Health Safety Net Grows in Brooklyn; Will Gore, or Bush, Nurture Its Kind?

Just past the reception area at the Park Ridge Family Health Center here is a Muslim prayer room. A few feet down the hall, in the center of the waiting room, is a large tank with brightly colored tropical fish--fish being a symbol of healing in Chinese culture. Along the wall in between, a patients’ bill of rights is displayed in Arabic and Chinese, Russian, Spanish and English.

The families that file into this sparkling clinic, with 21 examination rooms and a full-scale dental service bustling in the basement, are part of a wave of immigration revitalizing this wind-swept southwestern corner of Brooklyn. They labor in the businesses reclaiming abandoned factories and warehouses near the waterfront, or work in the stores and restaurants lining the crowded avenues, or ride the subway to jobs elsewhere in Brooklyn and Manhattan. They don’t make much money, and when they come to the clinic, many of them arrive without health insurance. None is ever sent away.

No matter who is elected president this fall, the challenge of providing health care to families like these will remain enormous. Both Vice President Al Gore (in impressive detail) and Texas Gov. George W. Bush (so far only in sketchy generalities) talk about incrementally expanding health coverage to some of the 44 million uninsured. Those plans promise tangible gains. But under any scenario, they will still leave tens of millions of Americans without health insurance. And that stark reality is forcing more attention on the thin line of safety-net institutions--like the Park Ridge health center--that care for the uninsured.

America’s safety net for those without insurance is a patchwork of public and religious hospitals; private doctors who provide some uncompensated care; and municipal health departments. At its heart are more than 1,000 community-based health centers, like Park Ridge, that receive federal grants to treat the uninsured. Located in both inner cities and remote rural areas, the federal health-care centers are unique, grass-roots institutions: By law, patients must constitute a majority of their governing boards. The centers now serve over 11 million patients--almost all of them low income and about 40% of them uninsured. Most of the other patients depend on Medicaid, the federal health-care program for the poor, or the new children’s health insurance program.

In an economy that is increasingly decoupling employment and health insurance, these community clinics have become a critical, if largely invisible, component of America’s social safety net. But as the federal Institute of Medicine reported recently, changes in the health care system are placing all the safety net providers increasingly “at risk.” From one side, these institutions are being squeezed by rising demand as the number of uninsured grows. From the other, they face a squeeze on revenue from declining Medicaid payments mandated under the 1997 balanced-budget law and the failure of the federal grants for the uninsured to keep pace with the rising caseload. Compounding the problem is the pressure that managed care has placed on the revenue of private physicians; that’s made many doctors more reluctant to provide free care for the uninsured.

The good news is that a growing number of legislators in both parties recognizes the need. In each of the last two years, Congress has increased funding for the community health centers by about $100 million--to some $1 billion in all. Now, Sens. Christopher S. Bond (R-Mo.) and Ernest F. Hollings (D-S.C.) have recruited more than 60 of their colleagues to support a $150-million increase this year--the first installment in what they hope will be a five-year program to double funding for the centers to $2 billion. Equally important, bipartisan coalitions in both chambers are pushing legislation to ensure that the centers’ Medicaid payments are increased to reflect the extra services (such as translation and transportation) they provide.

Along a separate track, the Clinton administration has launched a promising initiative to strengthen the links between the safety-net providers in needy communities. Typically the uninsured receive care in a fragmentary and episodic way--often in expensive emergency rooms, where they are treated by physicians who know nothing about their medical history and may never see them again. The administration is providing grants to help communities improve coordination in ways that both save money and allow families to receive more rational, sustained care.

Sunset Park shows the enormous payoff such efforts can produce. The Park Ridge center is part of the Sunset Park Family Health Center Network, an extraordinary constellation of 40 primary care, mental health, childhood development and school-based clinics revolving around the Lutheran Medical Center, a 500-bed hospital here. The network has created a virtually seamless system of care. All patients, insured or not, are assigned a set of records that follows them through every visit to any site in the network. They choose their own primary-care doctor, who replaces the emergency room as their first point of care. Even for its uninsured patients, the network can use its relationship with the hospital to guarantee referrals to specialists. “From the family’s point of view, we can help them navigate whatever is needed,” says Merle Cunningham, the network’s medical director.

Increasingly, that includes services beyond health care. The Sunset Park network has displayed a sense of synergy that would make any Information Age conglomerate proud. Jim Stiles, the network’s dynamic executive director, has steered it into day care, preschool and adult literacy programs; it now even routinely distributes free books at its health care clinics (complete with a prescription from the attending doctor) to encourage parents to read to their young children. With this inspiring breadth of vision, the network is evolving into a modern version of the settlement houses that eased the path into American life for the huddled masses who flocked here from Europe a century ago.

Not every community’s health providers will interpret their mission so creatively. But simply ensuring more rational and thorough care for the uninsured is a mission worthy enough. There’s no consensus yet in Washington on how to reduce the number of uninsured, but in the meantime there ought to be a consensus to strengthen the institutions that are caring for them today.

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See current and past Brownstein columns on The Times’ Web site at: https://www.latimes.com/brownstein.