Sondra Leonard of Jessup can't control her diabetes without the free samples of medication provided by the Health Alliance for Patients in Need, a free clinic in Columbia for chronically ill patients. She receives no health benefits at work, earning $10 an hour in a basic service job.
"If they don't have it, I can't afford it," she said of the medications. "It's just totally out of reach."
Health Alliance, staffed by volunteer physicians and nurses, is one link in an incomplete safety net for people in Howard County who can't afford care.
There is a national crisis in health care, experts agree, with more than 11 percent of Americans facing disease and illness without insurance. In Maryland, 9.9 percent of the population lacked medical insurance in 2000, according to a survey by the federal Centers for Disease Control and Prevention.
In contrast, less than 5 percent of Howard County's residents - fewer than 15,000 - lacked insurance, that survey showed. But Howard's health establishment is not satisfied.
At a time when health care costs are soaring and there is no promise of universal coverage, Howard health organizations are working to identify those denied basic care in this affluent community with the aim of providing them with affordable services. Often the only option for patients who don't qualify for Medicaid, the federal health insurance program for the poor, is the emergency room of Howard County General Hospital.
"The main question for Howard County is how do we build on the framework [of care available to the poor] that exists now and how to involve the medical community [in expanding access to care]," said Richard M. Krieg, president and chief executive officer of the Horizon Foundation, a nonprofit organization dedicated to county health care issues.
A safety net
The Health Alliance has long been a key source of care for county residents who do not have insurance. Concerned about uninsured patients with chronic diseases, a group of physicians and nurses started the foundation in 1994.
Since 1998, the volunteer physicians and nurses of the alliance have been providing free care in a clinic across the street from the hospital to uninsured adult patients with chronic conditions such as diabetes or heart disease. Last year, the clinic had more than 1,300 patient visits.
The Health Alliance hopes to expand the clinic's services in March to include routine care two Thursdays a month for poor children who lack government health insurance. It is unclear how many children would be eligible.
The Howard County Health Department also has been looking for ways to expand the medical safety net.
In April, it established a free dental clinic on U.S. 40 near Rogers Avenue in Ellicott City for children identified through a school screening program as needing dental care but lacking insurance. Adults referred to the dental clinic by Health Alliance are also treated.
Two dentists have been hired by the county to staff the clinic Mondays and Tuesdays. Volunteer specialists, including oral surgeons and orthodontists, supplement their work one half-day each Wednesday.
The county's oral health program, including education and oral cancer screening as well as the clinic, is funded by two state grants and one from the Horizon Foundation.
About 78 percent of students screened had untreated decay - 10 percent with disease so bad it required immediate treatment, according to Dr. Wendy Matt, director of the oral health program. Many factors, including a lack of insurance or fluoridated water, contributed to their condition, she said.
The program has served more than 130 patients in the past six months. Although the service has not been advertised, appointments are booked two to three months in advance.
Howard County also offers specific services that affect public health, such as screening for preventable cancers and sexually transmitted diseases. But the county can't offer comprehensive care, said Penny Borenstein, health officer for the state Department of Health and Mental Hygiene in Howard.
"We recognize that we're in much better shape than most communities in America," she said. But "it leaves me wanting for additional resources to provide care to even the relatively small population of uninsured."
"While our problems are always smaller, it doesn't make them any less a problem," agreed Pamela Mack, the Health Alliance's executive director.
"In the absence of a national health plan what we're left with is trying to expand on available services, pro bono services of health care providers," Borenstein said.
A health and human services study conducted by the county Department of Planning and Zoning last year shows that more than 14 percent of the county's residents depend on government health insurance - Medicare, Medicaid or Maryland Children's Health Insurance Program (M-CHIP).
More than 3,000 children in Howard County are registered for M-CHIP - children in families earning less than 200 percent of the poverty level (about $36,000 a year for a family of four), according to the state Department of Health and Mental Hygiene. About 98 percent of those eligible for M-CHIP in Howard are registered, according to Howard hospital statistics.
Because eligibility requirements for Medicaid, the basic federal health care program for the poor, are so daunting (income below $25,000 a year for a family of four and strictly limited assets), many of Howard's working poor are not covered. Almost 9,000 Howard households have income under $25,000 a year.
Hispanic population
In addition, Howard's small but growing population of foreign-born residents, particularly from Latin America, do not qualify for such government assistance if they are undocumented. Community leaders estimate that about 15,000 Hispanic immigrants live in the county, more than half of whom are undocumented. Howard's Hispanic population was estimated in the 2000 census at about 7,500.
"The biggest problem with not having insurance is that people delay care for minor problems and wind up needing more costly and more involved care," Borenstein said. "People simply cannot afford to pay out of pocket for health care, especially those with low family incomes "
Federal law - the Emergency Treatment and Active Labor Act - requires that hospitals provide at least a medical screening exam to all patients who present themselves at a hospital. But that is an expensive way to meet the needs of people without insurance. "All of us pay higher insurance premiums for indigent care," Mack said.
Howard County General Hospital spends more than $500,000 a year on "charity care" for patients who meet financial guidelines, said Paul M. Gleichauf, senior vice president of managed care, planning and marketing.
"There is no question that going to the hospital is an expensive proposition," he said. "It's not necessarily the best place to go for primary care. We have to have physicians here 24 hours a day, seven days a week. We have to pay for three shifts of staff."
Vision and dental
More inaccessible to the poor are vision and dental services, even with the county's new free clinic. "It really has been a void in health care even amongst people who are insured," Borenstein said. Those covered by government insurance are technically eligible for dental services, but the allowed reimbursements are only about half of dental fees typically charged in the county. As a consequence, few dentists in the county accept Medicaid or Medicare patients.
Only three county dentists accept M-CHIP patients and none are accepting new patients, said Dr. Wendy Matt, the dental clinic's program director. "Theoretically they would have access to care, but these patients really don't have any place to go," she said.
Language can affect access, as well. Of the patients seen at the dental clinic, 48 percent require a translator, usually Spanish, Matt said.
But it is more than simply translating the words, say advocates for the Hispanic community.
Several are working toward establishing Alianza de la Comunidad, an organization that would be an advocate for the needs of the Hispanic population, particularly in health care.
"The Hispanic minority in Howard County is the needier group and the one that is less likely to fight for their rights because they are newcomers in this area," said Marta Goodman, a member of Alianza's steering committee and an English for Speakers of Other Languages (ESOL) liaison for the Howard County school system.
Last year, Alianza members contacted the Health Alliance, worried about the health of foreign-born Hispanic children who were not eligible for M-CHIP.
A few days later, representatives of the Health Alliance were approached by pediatricians from the Howard County Muslim Council looking for opportunities to provide volunteer service in the community. Helping the Hispanic children and others who do not have insurance coverage seemed an obvious choice.
The Muslim doctors and a few other volunteers agreed to provide pediatric care at the Health Alliance clinic two Thursdays a month. They hope to start in March if pediatric medical equipment arrives on time.
"This was a marvelous confluence of events," Mack said of the Health Alliance. "There was a need espoused by the Hispanic community, and the Muslim community said, 'We can meet that need.' "
Many of those who lack health care are not asking for free services, Borenstein said. "We believe patients are willing to pay what they can afford," she said.
Health Alliance patients are asked to make a voluntary $5 co- payment. The dental clinic will soon move to a sliding-fee scale.
"I think the [members of the] Hispanic population that are here are willing to pay according to their means," Goodman said. "If we had a sliding-scale clinic, it would be the best thing not only for them but also for community in general."
Gleichauf, the Howard hospital executive, said that the donated services may not be the best plan for the future because the volunteer programs may not be sustainable in the face of growing needs.
The hospital included the issue of how best to increase access to health care in its 2001 strategic plan after affiliating with Johns Hopkins Health. To that end, it formed a committee of community leaders, including Mack, Borenstein and Krieg, to study the problem.
"Our task was to get our arms around" where care is lacking in the community, Gleichauf said.
The committee is working with the county Health Department and the Horizon Foundation to find groups that lack health care and identify ways to help them, such as seeking financing for a community health center.
The Horizon Foundation also established the Center for Community Health Strategies late last year to develop plans to provide affordable care and to deal with other health policy questions that will develop as Howard's population matures.
"It's designed to fill a gap - to bring hard information and best practices into the picture when trying to solve a problem in the community," Krieg said.
But officials recognize it will take more than strategic planning to fill the needs of those in Howard who can't afford care.
Is what is being done now enough?
"No," Gleichauf said. "I hate saying that, but we're all wrestling with scarce resources."