Clinics Have Too Little Money for Too Many Chronically Ill Patients

Like many low-income diabetes patients in Southern California, Margarita Vargas shuffled from clinic to clinic in hopes of finding one to treat her.

Nearly blind, she arrived at the Share Our Selves Free Medical and Dental Clinic in Costa Mesa last year, only to be told there was no room for her; she would need to go to a private doctor.

“We went, but when our money ran out, we came back,” Vargas said. Only because Vargas--who has Type II diabetes, the most common among adults--was persistent was she able to break through the nearly closed ranks of the clinic’s diabetes patients, said Mary Moyer, clinic nurse manager.

Vargas’ story is a familiar one in the region’s community clinics. Too often, low-income diabetes patients find themselves turned away, placed on months-long waiting lists to see doctors or charged significant fees to get medical attention at the clinics.

Complicating matters: More and more patients without health insurance treat the disease too late, fighting blindness and amputation in emergency rooms, health experts say.

“Diabetes is a good disease to look at to understand the crisis of the health safety net. Latinos are half of the clinic patients, and they are disproportionately impacted by diabetes,” said Carmela Castellano, chief executive officer of the California Primary Care Assn.

Community clinics, mostly nonprofit organizations with some federal funding, treat the area’s poorest patients who do not have health insurance. Patients with chronic illness require constant, expensive treatment; for diabetes, treatment costs are about $3,000 a year.

Given the clinics’ limited budgets, health care workers have to either force patients with chronic illnesses to wait for spots or refer them elsewhere.

“How bad is it? It is very bad. We have estimated that there are at least 70,000 Latinos in this county with diabetes. Although not all are poor, many don’t have care, either because they don’t have access to these clinics or because they don’t have a diagnosis. Add other [ethnic and racial] groups and you get the bigger picture,” said America Bracho, chief executive officer of Latino Health Access, an Orange County health education organization.

Rosilee Gamboa, executive director of the Sierra Health Center in Fullerton, said fees, waiting lists and referrals vary widely from one clinic to another, so “a person with a problem like diabetes has to shop around. For some patients, that’s very hard to do.”

Hector Lozano, 51, earns $7 an hour as a janitor. Without the clinic in Costa Mesa, “I’m not sure what I would do. When you don’t have insurance, when you don’t have resources, you live by the clinic. There is really no other option.”

Orange County clinic directors say their problem is fierce because there is no county hospital or county-supported clinic to help them. Los Angeles clinic directors, who in some cases get county contracts to provide service, say they are overwhelmed because there are so many patients--about 2.7 million, or 32% of the population--without insurance.

Orange County has given the clinics $20 million in the last 10 years, but that doesn’t begin to cover the need, said Herb Rosenzweig, Health Care Agency deputy director.

Millions of dollars in federal tobacco settlement funds that will be channeled to the clinics could provide some financial relief, he said.

When space runs short, Jackie Cherewick, director of the Huntington Beach Community Clinic, said that diabetic patients and others with chronic conditions are often referred to private doctors.

Why do these doctors treat patients with no money to pay them?

“We beg,” Cherewick said.

Kimberly Wyard, chief executive officer of Northeast Valley Health Corp., which operates nine clinics, said four of the clinics--in Valencia, Canoga Park, San Fernando and Pacoima--that treat diabetes patients closed to all new patients last week.

“The problem is wider than diabetes . . . and the situation is going to get worse. There is a rationing of health care to the uninsured,” Wyard said.

In Los Angeles County, 16% of Latinos older than 40 have diabetes, compared with 8% of whites, 13% of African Americans and 8% of Asian Americans and Pacific Islanders. Such statistics have not been tabulated for Orange County. Castellano estimates that half of community clinic patients in the state are Latino.

Responding to the funding shortage in Orange County, the HealthFunders Partnership, a group of grant donors, gave $2 million to several nonprofit organizations last month. The money will be used to create a statistical picture of diabetes and to treat some patients.

Susan Zepeda, chairwoman of HealthFunders, said the group realized there were patients who had been diagnosed by private doctors

but could not afford follow-up tests and treatment. Without a clear statistical picture, solutions cannot be found, she said.

Type II diabetes in adults is caused by the body’s inability to digest food for energy. The pancreas produces little or no insulin, causing glucose, the body’s main source of fuel, to build up in the blood, overflow into the urine and pass out of the body. Immediate problems include frequent urination and tiredness. Left untreated, diabetes can lead to heart failure, the need for limb amputation and blindness.

Martina Loera, a 54-year-old Santa Ana resident, said when she first became ill, she went to a doctor for the diagnosis. Getting regular care is another matter: The widowed mother of four children cannot afford it.

“I have my ups and downs. When things get pretty bad--usually my feet will swell up or my vision gets a little blurry--I’ll go to a doctor near my house, even go to Tijuana,” Loera said. She has become a regular patient at a clinic.

Like other clinic directors, Rocio Nunez-Magdaleno, whose program Puente a la Salud treats Orange County farm workers, said increased public funding of clinics could lead to less expensive treatment for someone like Loera. Many people do not get tested or treated until problems are severe, she said.

Regular treatment can keep blood sugar levels normal and patients healthy, which costs everyone less money, she said.

“We are talking about blindness and amputation that can be prevented. It’s important that people can get treatment. Diabetes can be managed,” she said.

In Los Angeles County, clinic directors say the money from the most recent of two bailouts from the federal government totaling more than $2 billion will be used by 2005, leaving clinics with county contracts in the lurch.

Assemblyman Tony Cardenas (D-Sylmar) proposed legislation last week that would triple the amount of state funds to primary- care clinics. The legislation would increase state funding from $21 million to $60 million.

Cardenas’ father died of complications of diabetes. Because he did not have health insurance, Cardenas said, his father resisted seeing doctors until he was quite ill.

“My upbringing is typical of the people I represent. There is a need. There is a disproportionate number of working people who don’t get health insurance through work. They don’t have access to health care,” Cardenas said.

The monetary costs wind up being even higher when patients seek more expensive treatment in emergency rooms and leave hospitals without paying the bills, he said.

Until more funding comes through, Castellano said, the clinics are working to track diabetes patients to be more efficient, and searching for private partnerships to bolster their budgets.

Vargas just hopes that the free care she receives in Costa Mesa won’t disappear: “I’m not sure what I would do if I didn’t have this clinic. I probably would be very, very sick.”