Economic policies have shaped the provision of hospital psychiatric care. The main theme of the past fifty years has been the shift from long-stay public hospitals to acute care provided in private settings. States have reduced their costs by shifting their financial burden to federal dollars and commercial insurers through managed care practices. The net result has been a reduction in, and shortage of, psychiatric beds. Positive developments include better services in the continuum of care, the subspecialization of hospital psychiatry practice, and an increasing emphasis on patient choice and recovery.