D.C.’s health-care restructuring puts the squeeze on the city’s nonprofit clinics.

The health-care crisis that erupted in D.C. in the autumn of 1997 was supposed to have marked a turning point in the ongoing saga of city government’s tortured relationship with the patchwork of nonprofit agencies that fill its public-health gaps. City officials had failed to pay out over $500,000 in reimbursements since early that summer, and as a result, several agencies that had contracted with the city to secure housing for indigent people with AIDS were about to go belly-up. In November 1997, a phalanx of D.C. Department of Health officials stood before an angry crowd of representatives from 60 health-care agencies and promised changes. The money owed to contractors would be paid immediately, the officials said. The crisis would be averted, and the recurring problems with compensation for services would be put to an end.

Many things have indeed changed since then. A new administration has taken over, along with a new D.C. Department of Health chief, and soon there will be an entirely new $80 million privately run system for providing health care to the city’s 65,000 uninsured.

The District’s 13 nonprofit health clinics, which offer primary care to an estimated two-thirds of the city’s uninsured residents, however, are worried that they’re in for more of the same old thing: shouldering the vast majority of D.C.’s low-income patient load without adequate compensation. The city’s payments have become more reliable under Mayor Anthony A. Williams, but several clinic directors grumble that checks often come late or at the last minute. Furthermore, they now complain that their concerns—and those of their collective thousands of patients—have gone largely ignored as yet another funding crisis has percolated and the debate over D.C. General Hospital’s pending closure has raged.

Already, more uninsured city residents are showing up at the doors of D.C.’s nonprofit clinics. In January 2001, as part of a downsizing ordered by the city’s financial control board, the Public Benefits Corp. (PBC), which runs D.C. General, closed two of its eight community clinics, located in Adams Morgan, at 2250 Champlain St. NW, and in Benning Heights, at 4650 Benning Road SE. The facilities closed by the PBC handled more than 20,000 patient visits a year, and those who seek care there now are redirected instead to the two closest existing PBC clinics, each of which is several miles and bus lines away from the now-shuttered sites.

Some area patients have chosen to make the journey to the alternative PBC sites, but many of them have instead chosen nonprofit clinics in their own neighborhoods. Not only has this migration threatened the continuity of care these patients receive, but it has strained many of the already overburdened nonprofit clinics to the breaking point.

“It’s beginning to stretch our existing resources,” warns Vincent Keane, director of Unity Health Care, whose network of clinics already treats approximately 30,000 patients a year, including an uninsured patient load that exceeds the number served by the PBC clinics or any of the other nonprofit facilities in the District. “At this point, it hasn’t reached crisis proportions,” Keane continues, “but there really has been an increase, and we are concerned about the long term….We don’t turn away people. But there’ll come a time when even an entity like ours will be overstretched. You can only see so many patients a day.”

Washington Free Clinic Director Sharon Zalewski says her staff has seen a steady stream of new patients to her clinic, located at 16th and Newton Streets NW, with a particular increase in undocumented Latino immigrants seeking prenatal care—one of the services that was in highest demand at the PBC’s Adams Morgan site.

Part of the reason that the Washington Free Clinic has been inundated with this new clientele, asserts Zalewski, is complaints by patients that the PBC’s Walker-Jones Clinic, at 1100 1st St. NW, to which PBC Adams Morgan clinic patients have been shunted, has an inadequate number of Spanish-speaking staff.

Whatever the reasons that more patients are showing up at her clinic, Zalewski warns that the Washington Free Clinic can welcome only so many more of them without reimbursement from the city. “There’s a large number of uninsured people in the District, and nonprofit clinics already take care of two-thirds of those,” she sighs. “If there’s another portion that’s displaced, that puts a lot of pressure on the providers.”

In Adams Morgan and elsewhere in the city, some local health-care professionals suggest that this squeeze on clinics is indeed nothing new. As PBC Director of Public Affairs Bill Jones readily offers, the city-funded Adams Morgan site never had the capacity to serve the needs of the area’s sizable homeless and undocumented immigrant populations, because of what he argues was inadequate public financing. As a result, the neighborhood has been seeded with nonprofit health-care providers that act as a private safety net for those who fall through public health safeguards.

The overwhelming fear among the nonprofit clinics, however, is that with no public clinic at all, and no additional public financing for the nonprofits, their vital net won’t last much longer.

“We can’t absorb 25,000 patients,” says the Whitman-Walker Clinic’s Pat Hawkins, who serves as the acting chair of the board of the Nonprofit Clinic Consortium (NPCC)—an umbrella group for 13 of the city’s nonprofits. “No nonprofit clinic could afford this without certainty of payment.”

Ward 1 Councilmember Jim Graham, who represents Adams Morgan, stepped in to facilitate a meeting between the Health Department and his area’s nonprofit providers in late January, shortly after the two PBC clinics closed. They wanted to discuss not only the closure of the PBC clinics, but their role in the long-term plans for revamping the public health system as well. At that meeting, the NPCC submitted a proposal for dealing with the immediate fallout from the shutdown of the Adams Morgan and Benning Heights sites. NPCC officials suggested offering patients vouchers that they could use wherever they decided to seek care. The provider would then cash those vouchers at the city’s till.

Up until this week, the NPCC hadn’t heard a word back from the Health Department, and fears that the city would ignore the problem until it became a crisis were rekindled. To highlight the urgency of their situation, NPCC members began rattling sabers and making phone calls in preparation for another tense confrontation, and the group’s director, Robert Cosby, sent a follow-up request to the department.

Finally, on March 12, the Department of Health approved the consortium’s proposal for compensating nonprofits in the short term. “We are going to work with them,” assured Deputy Director for Primary Care and Prevention Planning Andrew Schamess. “We are going to work something out with them.”

Under the proposal, which the city’s financial control board must also approve, patients who showed up at nonprofit clinics and stated that they had previously sought care at the Adams Morgan or Benning Heights PBC sites would fill out a voucher that the nonprofit provider would submit to the city for payment. This system would be in effect through early April, when an entirely new one would, theoretically, be developed in conjunction with the mayor’s redesign of public health in D.C. To further ease the strain, the Health Department would also begin working with the Washington Free Clinic to determine if it could expand its services into the Adams Morgan facility left vacant by the PBC.

Schamess explains that the department did not respond more promptly because it had hoped the city would first resolve its ongoing negotiations with Greater Southeast Community Hospital, which is expected to assume the city’s public-health-care contract from the PBC by the end of March.

The NPCC’s Cosby acknowledges that discussions with the city have also been complicated by the obvious self-interest involved for some of the consortium members. For instance, not only does the Washington Free Clinic stand to expand into a new space if the short-term proposal goes through, but Unity Health Care is among the top names being discussed to work with Greater Southeast in administering new public clinics.

Nevertheless, Cosby argues, the department’s willingness to put the issue on a back burner reflects its view of the nonprofit clinics as second-tier providers, when in actuality they serve far more uninsured people than the PBC does now or than Greater Southeast will in the future in its new role as health-care provider for the city’s indigent.

“I think anyone would say that the process was important,” says Cosby upon learning that the Health Department has approved the NPCC payment proposal. “This whole series of issues, as it relates to the PBC closings, has been an enlightening one. The community’s under the belief that the only people who need a safety net is the one-third served by the PBC.”

Zalewski concurs with Cosby’s assessment. “It’s really the first time the District has acknowledged our role in serving a large number of patients,” she says, “and I would hope that more funds will follow.”

Schamess promises they will. He also believes that the new relationship between the city and the nonprofit clinics will vastly improve as a result of the city’s upcoming health-policy reorganization. Clinic administrators routinely complain that under current policy, their patients are locked out of the benefits provided to uninsured patients who seek primary care at PBC clinics. They argue, for instance, that the existing process of referring uninsured patients to specialists is cumbersome at best and that their patients have no access whatsoever to D.C. General’s public pharmacy. Susan Wallin, administrator of Columbia Road Health Services at 1660 Columbia Road NW, says that her clinic is forced to rely on pharmaceutical company largess and donated drug samples to treat chronic illnesses such as diabetes under the current system.

“That’s gonna change,” Schamess declares emphatically. He explains that the new system will bring nonprofit providers that meet city standards into the fold. They will be compensated for treating uninsured patients, the referral process for those patients will be streamlined, and they will have access to the public pharmacy.

For Juan Romagoza, executive director of La Clinica del Pueblo in Mount Pleasant, such promises represent a light at the end of a bleak tunnel. Romagoza says that he has no idea if more patients came to his clinic following the closure of the PBC site, because his staff was already so overwhelmed that it regularly turned people away. In Romagoza’s view, the crisis started long ago. “The status quo does not work,” he says. “We are talking a crisis situation. This isn’t working, and we have to reform it. All of the nonprofit clinics are giving to the max, but that has been the case all along.”

Counting himself among the “cautiously optimistic,” Cosby likes Schamess’ promises as well. Seamlessly incorporating the nonprofits into a larger network of public-financed care would break new ground, he adds. Given the “hiccups” in the city’s history with nonprofit agencies in general, however, he’s taking a cautious view of even the short-term arrangement, let alone a pioneering effort to place nonprofit clinics under the city’s big tent.

“We are very hopeful that this will take place. We obviously have reservations, because there’s nothing we have that we can sign on the dotted line,” Cosby says. “It’s not clear until the check clears.” CP