From Snake Pits to Cash Cows: Politics and Public Institutions in New York (review)

After reading this book, students of the gloomy Max Weber might well conclude that they had examined a prime example of the perpetuation of bureaucracy. Indeed, the book is not so much a history of politics and policies as one of interlocking bureaucracies. Intellectual disabilities—what we formerly called mental retardation—are Paul Castellani's focus. What he explores are the changing details of public residential institutions in the state of New York. Between the Great Depression and the late 1960s, these facilities grew in both size and numbers. As they did so, however, they never met the demand for new admissions, their costs continued to stress the state's fiscal resources, and charges of neglect and abuse continued to plague them.

In 1965 the U.S. Congress enacted Title 19 of the Social Security Act, known as Medicaid, and states soon recognized a means for shifting state institutional costs to this new federal program. By the end of the decade, parent groups were calling for more and better services, and progressive academics insisted that community-based services were preferable to residential institutions. Accompanying these voices of advocacy were the prominently publicized scandals at the Willowbrook State School on Staten Island, and the court-mandated orders to improve institutional conditions that followed the scandals. Faced with advocates, a new community-based service philosophy, and judicial mandates, New York in the early 1990s moved to a goal of closing all the state's mental retardation institutions by 2000.

Institutional closure was a major undertaking, involving several interest groups. Central to the process were the service needs of newly deinstitutionalized residents, most of whom required multiple types of assistance for their complex disabilities. Could residents be integrated into existing services operated by parents and other agencies? How many and what kinds of new facilities should be built, and could those facilities avoid the institutional structures of the past? Could the closure of rural institutions mesh with the greater community needs of urban New York? How might the state integrate public employees who worked in the state's institutions into the network of small community agencies? And most importantly, Castellani argues, how would New York pay for the conversion?

In 1995, shortly after he took office, Republican governor George Pataki stopped what had been the state's four-year commitment to total institutional closure. "This was a remarkable reversal of what had seemed to be an inevitable process," Castellani observes (p. 241). Anticipating that the new governor would be favorably disposed toward their interests, private providers positioned themselves for greater influence and, hence, for greater benefits from the new course of institutional closure. Specialized service providers saw opportunities to provide new community services to the "frail elderly, behaviorally problematic, or criminally involved" (p. 259). By the late 1990s there seemed to be few voices of opposition to the Pataki administration's reversal. Federal Medicaid funding, now relieving the state of fiscal responsibilities, provided generous revenues to public agencies and private providers alike. These revenues, which seemed to satisfy everyone, muted the institutionalization-versus-deinstitutionalization debate of the earlier decade. What had once been "snake pit" institutions had, indeed, become a mixture of private and public, community-based and institutional, "cash cows." In the humor that only history can provide, New York's peculiar form of deinstitutionalization had become a strange union of Weber's iron cage of bureaucracy and Karl Marx's primacy of the economic order.

Castellani's book is an excellent one. People interested and working in the field of intellectual disabilities, as well students of bureaucracy, will find it fascinating, if also disturbing. The names of human beings who make decisions are identified, but the decisions they make and the implementation of those decisions have a disembodied quality about them. In chapter after chapter, the decisions and...