Wednesday, we looked at a report by Chicago's Civic Federation that recommended, among other measures, the closing of Chicago's mental health and primary care clinics months before the Chicago Department of Public Health announced it. Mayor Emmanuel seems to be following many of the other suggestions in the report rather closely too. Read part one of this post here.
Onto my second question: Does the recommendation to close Chicago's mental health clinics make sense?
The Civic Federation recommendation is based on the expectation that when the Affordable Care Act goes into effect in 2014, a lot of poor folks who don't currently qualify will now have access to Medicaid, meaning they can use the city's private for-profit and not-for-profit clinics.
I should note here that Civic Federation researcher Sarah Wetmore emphasized to me that the Federation didn't recommend closing clinics.
They recommended the city "evaluate its Department of Public Health with the intention of eventually eliminating clinical health services."
To me, that's like the difference between someone saying they think I need a nose job and them telling me I should evaluate my ugly face, with the intention of pursuing rhinoplasty. But hey, I thought I'd make the distinction.
For help on this, I turned to health care reform expert Colleen Grogan at the University of Chicago. Did the Affordable Care Act, the contentious health care reform law passed in 2010, justify the move to reduce city health care services?
Grogan noted that there are a couple of problems with the Civic Federation's argument. First, the 12 mental health clinics the city had were primarily located in medically underserved areas--places where it's just plain hard to get access to decent health care. Six clinics were recently closed.
"They are all located in high need areas where resources are already limited. The Medicaid expansion does not solve that capacity problem," said Grogan. "Ironically, the city public health clinics could take Medicaid dollars, but they need to stay open to do that."
The ACA may give people more access to private clinics, but it doesn't mean that there will suddenly be more places for them to go.
While more federal dollars will be able to go to private clinics to help cover uninsured people who need health care, Grogan says there's a serious concern that the already-overburdened primary care system will now have even more problems meeting people's needs.
The Civic Federation seems to have missed that many of the former clinics are in health care deserts.
Instead, they note in their report that Chicago's clinics may be "duplicative" because there's often a private clinic or a Cook County facility located nearby.
But if the services are indeed duplicative, why would the U.S. Department of Health and Human Services list Cook County as a medically underserved area?
In fact, a Feinberg School of Medicine report showed that the neighborhoods where clinics are located have doctor-to-patient ratios equal to that of third world countries.
Of course, having Medicaid is not much of a guarantee of quality health care.
Medicaid reimbursement rates, Grogan notes, are already low, and Governor Pat Quinn has just proposed cutting them even further to save money. Medicaid cuts create more problems in a system already unable to meet people's needs.
"Three things happen when the states cut Medicaid spending in this way. First, private providers refuse to take Medicaid recipients and so Medicaid enrollees have a limited number of providers to choose from--especially in shortage areas," says Grogan.
"Second, when benefits are not covered under Medicaid, Medicaid enrollees have to pay out of pocket," she said. Do people who can't afford insurance have the money to pay out of pocket? It seems unlikely.
"Third, when benefits are cut, community health centers have to shift what used to be paid for under Medicaid to some other revenue source, which is not easy to do since dollars are extremely tight, and so these Medicaid reductions force nonprofit clinics to cut back," said Grogan.
So, according to Grogan, not only can the city's clinics and the private health care system not take care of the current caseload of patients, but cutting clinics and Medicaid will make the system even more over-burdened, even when health care reform laws expand Medicaid coverage for poor folks.
There you have it: an unmentioned recommendation to shut down seemingly-vital services, which the city denies it's doing, and an argument that the recommendation is based on a shoddy understanding of the city's health care system.
In short, a troubling combination.
Photo credit: Sarah-Ji
© Community Renewal Society 2012