Providing Care for Uninsured More Daunting Than Expected

Officials Grapple With Program's Fiscal, Physical Needs

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.