STEPHEN FEE: Gail Davis is 52 years old and lives on Chicago's SouthSide. Every day she prepares lunch for her 82 year old mother who suffered a stroke.
Gail is her mom's primary caregiver — yet Gail herself has struggled for decades with mental illness.
GAIL DAVIS: "I was like that I guess before — when I come into the world I guess. I didn't match up, and I didn't um — seem to blend in with society, what society says what the world says this is what you have to be and do."
STEPHEN FEE: For years, anger, depression, and anxiety all kept Gail from holding a job. And she didn't have health insurance. That meant that for much of her life, except a few emergency room visits, Gail's mental conditions went untreated.
MARK ISHAUG: "People with serious mental illnesses generally don't show up to the doctor's office. They don't make medical appointments and psychiatric appointments."
STEPHEN FEE: That's Mark Ishaug — he runs Thresholds, Chicago's largest nonprofit mental health provider. He says Gail's story isn't unique among the millions of low-income, uninsured Americans with mental illness.
MARK ISHAUG: "So people with a serious or persistent mental illness in general have been treated very badly by the health care system. Either they haven't had insurance and so they weren't able to get care, or they used emergency rooms in hospitals for their care. And it's really hard to engage people and convince them that they can get help and they can be treated well."
STEPHEN FEE: In 2010, a family member referred Gail to a mental health clinic in her neighborhood — run and paid for by the city of Chicago. It was the first time in her life she'd seen a therapist.
GAIL DAVIS: "He's been a good force. He come into my life at the right time because that's probably what I needed all along."
STEPHEN FEE: But during the recession, Illinois was under financial strain. From 2009 to 2012, the state cut mental health spending by $187 million dollars — a pattern that was happening nationwide. During the same period, states slashed overall mental health budgets by $1.6 billion dollars.
And that meant mental health clinics like Gail's were suddenly on the chopping block.
By the end of 2012, Chicago had closed half of its outpatient mental health clinics — including Gail's.
GAIL DAVIS: "It's like we was dismissed. And that was the hardest part."
STEPHEN FEE: But the Chicago clinic closures — along with similar mental health facility closures around the country — weren't just about budget cuts.
When the Affordable Care Act, or Obamacare, was signed in 2010, it included a provision to expand Medicaid. Twenty-seven states, including Illinois, have opted in to the plan, which means the federal government — rather than states — will pay for treatment of newly qualified low-income people like Gail.
Bechara Choucair has been Chicago's public health commissioner for five years.
BECHARA CHOUCAIR: "Now all of a sudden they have more options. And if they choose to transition to another provider, we support them through that transition."
STEPHEN FEE: Just here in Illinois 120 thousand people with persistent mental illnesses are expected to enroll in Medicaid who weren't eligible before the new rules came into effect. But of course being eligible for insurance doesn't necessarily mean you're getting the coverage you need.
STEPHEN FEE: For Gail, signing up for Medicaid complicated her mental health care. After her clinic closed, her therapist began visiting her at home.
But according to her medical records, Gail's therapist in mid-2013 "was forced to inform [her] that [mental health] services…would likely have to wind down" and that she could only continue services if she dis-enrolled from her Medicaid plan.
A city spokesperson says there was initially uncertainty over whether Medicaid recipients could continue seeing city therapists — but that clinicians were never told services had to cease. Nevertheless, Gail went a year without seeing a mental health professional.
GAIL DAVIS: "If this is something that's working and this is somebody that I build a bond with, why break that up. You know, because I felt like that was really useless and senseless."
Mark Heyrman is a law professor at the University of Chicago and advocates for people with mental illness. He says they have a particularly difficult time when they move out of publicly financed facilities and must find new providers on their own using Medicaid.
MARK HEYRMAN: "Losing that human connection and a place that they've gone for treatment for quite a few years and being told 'Now you must go find a new person to be connected to.' That's a difficult thing. And people fall through the cracks. They fail to show up."
STEPHEN FEE: So far, Heyrman says figuring out just how many people like Gail have slipped through the system is nearly impossible.
MARK HEYRMAN: "I think the answer is we don't know yet. And unfortunately no one has the money or the time or wants to invest their money and time in sort of really figuring out what is happening to everyone who has a serious mental illness."
HAROLD POLLACK: "It's gonna be a wild ride I think over the next several years."
STEPHEN FEE: Harold Pollack is a public health researcher, also at the University of Chicago — he's an expert on the national health care reform law — and a supporter of it. He says Gail's difficulties show how important it is to help vulnerable people navigate the system.
HAROLD POLLACK: "Because it's not enough to just insure people. You actually have to have systems in place that are effective and economical and credible."
STEPHEN FEE: Is Medicaid and the private health insurance expansion enough to get people in Chicago who have persistent mental illness the care that they need?
MARK ISHAUG: "Medicaid and private insurance, they're– that's just what it is. It's insurance. It doesn't mean that it's care and it doesn't mean that it's access to care. But it's a necessary precondition to what we're able to do."
STEPHEN FEE: Not everyone agrees though that Medicaid expansion is the necessary first step. Twenty states have decided not to expand their Medicaid programs mostly out of cost concerns. The federal government has agreed to pay 100 percent of expansion costs, but that figure steadily declines to 90 percent by 2020.
So far, the A-C-A has survived court challenges and repeal efforts – and analyst Harold Pollack says the emerging consensus among states may be more about fixing implementation problems than eliminating the law altogether.
HAROLD POLLACK: "I do think that governors, both Democrats and Republicans are– you know, they do raise a number of very valid points with the Obama Administration that say, 'You know, health reform has to be tweaked so that it actually works well.' And as we start to really implement the Affordable Care Act, we will discover various things that have to be fixed along the way."
STEPHEN FEE: President Obama has said he welcome ideas to modify health care reform as problems arise.
PRESIDENT BARACK OBAMA: "I will always work with anyone who is willing to make this law work even better."
STEPHEN FEE: Meanwhile, back on the South Side of Chicago, Gail Davis is seeing her city-funded therapist again.
Are you getting the help and the assistance that you need to keep yourself healthy?
GAIL DAVIS: "Not like it should be, you know. But that as I speak will change because I do have an appointment by the way next Friday."
STEPHEN FEE: Though the city mental health clinics aren't taking Gail's Medicaid plan, they are keeping patients like her on board at least for now.