Clinical Trials

AT THE FREMONT Community Clinic in North Minneapolis, the plug is about to be pulled on the X-ray machine; doctors can't afford to X-ray their patients and instead will refer them to emergency rooms. Losing the radiology unit is only the latest austerity measure undertaken at publicly subsidized community clinics around the Twin Cities, where the cost of basic services is outstripping funding. Fremont can't afford to subsidize visits from specialists like cardiologists anymore. The mobile "dental Winnebago" no longer pays visits to the clinic to service low-income teeth. Other clinics are considering similar measures.

The cash-strapped clinics are even cutting back on medicine. "You can do a lot with a great staff. But you can't do a lot without medicine," says Deanna Mills, who oversees Fremont's three clinics in North Minneapolis. "Patients need antibiotics. They need those blood thinners. Diabetics need insulin." Community clinics have always relied on samples passed out by drug companies--free medicine for the poor. Increasingly, samples are all the clinics can count on. "Some of the expensive drugs we can't continue to give away."

Fremont is one of a handful of Twin Cities community clinics under federal mandate to provide health care on a sliding scale to under- or uninsured people whose only other option for basic care is the emergency room. Minnesota is touted as a national leader in health care, and under the state's state-of-the-art insurance schemes, the number of people needing the services of community clinics should be shrinking. But in fact, exactly the opposite is true: Visits by uninsured patients rose by 67 percent last year at Fremont Community Health Services; preliminary figures from 1996 show a 50 percent increase in patients at Twin Cities community clinics who are under the poverty level; administrators predict a 20 to 25 percent increase in clinic patients with no insurance coverage of any kind; at the Southside Community Clinic, unpaid bills have spiked from around $150,000 two years ago to $500,000 in 1996.

At the same time, funding from the county hasn't gone up along with costs, and federal funds are drying up. Meanwhile, the numbers of patients who can pay, or who have insurance, are dwindling. For community clinics, it adds up to growing budget deficits, and many have begun to eliminate programs just to keep up.

"Either we have to say we can't see uninsured people, or we have to cut services," explains Mills. Losing some of the services makes doctors' jobs harder: They take their own notes instead of hiring a transcribing service; assistants who helped patients understand their medical care (and freed doctors to treat more patients) are getting pink slips.

If the effects of serving more clients who can't pay is clear, the reasons behind the trend are uncertain. Theoretically, everyone in Minnesota has medical insurance: through an employer or a private plan, through Minnesota Care, a sliding-scale state-run plan, or through Medical Assistance. But in practice, the poor tend to be uninsured--especially the working poor who can't get insurance from their employers but who make too much money to qualify for Medical Assistance. At the same time, hospitals and insurance companies have shifted their priorities from care to cost-cutting, and under the new regime, low-income people seem to be suffering.

"It's how the industry has always worked," explains Bill Tendle, who runs the Southside Community Clinic. "People who can pay pick up the slack for people who can't. But with corporate managed care--whether it's the state or an HMO--they don't allow for people who can't pay. They're just looking for the cheapest way."

Under welfare reform, the crunch will get worse. As welfare recipients become working poor, and as access to Medical Assistance is curtailed over the course of the summer, beleaguered community clinics expect their problems to increase. In the short term, clinic directors hope to get debt relief from the federal government, but only through the end of this year. Long-term solutions--private grants, collaborative projects with other clinics and social agencies, set-asides from HMOs to help the poor--won't help the funding triage. The conundrum has dealt clinic personnel a whole new role--that of lobbyist. As each funding source dries up, they're forced to spend precious staff time searching for its replacement. And with welfare's demise, the funding food chain is about to get several links shorter.

"We're collecting numbers, trying to get a sense of how this is going to affect us. July 1 is when you're really going to see the numbers go up," says Tendle. And after that? "We may have to send all our lab work out. Things that are standard in the industry would go, and then you'd have to do just basic medical care. It'd be counter to our mandate. We wouldn't do that. We'd go out of business first."

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