However, the program is only offered to Medicaid patients with two or more persistent conditions, so "you pass up on the opportunity to get people in early stages of their treatment," says Dr. Joe Parks, the Director of Missouri Institute of Mental Health. "We have to wait till you've fallen completely to pick you up."

Adams-Jenkins' now has her symptoms under control and shares an apartment in the city with her new boyfriend, but she worries for the more than 5 million Americans who will fall through the cracks of health care reform.

Twenty-five states, including Missouri, have rejected a Medicaid expansion in their push back against PPACA. They say the initially generous subsidies will fall off and leave them with the financial burden in a few years' time.

In states that have opted not to expand, adults earning more than 100 percent of the poverty level, but less than the 139 percent or above required to be eligible for subsidies on the PPACA-administered exchanges, will find themselves in a health coverage no-man's land.

In effect, millions of adults who otherwise would have qualified for coverage will find health care still out of their reach. 

Mental health experts across the country warn that pulling the carpet from under the country's poorest and most vulnerable — the mentally ill — will force them to turn to more costly, and less effective, channels such as emergency rooms. 

In Missouri, "hospitals are decreasing their psychiatric beds because [those patients] are the highest percentage of non-payers," says Diane Maguire, a director at Places for People, another community health center in Missouri. "Often the people we serve are not able to get services at more traditional agencies due to their active symptoms."

It also will strain law enforcement, which is often forced to respond to emergencies involving the untreated mentally ill and typically needs to transport patients to distant centers. Prisoners with mental illness cost the nation an average of nearly $9 billion a year, according to the National Alliance on Mental Illness.

"Because of the lack of mental health beds, county jails have become the new community mental health units for many individuals who, after not receiving treatment or medications for an extended period of time, will commit crimes that cause them to be arrested and subsequently incarcerated," says Sheriff Kent Oberkrom, president of the Missouri Sheriffs' Association.

Last week, in an effort ensure more comprehensive and cost-effective coverage for the mentally ill, the Obama administration updated the 2008 Mental Health Parity and Addiction Equity Act with new regulations, which require carriers to cover mental illness and substance abuse just as they cover physical diseases.

The rules do away with stricter limits on hospital stays and higher out-of-pocket costs for mental health patients. However, according to the National Alliance on Mental Illness, the regulations will not cover managed care plans through Medicaid. This could exclude upwards of 15 percent of Medicaid patients.

"Some of our most vulnerable people are still being left behind," said Michael Fitzpatrick, the group's executive director.

For now, the integrated approach to care that the Healthcare Home initiative provides will remain available only to the most at-risk Medicaid recipients.

"We have no way of targeting the uninsured," says Dr. Parks, "and the major player insurance providers were invited to offer their most at-risk patients the opportunity to participate in the Healthcare Home program, but they declined."

Missouri's General Assembly continues to discuss their options surrounding Medicaid, but an expansion seems unlikely anytime soon.

While the debate is sure to be a long and complicated one, for Adams-Jenkins, it is simple: "I was given the opportunity to be a part of this community, which has made me a better woman. Why would you deny someone that?"