Democratizing Mental Health BY DANI ADAMS
How advocates put access to public mental health services back on the table
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n 2011, when then-Mayor Rahm Emanuel proposed a budget that closed half of the public mental health clinics in Chicago, City Council passed it unanimously. Less than a decade later, a progressive caucus in the council helped stall the confirmation of Dr. Allison Arwady, Mayor Lori Lightfoot’s choice for commissioner of the Chicago Department of Public Health (CDPH), citing concerns over her past statements regarding the closures. That sea change in political attitudes was the result of shifting public opinion driven by the tireless efforts of activists, advocates, and mental health providers. But the clinics remain closed, and the battle is far from over.
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he modern era of mental health delivery in the United States can be traced to 1963, when President John F. Kennedy passed the Community Mental Health Act (CMHA). The act aimed to reduce the population in the nation’s psychiatric institutions—which offered few opportunities for constructive activities or therapy, let alone recovery—by half, and federal funding incentivized states and municipalities to create a robust system 4 SOUTH SIDE WEEKLY
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of community mental health agencies. In response, Chicago opened a system of nineteen public mental health centers that spanned nearly the entire city over a fifteenyear period. Today, five of these public clinics remain. Operated by CDPH, they are financed through a mix of federal, state, and city dollars, in contrast to privately operated community mental health centers, which also sprang up in high numbers after the passage of the CMHA. The city-run public mental health clinics have always served the city’s most marginalized individuals. Unlike privately operated community mental health centers (even nonprofit ones), city-run clinics have a mandate to serve everyone, including those whom private clinics may turn away for lack of ability to pay or due to the severity of their illness. This makes them a safety net for low-income patients who are not eligible for Medicaid and/or Medicare (including the undocumented). Privately operated mental health centers generally do not gain patient revenue from these individuals, so they have little incentive to accept them as clients. CDPH representatives often point to Federally Qualified Health
Centers (FQHCs), which receive federal funding and are also mandated to serve undocumented and uninsured individuals, as an alternative to city-run public mental health clinics. Advocates disagree. “There is a real limit to what [FQHCs] can do,” said Patrick Brosnan, the executive director of the Brighton Park Neighborhood Council. Brosnan said FQHCs have thin financial margins and lack flexibility to provide services that are not reimbursable by Medicaid for free. “In order to get funded, you need to have a diagnosis, you need to have a treatment plan, and those things are important, but it’s not necessarily the kind of services that everybody needs.” Dr. Arturo Carrillo, who leads the Collaborative for Community Wellness (CCW), said that FQHCs are limited when it comes to serving individuals with severe mental illness and long-standing trauma. “When they say trauma, what we’re talking about is years, decades, of accumulated sense of loss, harm, and exploitation, and this is an issue that is more pronounced in low-income communities,” Carrillo said. FQHCs are set up to offer short-term treatment relative to the city-run public mental health clinics, which do not have
limits on the number of sessions one can attend, he explained, but establishing trust and safety with patients—who are often dealing with complex trauma—takes time. The public clinic model “is set up to be a resource for communities where people can have a continuing relationship with a therapist,” he said. “FQHCs are about churning through patients.” After the CMHA was passed in 1963, states, taking advantage of federal incentives and funding shifts, moved away from operating psychiatric institutions in favor of community-based care settings. At the same time, Medicaid and Medicare were created; Medicaid became the single largest funder of mental health services in the United States. As a result, today’s state mental health agencies rarely have direct responsibility for patient care, instead contracting services out to a variety of private entities, both forprofit and nonprofit. According to one 2006 analysis by health economists at Harvard and Columbia Universities, this fragmentation of public responsibility in caring for people with mental illness has reduced patients’ overall wellbeing.
