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Doing More With Less? The Closing of Chicago’s Mental Health Clinics

By Dr. Ram Krishnamoorthi
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Yesterday marked the official end to the NATO Summit in Chicago, an event that dominated the news of our city, not to mention disrupted our traffic patterns and weekend plans. While leaders from fifty countries gathered to discuss global security and economic issues, the real news of the summit was four days of protests. Demonstrators marched the streets for a wide gamut of causes and viewpoints—“End the war,” “Tax the rich,” “Capitalism has outlived its usefulness!”—mostly global themes that inspired ideological fervor.

But one group of Chicagoans used the international spotlight and took to the streets to highlight a local problem: the closure of a half-dozen Mental Health clinics by the Chicago Department of Public Health that served that uninsured and Medicaid patients. The city once had 12 health clinics that provided mental health services to about 5,100 underserved patients. Last fall, however, Mayor Rahm Emanuel and the CDPH announced that they would close six of these clinics and fully fund only two of them, lay off over 50 staff, transfer care of insured patients to private mental providers, and save $3 million by consolidating services.

After the first two planned clinic closures occurred, community organizations rose up in outrage. A series of protest rallies and vigils were organized over the next several months. The Mental Health Movement,  a coalition of groups including Southside Together Organizing for Power (STOP) and the American Federation of State, County, and Municipal Employees (AFSCME) union local. A sit-in at one of the slated to shut down, the Woodlawn Mental Health Center, led to dozens of arrests in April.

And yet, by the beginning of May, the City had closed the remainder of the clinics.

So on Friday, to kick-off the NATO protest weekend, a group of citizens took their message all the way to the top, to Mayor Emanuel. They rallied not at his office in City Hall, but at his home, and went door-to-door to recruit allies in his politically progressive neighborhood.

The closures came on the heels of Illinois’s cuts to in Medicaid payments to mental health provider across the state. That decision was made by Governor Patt Quinn, faced with a $8 billion state deficit and growing.

Yet, for a mayor also facing huge budget shortfalls, Mayor Emanuel said it’s not about the money. Instead, he claimed that psychiatric services would be enhanced and be more efficient because 1) they would now be available at all city clinics for 3,000 uninsured patients; 2) these patients would receive more time with their city-employed providers, because 1,100 insured patients, including Medicaid recipients, would be referred to over 60 community-based, non-profit, private mental health providers; and 3) $500,000 in grants would available to augment these private clinics. And starting in 2014, Medicaid eligibility would expand to more uninsured patients due to implementation of Affordable Care Act.

The CDPH commissioner, Dr. Bechara Choucair, re-iterated the financial and expansion logic to a crowd gathered at the University of Chicago’s Urban Health Initiative summit (the UHI has itself earned controversy, trying to resolve the challenge of preserving access and capacity while managing limited resources). The focus, Choucair stated, needed to be on the most vulnerable, uninsured patients with mental illness who would clearly have no recourse in the private sector, about 80 percent of those who seek the city’s help. Choucair has also tried to meet with protesting groups to explain this strategy.   

But consumer groups decry that closing down clinics subtracts services and that capacity needs have been clearly under-calculated. More than that, capacity is not the same as access. One article estimates that transportation to the remaining fewer clinics will mean extra bus trips and 4 extra miles for poor patients. Hispanic patients previously benefited from Spanish-speaking providers at the Northwest Mental Health Center but may now have to travel to other city or private clinics that have fewer language services. Finally, continuity between patient and provider, the relationship that is vital to mental health care, is disrupted.

These advocates have already stated the transition period is going poorly, reporting that patients falling through the cracks. Commissioner Choucair objects to these claims, saying that the department has been monitoring patients closely during the transition, for the very reason to make sure these gaps in care don’t occur. 

What frustrates protesters the most are the Mayor’s and CDPH’s claims that the closures will lead to more, not less, mental health service, through the consolidation of services and use of the private sector. It’s a claim that Dr. Lora Chamberlain found preposterous: "Rahm spins it. Somehow, out of less he's going to make more. He thinks nobody can add. They are cutting services when we have a greater and greater need." Her sentiment was echoed in a letter by 50 mental health providers to the City and to the Media harshly decrying the logic as “Orwellian” and complaining that CDPH staff had been “intentionally dismissed and excluded from the Commissioner's narrative.” The problem, they say, is not one of inefficiency in services, but of sheer inadequacy of resources, for which they have been demanding redress for years.

The providers and others claim that the City listened to the advice of The Civic Federation, a non-profit private research group that comments often on state and local budget problems, who suggested the City consider closing clinics because they were “dead meat anyway,” in anticipation of a private sector expansion under the Affordable Care Act.

Did the advent of future federal health care dollars through Medicaid expansion usher in a sort of reverse “crowd-out,” i.e., the closure of public services in anticipation of the expansion of Medicaid coverage for private services? 

The Chicago Reporter has written skeptically about the Civic Federation and its recommendations, and in an interview with University of Chicago expert Colleen Gorgan, found them rather weak. For one, private clinic support and future Medicaid expansion does not solve the capacity problem because the closed clinics are in already medically underserved areas, as designated by the Dept of Health and Human Services, where few private providers practice. Second, the states administer Medicaid, and Illinois’s cuts to mental health care signal that future budget problems will persist, ACA or not. For non-profit providers, they will simply have to scale back on services due to an inevitable shortfall, not likely made up by the half-million dollars promised by the City.  Ironically, if the city’s clinics had stayed open, they would have qualified for more Medicaid dollars from the ACA.

With regard to mental health care, is “doing more with less” valid? It’s not likely that outpatient mental health services are over-utilized. Instead, it is clear that less care and poor continuity lead to the use of the emergency department and the jail system for mental health problems, which are more expensive and less healthy.  Cook County Sheriff Tom Dart has weighed in against the closings, frustrated that many criminals should be patients instead of behind bars and many victims could have been spared the crimes committed by the mentally ill.

Chicago’s and Illinois’s problem with mental health services highlights the dilemma that deficit-strapped governments’ have with maintaining health care services. With unsustainable rises in health care costs, they look to public-private partnerships to save money without having reliable forecasts that the market can adequately serve. Progressives believe that minimum safety nets already fall short because all the variables of a comprehensive health care system are rarely estimated correctly, but their requests for increased funding is naïve to budget realities. Unfortunately, despite the fervor of thousands of NATO summit protestors’ marching and chanting on idealistic themes of equal opportunity and protecting the poor, slashing public services for the most vulnerable still provides the least resistance for policymakers faced with practical reality. As Dr. John Grohol, founder of writes: “Illinois, like many states, [found] it easiest to cut public mental health services first, because mental health has few lobbyists that work on behalf of the population most affected — the poor.” 

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  1. Julia Frank

    DC did something similar several years ago. It has not been a complete disaster, but it has created some real craziness in the system. People now get referred to clinics based on clinic slots, rather than on whether that particular clinic offers services patients need. Clinic services are also not standardized --some offer case management, some offer medical services, some offer only medication, and the waiting lists are often ridiculous. Apparently, part of the motivation was to get rid of city employees--including physicians--who staffed the public clinics and accepted lower salaries in return for good benefits. The system protected some less than stellar people, but also supported some real saints. While any public jobs can be a source of patronage and corruption, trying to fix this by depiving chronically ill people of essential services is shameful.

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