It’s no secret that both the city of Chicago and the state of Illinois have major budget problems. Both governments have made cuts to services in recent years. But there is evidence that shrinking mental health services could actually cost money.

Heather Linehan is a paramedic with the Chicago Fire Department. She is tall, with strong arms and gray hair. She has the kind of presence that is gentle, but also seems to say, you probably shouldn’t mess with me.

Linehan said she has developed that demeanor from working over 30 years in emergency medical services. She said that kind of work gives her a particular view of the city. When you deal with emergencies you see what is not working. You are with people in their worst moments, the times when all the other safety nets have failed.

“On the street we say, you know what rolls down hill and who it lands on,” she said.

Linehan said when policy decisions get made, she sees a difference in who shows up in her ambulance. Years ago, she noticed when state hospitals started to close and not enough community-based services filled the gap. More recently she noticed when the state cut funding and later when the city closed half of its mental health clinics.

If Gov. Bruce Rauner’s proposed budget passes she will be bracing herself again.

Linehan is not alone. People who work on mental health say the cuts to Medicaid and mental health services would mean more people with mental illness visiting emergency rooms.

It is a trend that is already underway. Data WBEZ obtained from the state show startling increases in Chicago. From 2009 to 2013, 37 percent more patients were discharged from emergency rooms for psychiatric treatment. The biggest jump came in 2012, the same year the city closed half of its mental health clinics.

The city did not agree to an interview for this story. But in a statement it said the mental health infrastructure in Chicago is stronger than it was four years ago.

Inside an Emergency Department

The emergency room spike has already forced some emergency departments to make big, costly changes, just so they can keep these patients safe, including literally rebuilding parts of their hospitals.

Sheri Richardt is the manager of Crisis and Behavioral Health at Advocate Illinois Masonic Medical Center, where construction is underway on a new behavioral health unit.

Richardt said when a psychiatric patients come in to the emergency department they need special examination rooms. She pointed out how the pipes under the sink and toilet are covered.

“There is nothing on the walls you could hang yourself with or hurt yourself with,” she said.

As visits climbed the hospital needed more spaces like this. The new rooms will be designed for safety, but also to give the patients a more quiet and private space, away from the hustle of the rest of the emergency department.

Richardt said she witnessed one reason why psychiatric ER visits rose by 37 percent. She said hospitals often recommend Medicaid patients that follow up with a therapist or maybe psychiatrist after they are discharged from the emergency room.

But  Richardt said some patients live in areas where there just are not enough places to get care. She said these patients could wait as long as nine months for an appointment, “and if you come to the emergency room because you are in crisis and then you can not get follow up care for nine months you are probably going to go back to the emergency room for care.”

The $2.5 million patient

Richardt saw the same patients rotate in again and again. So she pulled one patient’s files and found that woman had visited the Illinois Masonic Emergency Room 750 times over the course of about 10 years.

Richardt said the patient was picked up by an ambulance or police officer almost daily. Sometimes the emergency department would discharge her, only to have her appear back a few hours later.

“The cost of that for us was two and a half million dollars. Medicaid dollars,” said Richardt. “And that’s only at our hospital. This an individual who went between multiple hospitals and so we don’t have the true cost.”

Like many patients, she had different, interconnected problems. She had mental health needs, drank too much, fell down a lot. She didn’t have stable housing and started having seizures.

“And it wasn’t only about the money; this is an individual we believed was going to…die on the street,” said Richardt.

Richardt and her team decided to take full responsibility for this patient. They coordinated all aspects of her care, helped her get an apartment and worked with nurses and a chaplain. It worked. She’s only visited the emergency room a handful of times in the last year.

About a year ago they launched a team with social workers, chaplains and nurses to provide the same type of care to more patients. They work with the hardest cases, including people with mental illness who often visit the emergency room frequently.

The hospital said their visits have begun to plateau.

Shifting Cost

The kind of wrap-around care performed at Illinois Masonic relies on a range of services. Those services are threatened under Rauner’s proposed budget, which cuts millions from community services and housing.

We contacted his office and asked to speak to anyone from the administration about his budget. In a statement his office said cuts are needed because of reckless spending from the past. They refused to do an interview.

So we called other state Republican leaders and were referred to Rep. David Leitch. Leitch is a conservative who hates government bureaucracy and believes in fiscal responsibility. And that’s exactly why he says he opposes these mental health cuts.

The cuts mean “the emergency rooms pick up more and the jails pick up more. Any cuts the state makes, simply means somebody else has to pick up the cost,” said Leitch.

But don’t take Leitch’s word that cuts one place may show up as costs somewhere else. Take it from someone who lives it.

Kathy Powers went to the city’s Northtown Rogers Park Clinic for bipolar disorder. Even before the city closed her clinic, she was having trouble getting an appointment with a psychiatrist there, or anywhere else.

“So I went to the emergency room, because I was a girl with a purpose,” she said.

Workers at the emergency room said they had a reference for a psychiatrist at Northtown Rogers Park Clinic — the exact place she had not been able to get care.

“And I said, I just came from Northtown Rogers Park clinic… don’t recommend it anymore, they don’t have any psychiatrists,” said Powers.

Eventually the emergency doctors renewed her prescription for lithium. Medicaid picked up the tab. It really gets to Powers how much that simple prescription costs taxpayers. She said we could be giving her much better care for less money. 

Shannon Heffernan is a WBEZ reporter. Follow her @shannon_h