At one time, Florencia Cano was so depressed her younger sister would put food in her mouth to coax her to eat.
Eight years later, she is determined to stop the closing of the North Side mental health center where she received the counseling she credits with putting her back on her feet.
Cano has testified before a City Council budget hearing, passed out leaflets and trekked to the offices of three aldermen to mobilize opposition to a plan to consolidate Chicago's 12 public mental health centers into six.
On a recent dreary day, she sat frustrated near an artificial Christmas tree in the storefront office of 12th Ward Ald. George Cardenas, head of the City Council's health committee, after being told that a scheduled meeting had been canceled because Cardenas was tied up at City Hall.
"I'm disappointed," she said in a quiet voice. "I've told him that Mexican people get sick too, and we don't get enough help."
Municipalities across the country are looking for ways to cut costs in a fragile economy and wrestling with thorny questions about how to provide safety net services for socially vulnerable people. In Chicago, a debate rages over how to best care for thousands of poor people who battle mental illnesses.
City officials who support a plan to halve the number of mental health centers are pitted against some of the clinics' clients and their advocates, who are fighting to keep the facilities open and stave off layoffs.
The budget-cutting plan would close six centers early next year, a consolidation expected to save taxpayers about $3 million, according to the Chicago Department of Public Health.
Some 5,100 patients receive services through the city's network of mental health clinics. About 3,000 are uninsured or underinsured, and another 2,100 carry Medicaid, Medicare or private insurance.
The city will refer 1,100 clients with insurance to nonprofit community mental health providers. The other insured clients, and those without insurance, will be referred to the city's remaining mental health clinics, said Chicago Health Commissioner Dr. Bechara Choucair, who said the consolidation would make the system more efficient.
"We spent a lot of time speaking to consumers, advocates and mental health providers, and most said we should focus on the most vulnerable, the uninsured," Choucair said. "We also wanted to focus on what we could do to enhance the mental health infrastructure."
The health department is spending $500,000 to enhance psychiatric services at the nonprofit agencies where some insured patients will be referred.
"We did not want this budget process to be a Band-Aid fix," Choucair said. "We wanted to look at long-term sustainability."
A report by three organizations that make up the Mental Health Movement, which has been fighting the consolidation, asserts that the availability of treatment is decreasing at a time when the need is growing.
The group is made up of the Community Mental Health Board of Chicago, Southside Together Organizing for Power, and the American Federation of State, County and Municipal Employees Council 31, which represents some clinic employees.
"It will be particularly difficult for uninsured individuals to find services, since private providers are already struggling with shrinking budgets due to cutbacks in state funding," says the report, which is set to be released in January. "At a time of great unmet need closing mental health clinics is wrong from both an economic and humane point of view."
Some Hispanic clients fear the possible loss of Spanish-speaking therapists.
"This is what people don't understand," said Cano, a patient at Northwest Mental Health Center on North Milwaukee Avenue, which is slated for closing. Her therapist speaks to her in Spanish. "It's taken me a long time to trust my therapist, and I don't trust people easily. Now she's like a part of my family."
Cano, whose care is covered by Medicaid, is being referred to another city mental health center about four miles away, in a neighborhood she says she's unfamiliar with.
Some advocates say Spanish-speaking clients will be hit hardest because two of the clinics on the chopping block serve a high number of Spanish-speaking patients and employ more Spanish-speaking staff than the other clinics.
The health department's proposal calls for 34 employees to be laid off and 77 employees to be transferred to remaining clinics, Choucair said. It's not yet known how many Spanish-speaking therapists will keep their jobs or where they'll be based. That will be sorted out by a collective bargaining agreement.
Tony Kopera, president and CEO of Community Counseling Centers of Chicago, said his agency offers a broader range of services and longer hours than the city alone could provide and is prepared to accept referrals of insured patients.
"I think (the debate) is being blown out of proportion," said Kopera, who said he feels the community providers are being unfairly put down. "There are legitimate concerns; I don't want to minimize it. But we have been dealing with people with serious mental illness since 1972 and have successfully helped people stay with their families, work jobs and much more."
Chicago is one of a few large cities that run their own mental health centers, said Dr. Paul Appelbaum, director of the division of law, ethics and psychiatry at Columbia University in New York.
Mental health services in many big cities are funded by Medicaid and provided by nonprofit agencies under contract, he said.
"When care is provided directly through the public sector … there is greater continuity of care," said Appelbaum, former president of the American Psychiatric Association. "Typically there's a greater sense of responsibility for the health of the public. It's a very important component of mental health care and a very good way of delivering services."
Mark Heyrman, chairman of public policy for Mental Health America of Illinois, said a substantial reduction in state Medicaid funding, along with missed opportunities in the past to bill for treatment given to Medicaid beneficiaries, put Chicago officials in a bind. Given their options, they came up with the best plan to stretch their limited dollars and serve people who are not Medicaid-eligible, he said.
But the consolidation likely will have a negative impact, even though many nonprofit community providers offer a broad array of services and high-quality care, Heyrman said.
"It will be disruptive and there will be people who get lost, with all the bad things that happen to people disconnected from mental health services: becoming homeless, losing employment, being hospitalized or ending up in the criminal justice system," he said.
"Some private clinics are swamped as it is. ... Some people will be told to come back in 90 days. The connections will be broken, and it's the connections that are most important if you care about people with mental illnesses."
Heyrman questioned why officials can't wait to see if additional funding might be on the horizon.
"The (health reform) Affordable Care Act might help states and cities, in terms of ensuring there is a continuing funding stream for mental health services," he said. "It's not a panacea and won't be effective for some time … (but) if we can wait a little bit, we can save a lot of harm to people with mental illnesses."
Choucair said his department is working with other groups, including the Cook County sheriff's office and mental health courts, to use effective ways of assisting people diagnosed with serious mental illnesses who could be at risk for homelessness or incarceration.
He said the health department is preparing a detailed transition plan for clients, including regular meetings with community providers, letters and phone calls to clients, and information sessions at clinics.
The city will track patients to make sure they don't fall between the cracks, he said.
Cano is not convinced, so she resolutely continues her activism. She speaks out, she said, because many patients are too afraid, embarrassed or acutely ill to do so.
"I'm not a statistic," she said, before exiting the 12th Ward waiting room with several other advocates to meet with Cardenas' chief of staff. "I'm a human being."