Safety-net health centers struggle to meet demand

STONE MOUNTAIN, Ga. -- The health care safety net is straining. Just look at Jeffrey Taylor's parking lot.

Taylor oversees a community health center for the poor in this suburb a dozen miles east of downtown Atlanta. The center, a modest one-story brick building on a hillside, has never been busier. People who recently lost their jobs and health insurance fill the waiting rooms, and their cars jam into the clinic's 50-space parking lot -- with much of the overflow ending up at the nightclub next door.

"We need to expand this lot," said Taylor, who runs Oakhurst Medical Centers Inc., which operates two clinics.

Oakhurst is among 1,200 community health centers, 1,100 public hospitals and nearly 3,000 local health departments that are primary strands in the nation's health-care safety net. Most say they have become significantly busier in the last seven months, as the economy has worsened.

These last-resort centers coping with waves of new customers are looking forward to a jolt of new money from the $787 billion federal stimulus package signed into law last month.

Safety-net providers struggle as a rule, but times are unusually tough. Most community health centers and public hospitals are temporarily maintaining their razor-thin operating margins, but say they can't keep it up for long. Many health departments -- which play a leading role in preventive care and are heavily dependent on waning state revenue -- are doing worse, eliminating thousands of jobs and shedding services.

"We've never seen it this bad," said Dr. Georges Benjamin, executive director of the American Public Health Association.

The stimulus package includes $87 billion for government health insurance for children and the poor, and another $3.5 billion to bolster public health services and safety net care. Federal officials are still deciding specifically how and where to spend that money, causing hand-wringing at these facilities.

A survey released last month indicates most ER doctors are seeing more unemployed patients who have lost health benefits. About 88 percent of the 1,200 doctors who answered a survey from the American College of Emergency Physicians said they had patients who had been turned away elsewhere because they couldn't pay. (Federal law bars ERs from turning away patients with emergency needs for lack of money.)

Perhaps the most common theme involves the recently unemployed who have chronic health problems, like heart disease, that require prescription drugs. When their work coverage runs out, they turn to safety-net providers to keep the medications going, said Dr. Michael Brooks of West End Medical Centers Inc., an Atlanta-based community health center organization.

But in some cases, patients have simply put off care -- like Sharon Moore. Uninsured and recently unemployed, the soft-spoken 59-year-old was suffering worsening headaches but saw a doctor visit as too costly.

A friend, also uninsured, told Moore about Southside Medical Center, which runs a bustling clinic in a poor area a few blocks from the Atlanta Braves baseball stadium. Moore made her first visit late last year and learned the cause of her headaches was severe high blood pressure.

She was given water pills that lowered her blood pressure, eased her pain and potentially averted a heart attack or stroke. She pays $30 per doctor visit, a sliding-fee scale based on income. The pills cost just $9 for a three-month supply. "It's a blessing," Moore said.

Comprehensive statistics about the U.S. health safety net are hard to come by, and details vary by community. But it's clear that many of the medically needy go to hospital emergency rooms.

Hospital officials say the recession has hit them hard. Hospital funds lost money in the stock market like everyone else. Charitable donations are drying up. It's harder to borrow from banks or through tax-exempt bonds. Medicaid funding, which depends on state tax revenue, is precarious. And more affluent patients -- whose business offsets the unreimbursed care of the uninsured -- are cutting back on elective procedures and other care.

Most safety-net hospitals seem to be managing at the moment, but some are showing signs of strain. This week Atlanta's Grady Health System, which runs one of the largest public hospitals in the country, announced it cut 150 jobs because of the economy.

Many more public hospitals probably will end the year in the red, said Larry Gage, president of the National Association of Public Hospitals and Health Systems. "For some, the situation is even more dire, with projected losses potentially reaching tens of millions of dollars next year," he added.

Federally funded community health centers, first created in the 1960s, have long been a mainstay of the safety net. Annual funding almost doubled in the last decade, to about $2 billion. In many towns, hospitals and health departments have abdicated patients to these clinics.

"We've held our own for the past several years," said Craig Kennedy, an official with the National Association of Community Health Centers. "But we're facing the worst difficulties we've seen in quite some time."

Health departments are another piece of the safety net. Most aim at disease prevention, like vaccine clinics, restaurant inspections and tuberculosis-monitoring to make sure patients take their medicine. About 10 percent offer full-service clinics, partly because that brings in some income, whether it's cash or Medicaid reimbursement.

But many are looking at cutting services, or restricting what they pay for.

Northern California's Santa Cruz Health Department likely will cut as many as 30 of its 150 jobs this year. The department -- which manages state and local funds for indigent care -- also stopped paying for such things as joint replacements and cataract surgery.

"They're all wrenching decisions," said Dr. Poki Namkung, the department's director. "It's not the level of services people would expect to have in a civilized country."

Last year, health departments cut 11,000 jobs and this year expect to shed another 10,000, according to a report this week by Trust for America's Health, a research group.

Some health departments have been getting out of the patient care business. In Georgia, the suburban DeKalb County Board of Health treated patients for a dozen years at two clinics. That ended in September, in part because the state's Medicaid HMO system quit paying for care at health departments.

The department is now referring its previous patients to nearby community health centers. That's how Kordie Green ended up at Jeffrey Taylor's Stone Mountain clinic one morning this week.

It's hard to find a doctor, especially an attentive one, when you don't have good health coverage, said Green, 52, an uninsured child care worker who needs a continuing prescription for a thyroid condition.

"You want someone to take the time to see you and take the time to explain what's going on with you," she said.

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On the Net:

National Association of Coummunity Health Centers: http://www.nachc.com/

American Public Health Association: http://www.apha.org/