 30 years, Olmstead has generally been understood to mean that states must provide services to people with disabilities in the most integrated setting appropriate to their needs. The interpretation became known as the “integration mandate” and has been used to support home-based services, community programs, supported living, and other efforts to prevent unnecessary institutionalization. The integration mandate helps protect the right of people with disabilities to live and get services in the community and not be forced into institutions.

The Olmstead case began when two women, identified as L.C. and E.W., had intellectual and psychiatric disabilities and were living in a state institution in Georgia. Their treatment professionals agreed that the women would be much better served in community-based settings rather than remain institutionalized. Despite this, they continued to be kept in the institution.

The women sued, arguing that unnecessary institutionalization violated the ADA. On June 22, 1999, the Supreme Court held that unjustified segregation of people with disabilities is discrimination under the ADA and that states must provide services in the most integrated setting appropriate to an individual’s needs. The caveat is that the law is applied when community placement is appropriate, the individual does not oppose the placement and the placement can be reasonably accommodated.

The majority of the High Court held that unjustified institutional isolation can constitute disability discrimination. Justice Clarence Thomas wrote the principal dissent and argued that the ADA’s prohibition on discrimination did not require states to move people from institutions into community settings simply because community placement was available. He also voiced skepticism that segregation itself is discriminatory.

The Justice Department memo does not have the power to overturn Olmstead but it says that Olmstead guidance and similar guidance documents are “not enforceable” and that the Justice Department plans to revisit the guidance under a narrower reading of federal law. The memo may influence future litigation, enforcement decisions, and ongoing court cases challenging the “integration mandate.”

The new Justice Department memo says that the “integration mandate” went too far and that Olmstead held only that a state cannot institutionalize a person without adequate justification. The memo also says that the Olmstead decision did not create a broad federal requirement that states provide community-based services. It finally instructs that while federal disability laws prohibit discrimination, the law does not necessarily require states to fund or provide services in community settings instead of institutional settings.

The people who would be affected by the Justice Department conclusion include children receiving Medicaid waivers; adults receiving community-based supports; people with intellectual disabilities, autism and mental health disabilities; and people receiving home care instead of institutional care.

The Arc, a national advocacy organization for people with disabilities, said the Justice Department opinion is “another serious step away from federal enforcement of community living rights for people with disabilities.”

“This guidance seeks to undermine one of the strongest protections people with disabilities have from being pushed into institutions when they can and want to live in the community,” said the Arc statement.

Legal Ruling Author

The Justice Department memo was written by Lanora Petitt, the Principal Deputy Assistant Attorney General in the Justice Department’s Office of Legal Counsel, the office that provides legal opinions to the executive branch. Among her recent other opinions, Pettit rejected a nearly 90-year-old precedent governing national monuments, in support of trump’s plans to abolish national monuments in California.

Before joining the justice department in early 2025, Pettit was the Principal Deputy Solicitor General in the office of ultra-conservative trump supporter, Attorney General Ken Paxton. Pettit, who is affiliated with the far right, Federalist Society, had no experience in issues involving the disability community but instead focused on such issues as border security, election litigation and constitutional law.

Pettit works under Elliot Gaiser, the head of the Office of Legal Counsel. Gaiser was previously legal counsel for trump’s 2020 presidential campaign. In confirmation hearings, Gaiser did not directly answer whether trump won the 2020 presidential election and avoided questions as to whether he would advise trump to ignore orders issued by federal courts.

Paxton is the Republican nominee for U.S. Senate from Texas. As attorney general, Paxton faced felony securities fraud indictments, an FBI investigation, whistleblower allegations from his own staff, and impeachment by the Texas House. Paxton supported trump’s bogus claims that he lost the 2020 presidential race to Joe Biden because of widespread fraud.