He goes so far as to assert that for some payers, including states, cost shifting has been as important in designing policies as the impetus to construct a “rational” system. “Deinstitutionalizing” the mentally ill refers to shrinking or closing state hospitals, and transferring the care of previously hospitalized patients to a diverse set of care providers. While a rationale for deinstitutionalization can be made on the basis of single system cost-effectiveness, cost-shifting was also a motive. State government in the U.S. paid the costs in state hospitals, and only a share of the costs of care given by alternative providers, courtesy of the federal Medicaid program. Since states (and other regional governments outside the U.S.) make the majority of spending decisions about public funds for care of mental disorders, the literature has naturally directed attention towards state choices regarding mental health policy.