Carmen Martinez, a cafeteria worker who helps support her family in El Salvador on minimum wage, was among dozens who lined up outside the Rotacare Clinic -– Monterey County’s only free clinic –- on a recent Wednesday. Martinez needed a prescription to ease her asthma symptoms.

In Monterey County, an estimated 68,000 people lack health insurance, according to researchers at the UCLA School of Public Health, and many can’t afford the medical care they need. The Rotacare Clinic, staffed by volunteers and funded by local Rotary Clubs, opens just one evening a week in Seaside, about 15 miles west of Salinas. It’s housed in a county-run health center, which also cares for the poor. But some in the queue said they can’t even afford the county’s reduced rates.

A 50-year old man, who didn’t want his name used, is on his feet constantly as a part-time bellman at a pricey Carmel hotel. But now he’s limping because of a sore knee, and he’s at the clinic to find out what’s wrong.

“I haven’t seen a doctor in 20 years,” he said.

The need for healthcare is overwhelming and it’s been growing recently, said Pamela Norton, who has directed the once-weekly clinic for 17 years.

“We are their only means of care,” Norton said of the men, women and kids who fill the clinic waiting room.

Relief will come for some when the Patient Protection and Affordable Health Act, or federal heath reform goes into full effect in 2014. County officials predict that 23,000 uninsured residents will join the Medi-Cal rolls, and the federal government will foot the bill.

Some people will get help as early as this September from the state’s Low Income Health Program, which will use federal dollars to expand care to people previously excluded from Medi-Cal benefits. Adults ages 19 – 64 who earn less than the federal poverty level of $10,890 annually, and who’d previously been disqualified from Medi-Cal because they have no children at home, can now apply for benefits. The federal funds, called the Bridge to Reform program, will help counties get a head start on Medi-Cal expansion and the coming federal healthcare reform.

Eleven thousand Monterey County residents are expected to be eligible, according to an estimate by the UCLA Center for Public Health Research.

But the county can only afford to insure 1,000 to 1,500 of them this year, even though the federal government will match its spending dollar for dollar.

“We don’t have the resources to meet the need,” said Elsa Jimenez, a management analyst for the Monterey County Health Department.

Most of the state’s counties have set similar enrollment limits and restricted the program to their poorest residents. But seven counties, including Alameda, Riverside and Yolo, will extend benefits to those who earn as much $21,180 a year for a single individual.

Still, Jimenez argued that the Monterey program will make a real difference despite its modest size.

Reducing ER visits

County officials will test the idea, laid out in the Affordable Care Act, that more consistent medical attention can improve patients’ overall health, and save the county money on costly ER visits.

The county plans a full range of health services for the newly insured, whose only previous options had been the emergency room, the free clinic, or the county’s medically indigent adult program, which offers limited acute care.

Dr. Craig Walls, who heads the emergency department at Monterey’s county hospital, Natividad Medical Center, said his ER census has almost doubled from five years ago, from 70 patients a day to 128.

“We have some patients who come every day. Some patients come in on an ambulance every day. We have patients who are here more than I am,” Walls said.

To steer the new Medi-cal enrollees away from the ER, they’ll be assigned to county health centers where social workers and case managers will help them navigate regular appointments, lab tests, preventive and specialty care.

“We want to show that by offering more services we can reduce costs,” Jimenez said.

Improving mental healthcare

The county has also aligned itself with federal health reform in moving mental health practitioners into its clinics, and allowing patients to get mental and physical health care under one roof.

“Taking care of mental health is huge,” Walls noted. “If you’re talking to God, chances are you’re not going to be checking your blood sugar.”

A 2006 report by the National Association of State Mental Health Directors found that people with serious mental illness die 25 years younger on average than those in the general population, mostly of diseases related to smoking, alcohol and drug abuse and lack of medical care.

Likewise, people with serious medical conditions are more inclined to also suffer from mental illness.

“These things track really tightly,” Walls said. “Depression and adjustment disorder are tied right in with diabetes.”

Dr. Gerard Fernandez, a psychiatrist who made the move from a behavioral health center to the county’s Seaside Clinic several months ago, said he’s already seen results. A man recently came in complaining of panic attacks and heart palpitations. He worried he was having a heart attack.

“Since I’m here, I was able to do an EKG and talk to the primary care doctor,” Fernandez said.

Within an hour, the two doctors determined the patient’s heart was fine.

“He might have ended up in the ER,” Fernandez said, if he’d had to wait days for a medical referral.

“We were able to shorten his suffering.”

Preparing for the flood

In addition to mental health care, Jimenez said, Monterey County’s program will focus on treating and preventing some of the most common serious medical problems: COPD (chronic obstructive pulmonary disorder), asthma, chronic pain, diabetes and heart failure.

Shoring up the health of the county’s neediest residents now will reduce at least some pent-up demand when a flood of people are newly insured in three years, Jimenez said.

But, many in Monterey County will remain outside the healthcare system because they’re undocumented and ineligible for benefits under federal health reform. Jimenez said she doesn’t know how many because reliable data aren’t available.

Among them are the Carmel hotel bellman, who got a diagnosis of arthritis and high cholesterol, and Martinez, the cafeteria worker with asthma.

Norton said 80 percent of her clients, many of whom work in the local tourism industry, are in the same situation, and she doesn’t expect either their needs or long lines at her clinic to dwindle, even when federal health reform kicks in.