They came to a church basement in Silver Spring to celebrate health care for the uninsured in Montgomery County: West African women in neon-bright cotton prints; robed and collared clergy from Bangladesh, Canada and Vietnam; business-suited doctors and elected officials.
Community organizer Jean-Bernard Neim, originally from Cameroon, beamed at the crowd assembled at Our Lady of Vietnam Church that afternoon in June. "It's a day we never thought would come," he said. "The opening of . . . the very first pan-African, Haitian clinic in the greater Washington area."
A choir of a dozen men and women, representing nine African nations and Haiti, took the stage. "It's marvelous, really marvelous," they sang in French, clapping and swaying and bringing the audience to its feet.
The pan-African clinic is part of a network of 10 independent, nonprofit health clinics that county leaders hope will expand and become a de facto system of universal health care in Montgomery. An initiative that started five years ago with a $100,000 county grant to promote primary health care for uninsured adults has grown into a $2.1 million annual investment.
Health care advocates, politicians and public-health officials -- prodded by County Council member George L. Leventhal (D-At Large) -- are now considering how to extend primary care to all low-income, uninsured adults in Montgomery, including undocumented immigrants.
There are a variety of state and federal programs for children, the elderly and pregnant women. But as the costs of health care and insurance have risen, adults have emerged as the group most in need. The clinics already provide primary care to more than 11,400 adults a year, out of the 80,000 to 100,000 people thought to be uninsured in this county of nearly a million.
Without state or federal solutions to the plight of the uninsured, about 600 local jurisdictions have assembled some form of low-cost coverage or access program the past decade or so.
Few, if any, have embraced the goal of universal care. Under a plan endorsed by Leventhal, county residents earning less than 250 percent of the federal poverty level -- $47,125 a year for a family of four -- would be eligible. This relatively low threshold "is a bolder step than most states or counties have ever undertaken," says Diane Rowland, a health policy expert at the Henry J. Kaiser Family Foundation in Washington.
The expansion would cost Montgomery an additional $20 million a year, a nearly tenfold increase in the $2.1 million it spends to provide primary care to uninsured adults. "We're asking the question," Leventhal said, "can we really do this for everyone?"
If any Maryland jurisdiction can, perhaps it is Montgomery, the state's most populous county and one of its richest, endowed also with an unusually large community of medical professionals, attributable in part to the presence of the National Institutes of Health in Bethesda.
"No one else does anything as elaborate as we do," Leventhal said.
County Executive Douglas M. Duncan (D) and his administration are responding with what may best be described as grudging support. "We're doing what we can in the absence of the others doing what they should," he said. Still, Duncan said, there will be more money for the program in next year's budget.
Apart from money is the question of whether the county should become a primary-care provider. "The goal is not to have the county carry the burden," said Ulder Tillman, Montgomery's health officer. "We've got to avoid going into a black hole."
The system under construction in Montgomery is a collaboration between community groups, nonprofit clinics, volunteers and the county government. It focuses on providing primary care and medication, leaving aside specialty care, mental health treatment, dental care and hospitalization in favor of addressing basic needs.
"It's not perfect, but 80 percent of the time it's okay," said Steven M. Galen, executive director of the nonprofit Primary Care Coalition, the organizational hub, fundraiser and advocate for the new pan-African facility and the nine other clinics in Montgomery. Some have served poor and homeless people for decades.
The objective, said Alvina Long, executive director of Mercy Health Clinic, a church-based nonprofit run out of the county's Germantown regional service center, is "health care for those who can't get it in any other place."
Losing weight, feeling weak and suffering from digestive troubles, Ignatius De Costa took himself to the basement of Our Lady of Vietnam.
In the polyglot world of Montgomery, it turns out that the pan-African clinic caters to some Asians as well: Bangladeshis and Vietnamese. The latter is because the clinic functions out of a Catholic church with a mainly Vietnamese congregation; the former because Bangladeshi nurse Cecilia Rozario volunteers with Mobile Medical Care Inc., a 38-year-old Montgomery nonprofit group that provides the clinic with medical facilities and staff.
Rozario's presence draws fellow Bangladeshis, such as De Costa. "They feel comfortable," she said. "I can speak our [Bengali] language." She introduced De Costa to Joanne King, a nurse practitioner who helps staff one of the group's two mobile units.
King quickly figured out what was wrong: diabetes. De Costa's blood sugar level was about four times higher than normal. She gave him medication, taught him how to manage his condition and sent him to Suburban Hospital for more tests. Suburban provides such services for free to Mobile Medical patients.
The drugs worked, cutting the glucose in his blood by half. At their second meeting a week later, King provided more medication and a device he could use to test his blood sugar levels.
Untreated, King said, De Costa would surely have ended up in an emergency room, possibly in a diabetic coma. His case would have added to the costs hospitals incur for treating the uninsured.
"I think at the right time I got to the right person," said De Costa, who earns about $1,400 a month in an auto parts store and has no insurance. He paid Mobile Medical's suggested donation of $20, which has been his total payment for care so far.
Health care advocates emphasize that the clinics are open to all uninsured residents who meet the income requirement. But because Montgomery has become a magnet for immigrants -- one-fourth of its population was born outside the United States -- more attention has been paid to delivering services in settings that make people feel comfortable.
The pan-African clinic was founded by parishioners of St. Camillus Church, a Catholic congregation in Silver Spring. Formally known as L'Acceuil Marie-de-l'Incarnation Family Health Clinic, it is the newest in a line of "culturally competent" facilities in the county. Others include Proyecto Salud and the Spanish Catholic Center, which primarily serve Latino patients; the Pan Asian Volunteer Health Clinic, run in part by the Chinese Culture and Community Service Center; and the People's Community Wellness Center, which targets African Americans in the eastern part of the county.
"Some people might say, 'Why have you Balkanized the clinics?' " said Carol Garvey, former county health officer. "But it's so very crucial to the delivery of care that's accessible to people if you understand the cultural implications."
The immigrant-friendly approach is a signal feature of Montgomery's effort. No matter their income, undocumented immigrants are shut out of many medical insurance systems and other programs. The county's commitment to their health care comes from advocates and political leaders alike.
Duncan, at the opening of the pan-African clinic, told the story of his father's immigration to the United States from France in the middle of the last century. "We celebrate diversity," Duncan told his audience. "We celebrate the diversity we see in the county because we know it makes us stronger."
Two years ago, Katherin Blanken found that she couldn't get from the bedroom to the bathroom without falling on her face. Her legs kept giving out. She went to Mercy, where volunteer doctors ordered a CAT scan and other tests.
A lifelong county resident and uninsured since her marriage broke apart in 1996, Blanken has spent time in homeless shelters. Mercy workers did not charge her.
Tests revealed a blockage in her abdominal aorta, the main artery that ferries blood from the heart to the lower body. Without surgery, vascular specialist Robert Fox warned her, Blanken might lose her legs. He corrected the blockage in a four-hour operation at Shady Grove Adventist Hospital in August 2003. The hospital provided the care pro bono.
Today, Blanken, 33, is back on her feet, although she cannot work because of health problems. Yet without Mercy, she said, her condition "would probably have progressed to the point where I would have died."
Her experience illustrates another key component of Montgomery's emerging health care network: It relies on nonprofit clinics and volunteers.
Mercy, for example, sees more than 1,100 patients a year but has only two full-time staff members. In 2003, it had an operating budget of $249,900 and received $689,097 in donated services, roughly half in the form of volunteer time.
Montgomery's wealth of volunteer medical professionals -- bolstered by the presence of the National Institutes of Health -- is one reason why the county's system of health care for the uninsured would be difficult to replicate elsewhere. "I'm not sure I could come up with a more responsive environment," Galen said.
In 1999, Duncan assembled a package of programs intended to benefit the working poor. It included a $100,000 grant to the Primary Care Coalition for research into making health care available to uninsured working adults.
That seed money, together with foundation grants and the work of the clinics, was a key step toward the system that exists today. Like many politicians across the county, Duncan addressed the issue reluctantly. But the reality, he said, is that "we've got people who have shown up at our doorstep every day with health issues."
Five years after Duncan began the "Rewarding Work" initiative, the county is spending at least $2.1 million to support the coalition and nonprofit clinics. That amount doesn't include other county contributions, such as office space for clinics and malpractice insurance for volunteer staff.
The figure does include two programs that the council, with Duncan's support, funded just this year: $350,000 for a community pharmacy that stocks the clinics with medications and $100,000 to create an electronic database of patient records that would be available to clinics in the network.
Other county health programs, with a combined budget of about $23 million, also treat the uninsured, but they are not focused on providing primary care to adults.
Last year, Leventhal, who chairs the County Council's health and human services committee, asked Galen to propose a way to reach all the uninsured people in the county. Experts assume that half of any given population of uninsured won't take advantage of available services, so Galen estimated Montgomery's target group to be 40,000.
Galen led a committee that developed a proposal called "Montgomery Cares" and calculated that providing primary care and medicine to that population would cost the county $15 million a year. County health officials said annual implementation costs would come to $4.7 million, for a total of nearly $20 million.
The county budget for this fiscal year is about $3.3 billion; nearly $206 million will fund the department of health and human services.
Montgomery's nonprofit clinics also will have to increase the amounts of money they raise and the volunteer help they solicit to implement Montgomery Cares.
In spring 2005, it will be up to Duncan and the council to decide how much to spend to continue building toward universal care. Leventhal envisions achieving full implementation over several years. "I will strive and I will succeed in increasing the funding every year," he said.