Middleboro Review 2: In a landmark 2024 legal settlement, Massachusetts promised community-based care for those with serious mental illness. Budget cuts could undermine that.

Sunday, May 3, 2026

In a landmark 2024 legal settlement, Massachusetts promised community-based care for those with serious mental illness. Budget cuts could undermine that.

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In a landmark 2024 legal settlement, Massachusetts promised community-based care for those with serious mental illness. Budget cuts could undermine that.

May 3, 2026

By James Lomastro

A mother’s recent New York Times essay on her struggle to help her adult son, who suffers from schizophrenia, has sparked the latest round of a longstanding national debate over whether families should have greater access to legal proceedings that determine treatment for their loved ones. Some propose a family bill of rights: awareness, presence, and voice.

They are asking the wrong question. Or rather, they are asking the right question about the wrong problem.

The problem is not that families lack adequate standing in commitment hearings, where courts decide whether someone can be involuntarily placed in treatment. The problem is what those hearings route people into.

In Massachusetts, we know what that is: a system that places people with serious mental illness in nursing facilities and other institutional settings not because those settings are clinically appropriate, but because the community infrastructure that would allow them to live otherwise does not exist at sufficient scale. 

Fixing the hearing process without fixing the system is like training the triage nurse more carefully when the only ward with open beds is the one people never leave.

I have spent more than 40 years inside health and human services administration in Massachusetts, including the early years of deinstitutionalization. I lived in one of the state's first group homes as a full-time residential “parent” while completing my doctorate at Brandeis. I know what happens when the promise of community integration is made without the infrastructure to keep it.

The promise becomes a talking point. The institution absorbs the unmet need. And the cycle the mother in the Times essay describes — hospitalization, discharge, streets, crisis, hospitalization again — continues, not because families lack legal standing, but because there is nowhere for her son to land that is not an emergency room or a nursing facility.

Two years ago, Massachusetts made a different kind of promise. In April 2024, the state signed on to the Marsters v. Healey settlement, a federal court-enforced agreement to transition at least 2,400 residents with serious mental illness and other disabilities out of nursing facilities and into community settings over eight years, backed by projected investments exceeding $1 billion.

It is the most structurally honest answer this state has ever given to the question of what people with serious mental illness need: not better access to commitment proceedings, but a legally enforceable right to live outside institutions, with the community infrastructure to make that possible.

In its first year, the settlement produced real results: more than 1,200 residents received information about their transition rights, 750 individuals with serious mental illness gained behavioral health coordination supports, and 720 were enrolled in transition programming — the individualized, person-centered process of identifying where someone will live, what services they will need, and how those services will be in place before, not after, they walk out the door.

These are not small numbers. They represent people who had been told, implicitly and explicitly, that the nursing facility was their permanent home — and who discovered, with the help of court-mandated transition liaisons, that it did not have to be.

The promise of the landmark Marsters settlement, however, is now colliding with potential cuts to the very funding needed to support the move to community care that the case calls for. These would undercut the ability to transition 2,400 nursing home residents to community settings, as mandated, never mind the spirit of the settlement to go beyond that figure.

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