Carmela Castellano-Garcia has watched the rise and fall of community clinics in California for many years, and she said she's never seen anything like it.
"We have seen 12 clinics close in the past 18 months," she said. "That is just unprecedented in the time I've been doing this."
Castellano-Garcia is the longtime president and CEO of the California Primary Care Association. She said the burgeoning ranks of the uninsured and the continued slashing of state dollars for health care have combined to undermine many community clinics across the state.
"The rash of clinic closures is a sign of the times," Castellano-Garcia said. "It's a direct impact of losing money in the state budget." And beyond the dozen that have closed so far, she said, "Some other clinics right now are on the brink of closure. We're talking to a number of them, about six others, that are struggling to survive, to keep the doors open."
But it's not all dire news. There are some clinics in California that have not only survived, but thrived.
"It might be fair to say they're all over the map," Castellano-Garcia said. "There are clinics that are expanding, where existing clinics are opening new satellite sites."
In general, she said, community clinics in California are gearing up to handle the increased patient load and windfall of federal dollars from the health care reform law. But even that brighter outlook has been dimmed recently, she said.
"The recent federal cuts to community clinics have really put a damper on expansion plans," she said. "A lot of the clinics that were talking about expanding have put those plans on hold as a result of that."
One other factor, according to Castellano-Garcia, is that the need keeps rising in California, as many counties have cut specialty services. That means community clinics have taken on a wider range of services, from mental health counseling to setting up anger management groups.
"So you really have this range throughout the state," Castellano-Garcia said. "More services, more needs, some struggling to survive, some doing well. Overall, I'd say, they're in a challenging position financially."
What's a Clinic To Do?
As Executive Director Britta Guerrero walked along the halls of her Sacramento Native American Health Center, less than a dozen blocks from the Capitol building, she ticked off the improvements and upgrades made there in the past year.
"So the children's dental area, that's new," Guerrero said. "We added three dental bays last year. We now have nine, total. Here's our patient care coordinator. We recently added that, too. Here's our nutritionist."
She stopped in the hallway and tried to sum up all of the other changes in the past year: six new exam rooms, a lab for blood draws and EKGs, a physician assistant, two family counseling rooms, and a raft of health-related classes, including a fatherhood class and an unintentionally risqué-sounding seminar called "Making Parenting a Pleasure."
"It's pretty busy around here," Guerrero said with a smile and a nodding of her head. "We have definitely been busy."
Why is this clinic different from so many other clinics?
Guerrero said it's a state of mind, a different approach to running the clinic that's borne, in part, from her culture's historical poverty.
"We come from a place of being disenfranchised, low-income, from poverty," Guerrero said. "That's our mode of operation. That's where we live. We are good at being poor," she said with a slight smile. "Really, as a clinic, you have to live within your means, you have to get creative and empower the staff. There's always a way."
She said the clinic makes an effort to keep overhead as low as possible, putting 80% of its cash directly into patient care and programs.
The Native American Health Center also is helped by its federally qualified health center status, Guerrero. As such, the clinic gets an enhanced rate from Medi-Cal, California's Medicaid program.
According to Castellano-Garcia, that's the lifeblood of many successful community clinics. "There are over a hundred of them now in the state of California," Castellano-Garcia said. "Those clinics are financially more able to handle things. It's been a big changeover in the last decade."
In an era where many health care providers take a loss on every Medi-Cal patient, this clinic handles as many Medi-Cal patients as it can get.
"We want more. Give us more," Guerrero said. She added that the clinic is open to everyone in the community. "Right now, the patient split here is about 60-40, Native Americans to non-Native American," Guerrero said, adding "We want everyone to come here."
A Broader Vision
In fact, Guerrero has a much grander vision for the health center, beyond its many health care accomplishments.
"I've had something bigger in mind," Guerrero said. "We're not done yet, not by a long shot."
She believes the clinic could be a social center for the Sacramento neighborhood, and a bridge between the mainstream and Native American communities.
"We're the hub of the Indian community," she said. "We're visible. We are a rich community, we have a rich culture, and yet we get missed. Other communities have neighborhoods, and I want that for this area. I want this to be the Indian block, with Indians all through the neighborhood. I want people to see that we contribute more to society than just casinos."
She added, "We do culturally competent care really well. Indian people, we know how to respond to other Indian people -- only an Indian knows the heart of another Indian person." The clinic brings that patient-centered approach to other cultures, using other languages. "I think that approach works for all people," she said.
The rapid expansion of the Sacramento clinic has been fueled by several factors. For one thing, the overall need for inexpensive, quality care has skyrocketed. "As the economy gets worse, our patient load increases," Guerrero said.
Locally, cash-strapped Sacramento County has shuttered some programs and specialty health clinics, which also boosted demand for services.
"We are looking at establishing a county partnership," she said, "but there's not that much to partner with anymore. We're taking over a lot of what they can't do now -- domestic violence, anger management, that kind of thing."
The secret of this clinic's success, Guerrero said, lies in its inclusive approach. "A good clinic has to be community-driven," she said. "You have to connect to the needs of the community. You have to do what the community actually needs, not what you think the community might need."
For instance, she said, the clinic launched a re-entry program after clinic workers said that some patients coming out of the prison system were in need of transitional help.
That expansion has slowed a little with recent federal health care cuts, she said. "You're already seeing [some expansion], it's happening. The pace has slowed recently because of the federal cuts, but I don’t expect expansion to stop."
The trick for community clinics in California, she said, is trying to rein in costs and stay financially solvent, while also trying to expand services to meet the growing needs of a burgeoning patient population.
According to Guerrero, that can be done. The success of the Sacramento clinic is a pretty good argument for her.