When you're poor and sick, you can go to an emergency room and federal law says they have to treat you. But when you're poor and want to try to stay well, you might not get the care you need.
For more than 18 million Americans trying to stay healthy, primary care is accessible mainly through thousands of community health center clinics.
In some towns they're the "free clinic" or the community clinic or the evening clinic, or simply the place where you can go and get seen, paying what you can, sometimes even if it's nothing.
"I tend to go about every three months to get blood work done,'' said Mark Southern, an uninsured diabetes patient at Georgia Mountain Health Services in Morganton, Ga. "If something occurs, I go back. No other place is close. I can't afford to go anyplace else."
A recent study by the Morehouse School of Medicine in Atlanta found that emergency room visits were one-third fewer in counties with health centers. And the National Association of Community Health Centers -- which represents federally subsidized clinics -- says a complete network of centers across the country could reduce spending on ER care by more than $18 billion a year.
"Free clinics" generally operate primarily with volunteer staff, either as independent charities or as an arm of another community or faith-based organization, and mainly serve patients who have no insurance and little or no income. They work mainly with charitable donations from health providers and others, although some get limited government help, too.
While some people who use federally subsidized community centers have Medicare, Medicaid or private health insurance, about 40 percent also have no health coverage and pay only what they can on a sliding scale.
A Scripps Howard News Service review found that access to primary care is deteriorating across much of the country, driving millions of people outside traditional family practices, or leaving them without care. While safety net health centers take up some of the slack, experts say they're not able to serve as a medical home for everyone left out of a relationship with a doctor, even with more charitable or government support. The federal government subsidizes community health centers with grants totaling about $2 billion a year, yet this covers only about half of uninsured patient costs. The centers try to cover the rest from grants by state and local governments, and charitable donations.
The recent federal economic stimulus spending package recognized the importance of the centers, providing $500 million in extra funding over two years in anticipation that more people would flock to them.
And the government is also planning to spend $1.5 billion toward the construction of 126 new community health centers around the country, which are expected to serve an additional 700,000 people.
At the Public Health Management Corp. Health Connection in north Philadelphia, people who once relied on Temple University's hospital emergency room now have a place that specializes in preventive care.
"We take anyone, regardless of their ability to pay. There have been times when 50 to 60 percent of our caseload is uninsured,'' said Nancy Rothman, a nurse practitioner and instructor at Temple who helped found the clinic.
The clinic and three affiliated operations around Philadelphia are run by nurse practitioners.
"I think nurses look at health very holistically," Rothman said. "When someone comes in with a chief complaint, a nurse isn't just going to treat that complaint. She's going to take a family history and do a physical and is more likely to find other things that might be caught earlier."
Nurses are critical in many community health centers because primary care doctors -- the mainstays of the clinics -- are hard to find and harder to keep. A recent report from the National Association of Community Health Centers found the clinics were short 2,000 family doctors and would need 29,000 more doctors to cover everyone.
"We're small and we're flexible," Rothman said. "If someone walks in with a sick child, we'll try and see them. If we can't right then, we'll send them home for an hour or two and then call them when there's an opening.
"We're right in the heart of the neighborhood, so we can work with people who are usually walking to appointments."
Rothman recalled how a community leader came in to see a nurse practitioner who "took a lot of time with her, did a complete work up. She had been treated by a physician for years for stomach ulcers. But the NP found that her real problem was with her gall bladder. She said all those years, she went to the doctor and he never touched her, just shuttled her in and out. So she had her gall bladder removed and no more discomfort.
"That's what time and a little connectedness can do for you," Rothman said.

E-mail Lee Bowman at bowmanl(at)shns.com. (Distributed by Scripps Howard News Service, http://www.scrippsnews.com)
With DOCS-EMERGENCY, DOCS-FACTBOX, DOCS-DATABASE