Ration or Rationalize? Allocating Psychiatric Care in France and the United States

Public mental health care systems in developed countries face two competing and contradictory imperatives. On one hand, a steadily widening range of psychological states have been ‘medicalized’, creating an explosion of demand for specialty mental health services in a context of growing precarity. On the other, public systems are under increasing pressure to demonstrate efficacy while reducing costs. I compare responses to these two challenges in France and the United States, drawing on nearly 300 interviews and 20 months of fieldwork. In France, psychiatrists work to maintain their vision of a truly public system through rationing—drawing rigid boundaries between those who do and do not deserve care—and by disengaging with tools like epidemiology, screening, or preventative care that might make unmet need visible. In the United States, both public policies and ground-level practitioners focus on rationalization—using public health tools to expand access while carefully calibrating care and limiting the time patients can spend in the system. Paradoxically, the “universal” French system renders invisible and untreated individuals who do not fit a classic typology of “severely mental ill”, while the U.S. system excludes the most difficult cases upon which the “targeted” logic of liberal welfare states is supposed to focus.