Francisco Lupercio has insurance for his house, his truck and the store he runs with his wife. But he can't afford health insurance, so he joined dozens of other people lining up for exams at a community clinic.
As the recession grinds on, more and more people are relying on taxpayer-supported health centers that offer care on a sliding fee scale. If Congress passes a law giving more Americans access to health insurance, the clinics will also be a critical element to ramping up capacity to care for millions of new patients.
"There is going to be a wave of chronically ill people," said Tanir Ami, executive director of the Community Clinic Consortium for Contra Costa and Solano counties, east of San Francisco. "We're well positioned to care for them."
This year, federally qualified clinics are on track to handle more than 20 million patients _ 2 million more than last year. Visits by uninsured patients jumped 21 percent from 2008 to 2009.
Legislators working to restructure the health care system are planning to nearly quadruple the clinics' federal funding. House Democrats would provide billions of dollars over the next decade, as would a version of the Senate health care bill.
But first, the clinics spread across 7,500 communities nationwide must cope with a historic surge in demand at a time when 27 states have cut their health care budgets.
Waiting lists at some centers have grown to hundreds of families, according to the National Association of Community Health Centers.
At the San Joaquin Health Center, in California's rural heartland, Lupercio and other patients lined up for services. Among them was Maria Gomez, the wife of a farmworker who drove from the nearby town of Cantua Creek to have her 5-year-old son's eyes checked.
The farmworker used to pick tomatoes, onions and cotton alongside her husband, but a drought and the sour economy have left them both without jobs. Now they have no insurance and no income.
Her own visit to the optometrist is no longer covered after California cut benefits such as dental and eye care for adults from the state's Medicaid program.
"I will always put my children's health first, but I wonder what will happen tomorrow? What will happen if even this clinic goes away?" she asked.
The centers cut health costs by providing primary care to a population that might otherwise delay treatment and end up in an emergency room _ a far more expensive alternative.
Unlike free clinics, which run mostly on private donations and city funding, federally qualified health care centers receive money from the federal and state governments to varying degrees. The fees paid by uninsured patients are important, but they only cover a fraction of costs, providers said.
House and Senate health care proposals would bolster the clinics' mission of caring for low-income and underserved communities, a mandate dating to President Lyndon Johnson's war on poverty.
The money would also prepare community clinics for the onslaught of new patients that would probably result from giving more Americans access to care _ a national version of what happened in Massachusetts after the state required patients to be insured.
Clinics in Ami's consortium, such as the Clinica de la Raza in Oakland, have seen their waiting list go from 300 patients three months ago to more than 700.
"We're stretched to the limit," said Jane Garcia, the clinic's CEO.
The new patients are just as eager for a new approach to health care.
Wendi Niehuis, an information security analyst from Walnut Creek, lost her job with Washington Mutual in February. Eight months later, she has cashed in her retirement plan, but feels she is one serious illness away from financial ruin.
"I didn't think I'd ever be without health insurance," she said. "Now I don't know if I'll ever have it again."
Such patients are walking into centers in rcord numbers, said Dan Hawkins, Senior Vice President of Policy and Research for the National Association of Community Health Centers.
"Many of them had a good job, had insurance, were pretty solidly in the middle class, and the bottom just fell out," Hawkins said.
A one-time injection of $2 billion in stimulus money is helping cover the rise in demand. But much of that money was intended for capital expenditures such as building new clinics, not new patients.
In Richmond, Calif., stimulus funding is helping Brookside Community Health Center add a second level, double the number of dental exam rooms, expand the children's clinic and add to the prenatal wing.
But the center is seeing an average of 358 new patient visits a month right now.
"We're maxed-out on space," said Sheryl Johnson, executive director at Brookside.
Other clinics were hit so hard by state cuts they had to lay off staff or close their doors entirely.
At least 27 states slashed funding for health programs, with California leading the way. Gov. Arnold Schwarzenegger eliminated in July a $35 million pool of money designed to support centers serving rural areas, migrant agricultural workers and Native Americans.
In the rural community of Potter Valley, about 110 miles north of San Francisco, the clinic that had served the region for 30 years was forced to close.
"A lot of rural community centers are facing the same fate," said Cathy Frey, executive director of the Alliance for Rural Community Health. "People don't have anywhere to go."
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