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Photograph by Curtis Cartier
CHECK-UP, PLEASE: At Santa Cruz Women's Health Center, physician's assistant Marilyn Marzell goes over patient Regina Ann's health history while 3-year-old Reilly Ann looks on.

Safety First

The county's strained safety-net clinics look for relief in the health care bill

By Jessica Lussenhop

ERIKA HEARON spent Sunday night glued to the television in the small, handsome living room of her mobile home in Live Oak, watching as the House of Representatives slowly collected itself to pass historical health care reform legislation. "For about two, three hours I watched pretty intently," she says.

The 44-year-old was laid off last May and has spent the better part of a year unemployed and uninsured. Now that the bill is on its way to final passage, she and her husband will likely fall within the parameters of Medicaid expansion and become insurable under MediCal. Those parts of reform, however, won't kick in until about 2014. "We both have significant health problems, so waiting three years with no insurance—it's daunting. It's scary," she says.

Until then, or until she finds employment, Hearon will continue to rely on the Santa Cruz Women's Health Center, a "safety net" clinic that provides primary care regardless of patients' ability to pay. Hearon pays about $15 per visit in emergency situations. "It's not something I can do weekly," she says. "But it is affordable for that urgent situation."

These types of clinics stand to benefit greatly from the reform, although SCWHC medical director Dr. Patrick Meehan expresses similar anxiety about the near future. "We have noticed a pretty big increase in uninsured people," he says. "The downside is that a lot of the changes like the Medicaid expansion, which would expand MediCal, do not happen until 2014. So that's three or four more years of trying to limp along absorbing the cost of uninsured people."

According to the Santa Cruz Community Assessment Project, 8.4 percent more people in the county are uninsured than in 2007; statewide, 1.6 million people have lost insurance since then. In the last year, Meehan estimates his clinic provided more than half a million dollars' worth of uncompensated care to uninsured patients, who make up about 42 percent of his 5,000-patient annual caseload.

The new reforms should ease the burden. Once Medicaid expands to cover those whose income falls below 133 percent of the federal poverty line, Meehan estimates that about 25 percent to 30 percent of his uninsured patients will become insured. That means more compensation for the clinic and more resources to shift toward the neediest cases.

"Not only will they be able to care for more patients, they'll be able to cover more uninsured patients," says Leslie Conner, program and policy director for the Health Improvement Partnership of Santa Cruz County. "That's the clinics' ongoing challenge, to be able to subsidize care for people who aren't insured."

There are other provisions of reform that will benefit safety-net clinics more quickly, like a huge $11 billion infusion of cash for community clinics over the next five years. The California Primary Care Association, which represents nonprofit clinics statewide, estimates California could get up to a 10th of this money, doled out similarly to the way American Recovery and Reinvestment Act Funds were. Watsonville's Salud Para La Gente already used ARRA funds to build a 9,000-square-foot clinic expansion, hire two new physicians and install community health clinics in schools.

Another program Salud has benefited from is the National Health Service Corps, which provides loan repayment for medical school students who commit to spending two to four years in medically underserved areas like Watsonville. The program will receive a $1.5 billion boost over the next five years. CPCA president Carmela Castellano-Garcia says the money could help place as many as 15,000 new primary care physicians in safety-net clinics nationwide. "This could fundamentally revive primary care as a viable career choice," she says. The first round of money should be available as soon as 2011.

The plan does have limitations, of course. To be eligible, clinics must be designated as Federally Qualified Health Centers. So while Salud Para La Gente and the Santa Cruz County–run health clinics can immediately apply for funds, Santa Cruz Women's Health Center and Planned Parenthood cannot (though they will have the opportunity to apply for FQHC status).

And federal health care reform is passing at the same time California's fiscal nightmare is deepening. Gov. Schwarzenegger is knocking on the federal government's door, asking for a $6.9 billion bailout for California, and says that trigger cuts to health care services will ensue if the funds do not arrive. Threatened programs include Healthy Families (which was targeted last year), a family planning program called FamilyPACT and some cancer screening programs. Castellano-Garcia says that not only will community clinics lose the funds, they will lose the federal matching funds many programs are awarded.

"There's an urgency around health care in California right now, around services and access," says Leslie Conner. "The need [is] growing and services [are] dwindling. It makes the national piece that much more critical. But it also makes you question: how much can the feds do with all this new money when on the other side California is taking money away or doesn't have money to match it?"

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