Providing Care For Uninsured More Daunting Than Expected

February 16, 2008

Mercy Clinic's doors won't open for another hour, but already the waiting room is crowded with patients. A grandmother, a single man, a petite brown-haired woman with a slight cough and her boyfriend -- they've all come to this Gaithersburg clinic, one of 10 across Montgomery County that care for those whose only other option is a hospital emergency room.

The number of adults without medical insurance has continued to grow, and officials in Montgomery are struggling to keep up. Four years ago, county officials launched Montgomery Cares, a program to care for the uninsured. They set the bar high, pledging to cover half of the county's estimated 80,000 uninsured residents by 2010.

But two years from the deadline, officials say they won't come close to meeting their goal. That's even with the opening of three new clinics and a 58 percent increase in the number of people receiving care. In 2007, about 13,019 uninsured residents received care, up from the 8,251 before the program began.

"I don't want people to think the program isn't working,'' said Uma S. Ahluwalia, director of the county's Department of Health and Human Services. "Our goals were never modest. We never realized what the challenges were until we launched.''

Added Steve Galen, executive director of the Primary Care Coalition, the nonprofit entity that oversees the program: "It looks like we're struggling, but we are making progress.''

A shortage of health-care providers, high real estate prices and escalating operating costs are among the problems facing the county and its medical partners.

The challenges are common across the country. California and Massachusetts have run into cost dilemmas in their efforts to cover the uninsured. San Francisco County officials faced opposition from the business community. Locally, regulatory issues in Howard County are threatening to delay a plan to provide care for the uninsured that officials hoped to launch this year.

Under Montgomery's program, adults who don't have health insurance can receive care at one of 10 nonprofit clinics scattered across the county. Fees are based on a patient's ability to pay, but no one is turned away. The clinics operate independently but receive financial support, and in some cases clinic space, from the county.

Because they were depending on an existing network of clinics that were caring for the uninsured, county officials didn't think they would face the problems other communities have as they tried to expand coverage.

Even with county support, clinic administrators say they struggle with issues ranging from patient record-keeping to finding qualified bilingual doctors and nurses when the entire region is competing for their services. The high price of real estate has made it difficult to find space. Although the county's hospitals have donated millions of dollars in services and support, they, too, face financial pressures. Clinics must raise the balance to fund their operations.

Along with the nitty-gritty of day-to-day operations, county officials and their partners are dealing with broader questions, such as how to define what services clinics should provide their clients. Initially, the thinking was that the clinics would be places where individuals could get basic health care. As more information has been collected about patients' needs, there have been efforts to include dental care and mental health services. But more services means more expenses.

A report by the Montgomery Cares Advisory Board estimates it would take the creation of 11 clinics at a cost of $9.4 million to serve 40,000. That addresses only buildings, not taking into account operating costs. The same report estimates -- although it cautions the figure is far from firm -- that it would cost the county $20 million to expand services to 40,000. By comparison, in fiscal 2008, the county allocated $11.4 million to the Montgomery Cares program. All this comes as the county is facing a potential $400 million shortfall.

When clinics tackle one problem, another pops up. In June, Mercy Health Clinic moved into a new space in a Gaithersburg county building twice the size of its previous home in Germantown. But because the clinic depends on volunteer doctors and nurses, it's only open three days a week. Clinic Administrator Amra Slakovic-McClanen would love to open the doors Mondays and Fridays, but finding doctors and nurses willing to volunteer time on those days is a challenge, she said.

By contrast, Proyecto Salud, a clinic in Wheaton, could easily fill that space and more with its current patient load, Executive Director Cesar Palacios said.

On a recent weekday morning, clients spilled out the clinic's front doors. Last year, physicians and nurses here saw about 3,000 patients at the site across from the Westfield Shoppingtown Wheaton mall, Palacios said. The clinic expanded its hours twice last year, staying open until 8 p.m. instead of 5 p.m. five days a week. It added Saturday hours twice a month.

Guadalupe Berger, 53, of Silver Spring said the medical staff at Proyecto has helped her manage her diabetes and enables her to afford the medications she needs. Berger works as a home health care aide but said not all the companies she works for offer health care coverage. She said she can't afford to buy private health insurance.

"This is a very good clinic,'' she said. "The people are very caring and very nice. I wish there were more clinics like this.''

Montgomery is among a growing number of counties and states that are establishing partnerships to care for the uninsured. Anne Arundel and Fairfax counties both have initiatives in place.

According to the Henry J. Kaiser Family Foundation, 46.5 million non-elderly Americans lack health insurance. Between 2005 and 2006, the number of uninsured increased by 2.1 million.

In Maryland, about 800,000 residents are uninsured. Last November, Gov. Martin O'Malley (D) launched a program to expand coverage to 140,000 people by expanding Medicaid and offering subsidies to small businesses. But absent larger efforts at the state and federal levels, it has fallen to counties to fill the void.

"There is a fundamental problem in that the buck has to stop somewhere,'' said Robert Friedland, an associate professor of health systems administration at Georgetown University School of Nursing and Health Studies, about why states and counties have established programs.

Montgomery officials say they don't know when they'll reach their 40,000 patient target.

"We're getting close to that tipping point,'' Galen said. "In the next two or three years, if we can get ourselves [to the point where] clinics can see 3,000 to 4,000 patients and we add a couple of clinics, we really [can] increase the capacity.''

Ahluwalia urged patience, saying creating a program to care for the uninsured "is a little like laying the train tracks as the train's coming toward you.''