Outside In :: Serving homeless youth and low-income adults in Portland Oregon

The doctor is in, sort of: Safety net of ‘free' clinics expands, as do its holes

The Portland Tribune Copyright 2006;
Written by Peter Korn;

Jill Ginsberg wasn't feeling guilty, exactly, last November as she watched the aftermath of Hurricane Katrina on her television. Helpless would be a more accurate description.

Ginsberg, a family medicine physician, wanted to help.

So Ginsberg arranged a meeting with Mary Overstreet Smith, the pastor at Powerhouse Temple Church in North Portland, who had helped to bring Katrina refugees to Portland.

But "Pastor Mary," as she is known, told Ginsberg that there were crisis issues closer to home — issues that weren't making the 6 o'clock news.

Overstreet Smith told Ginsberg that people in her entire North/Northeast neighborhood desperately needed a free medical clinic. Many of the residents had no health insurance, Overstreet Smith explained, and the only clinic in the area that kept evening hours had closed down about five years ago.

"She basically took me by the hand and marched me a couple blocks north to their church annex and said, ‘This is where we're going to do it. When do you think you can start?' " Ginsberg recalled.

The unofficially named North by Northeast Community Health Center will open this summer, one evening a week. In a modest facility with two low-tech exam rooms, the clinic will offer free primary health care on a first-come, first-served basis.

Ginsberg knows the local health-care landscape well enough to understand her clinic is much closer to a Band-Aid than a neighborhood cure. "No matter what we do," she said, "the need is going to be greater than what we can provide."

Holes grow in the safety net

Welcome to what Portland's health practitioners call the safety net, although exactly whom is being kept from falling is debatable.

What isn't debatable is that the safety net of medical care for the uninsured is failing. People are dying, and the system is going broke.

The system is the dozens of clinics, some big, some small — like the upcoming Northeast center — that are struggling to deliver health care to people who have nowhere else to go.

But thousands of uninsured Portland residents are routinely turned away even from these clinics of last resort. And those who receive care frequently are given the bare minimum — stopgap care rather than state-of-the-art diagnosis and treatment. And those who receive such care are becoming the biggest drain of all on the health-care system.

The untreated physically ill are waiting until their diseases become acute and then show up for care in emergency departments — care for which they cannot pay, Portland medical officials say. Conditions for the untreated mentally ill are deteriorating; some are killing themselves, while others are showing up at hospitals that will not turn them away, taking up the few inpatient beds available in psychiatric departments, Portland doctors say.

As bad as the situation is, the future looks even worse to Tracy Gratto, director of the Coalition of Community Health Clinics, which serves as an umbrella organization for 13 independent clinics in the Portland area. "We are going to drain our community resources dry eventually," Gratto said.

$5 pays a ticket to health

A few miles away from the church annex that will host the Northeast community clinic is the heart of Old Town, where Wallace Medical Concern Executive Director Kathy Hammock prepares to open the facility for its weekly Thursday night clinic.

Wallace, which opened in 1984, is one of the oldest "free" clinics in Portland; like many of the facilities that serve the uninsured, it's not altogether free. Clients are asked to make a donation toward their health care at Wallace; and many do manage to scrape together $5. "It's a matter of dignity for them to give something," Hammock said.

In the hierarchy of community health-care clinics, Wallace sits near the bottom — "the safety net to the safety net," Hammock called it.

Wallace operates another clinic, catering to uninsured Hispanics in the Rockwood neighborhood in outer Southeast Portland. But the facility, 225 N.W Couch St., treats a population among which drug use is occasional, mental illness frequent, infections and chronic illnesses expected.

The clinic's five exam rooms hold a collection of ancient examination tables and outdated equipment, either donated or scrounged. The medications available are minimal — free samples donated by doctors and pharmaceutical companies, but no antibiotics. The volunteer physicians, nurses and interpreters do what they can, and know it often isn't enough. Delivering health care to the homeless and working poor, to the drug addicted and the mentally ill, is not what the American health care system is set up to do, Hammond said.

"In some ways we're trying to do the impossible — things the federal government doesn't know how to do," Hammond said.

Others get tab for uninsured

The safety net, growing with new clinics but increasingly inadequate as the number of uninsured grows even faster, has reached a crisis point. As it fails, everybody pays, according to medical experts.

Matthew Carlson, Portland State University sociology professor, studies the link between health care for the uninsured and the rest of society. "We pay for them," he said. Carlson cites a recent study showing that people who have health insurance pay an extra $922 a year as part of their premiums to support those who do not.

In the last few years Portland-area emergency departments have seen dramatic increases in uninsured people suffering chronic diseases, Carlson said. These are people who could have been treated more cheaply and effectively with primary health care, but who went without, and ended up in overcrowded emergency departments seeking much more expensive urgent care.

And overcrowded emergency departments translate into longer waits and potentially substandard care for everybody, insured or not, according to emergency room physicians.

More than 550,000 Oregonians have no health insurance, according to a 2005 Families USA report. The Coalition of Community Health Clinics' Gratto sees the community health clinics not only as serving their clients, but public health as well.

"They are keeping this community healthy in a way our mainstream health care cannot," Gratto said. "We're treating homeless people with tuberculosis and other communicable diseases. We are the people who can do outreach into these hard-to-reach populations such as the homeless and migrant farmworkers."

Clinics start sprouting

Under the umbrella of the coalition, the Portland area 13 clinics operate independently, each keeping its own hours, targeting different populations. Some are nominally free; some operate on a sliding scale. Eight are community sponsored, five receive federal funding. The Multnomah County Health Department and hospitals maintain clinics of their own as well. According to Gratto, seven new clinics have started in the last three years.

And that's a bad sign, Gratto said — not only because it shows that the need is greater, but because all the clinics are competing for funding from the same sources. The money, Gratto said, is just not there.

"These safety-net clinics, most of them are on the brink of survival and not surviving," Gratto said.

On a Tuesday afternoon downtown, a young woman named Sarah is aware of a different, but related competition. Sarah, who asked that her last name not be used, is sitting in the waiting room at the Portland nonprofit Outside In's downtown medical clinic.

Sarah has a serious infection causing pain in her leg. She needs to see one of the clinic's naturopathic physicians; she needs medication to treat her infection. But the waiting room is filling up, and she knows not everybody will get past the waiting room door into the clinic itself.

Most of the people in the waiting room are young, but there also are a few middle-age people with fresh haircuts and fashionable clothes, who might be here on lunch breaks. They, too, represent the changing face of the uninsured — people with jobs and middle-class lives but with no health insurance.

Outside In is big and busy

In 2002, Outside In began accepting federal funding and saw its annual budget grow from $400,000 to more than $2 million. The shelves in the medication room are stocked with a wide range of drugs, from herbal remedies to the antibiotics so absent at Wallace Medical Concern.

No scavenged beds and equipment here. There are laptop computers in each of the rooms, and the entire clinic is paperless.

Last year, Sarah passed out in a shopping center and was taken to a hospital emergency department. She was treated for an antibiotic-resistant infection and stayed in the hospital three weeks, a stay for which she could not pay.

"They told me if I had come in a week before they could have treated me orally with antibiotics, outpatient," she said.

John Duke, clinical director at Outside In, said that 10 years ago nearly half of the people treated at the clinic were covered by Oregon Health Plan insurance, which meant the clinic received Medicaid reimbursement. Now, Duke said, only about 10 percent of the clients are eligible for coverage, but many don't bother to obtain it because they cannot or will not pay the monthly premiums the health plan requires (often about $10 a month).

Health-care players step up

In 1997, when the Oregon Health Plan was covering more Oregonians, Outside In received 2,000 patient visits. Last year, 15,000 patient visits were made by about 8,000 individuals. And that doesn't include the 10 to 20 turned away each day.

But as Duke looks at his figures, and considers patients such as Sarah, he notes that his clinic and others are starting to receive more support from bigger providers of health care. This year Outside In received $90,000 from Kaiser Permanente and about the same from Providence Health Systems. Oregon Health & Science University, Duke points out, operates its own clinic, the OHSU Richmond Clinic on Southeast Division Street.

The hospitals, Duke said, are taking note of the crowding in their emergency departments by people like Sarah. They're looking at the hidden costs of the uninsured. They have begun to recognize, Duke said, that supporting the safety net will allow them to do their jobs and might even save them money, if fewer people like Sarah show up for three-week unreimbursed stays.

"We have reached a tipping point," Duke said. "All the doctors know there's an uninsured crisis, and they want to do something about it."