Can state mental health agencies survive health care reform?

State mental health systems have undergone dramatic changes in the last 40 years, including decreases in state hospital capacity and increases in the proportion of mental health care provided in ambulatory settings and in general hospital units and private psychiatric hospitals. Health care reform is likely to accelerate these changes. The authors consider whether state mental health agencies have a future, given that they were created to operate state hospitals, a role that has been greatly diminished. The authors suggest that state mental health agencies will continue to exist, but that their role will change significantly.