Brave New Medicine

Claudia Lopez tries to comfort her 9-month-old son Brian as the doctor examines the baby to figure out why he’d been vomiting all night. She explains, in Spanish, why she relies on this low-cost clinic: “I need this place because I make so little at work and I don’t have insurance.” Lopez is 26 years old – a single mother of three – who had to quit school at 14 years old when her parents brought her to the U.S. from Mexico and sent her to work in the fields.

Lopez is a typical patient at Clinicas de Salud del Pueblo – poor and undocumented, but working to provide a better life for her family. Dr. Randolph Gibbs, a family practitioner there, says “The first thing I tell folks is that we don’t care if you have insurance. We don’t care if you’re a citizen. We’re here to practice medicine to provide the best care we can.”

Clinicas de Salud del Pueblo is a network of low-cost clinics in Riverside and Imperial Counties; their name translates as “Community Health Clinic.” Patients pay on a sliding scale according to their income, but none is turned away if he or she can’t pay. Clinicas serves thousands of people a month at their nine clinics, three dental centers, three Nutrition Education Centers and eight WIC voucher distribution sites.

Dr. Gibbs is optimistic that the Affordable Care Act will help improve the health of his low-income clients if it takes full effect in 2014. Although undocumented immigrants will not be eligible for the Act’s subsidized insurance, even if they want to buy it with their own money, he hopes that many of his patients will get insurance and be more likely to see a doctor instead of letting problems fester: “The ACA means doctors will be able to get the necessary tests done in a timely manner, so conditions are diagnosed and treated earlier.”

“People will come more regularly,” adds Eva Romero, manager at the Mecca Clinic, “not just when they are desperate.”

Dr. Gibbs says diabetics need to be seen every three to four months, but some folks won’t come for six months, even if they ran out of medications two months earlier.

Clinicas is reaching out to educate people in the low-income communities in the east Coachella Valley. A team of six women, called “promotoras” are canvassing the trailer parks and visiting churches to make people aware of the services available.

“Thousands of people here lack a medical and dental home,” says Lucy Moreno, the promotora program coordinator. “Forty-five percent of the community in the eastern Coachella Valley needs this program and probably qualify for some type of program or another.”

The promotoras help people apply for Medi-Cal or Riverside County’s Medically Indigent Services Program (MISP), which does not require patients to prove citizenship.

The doctors at Clinicas are enthusiastic about a new program that debuted in January, called Riverside County Healthcare (RCHC). RCHC offers free health insurance to legal residents who make a little too much to qualify for Medi-Cal but still cannot afford insurance. Clinicas is one of only two federally qualified clinics in the county that take RCHC. The other one is 75 miles away in Riverside. That designation is important because it makes Clinicas eligible for limited federal funding. It means they can offer additional services like dental care and treatment for mental health issues.

According to Romero, getting prescriptions through RCHC is still a problem because no local pharmacies work with the program yet. So patients have to go to the county pharmacy in Moreno Valley, just like MISP. She says the county is working to resolve the issue. RCHC is intended to be used as a bridge until the Affordable Care Act goes into full effect, at which point more people will be transitioned to Medi-Cal.

Dr. Gibbs hopes that as healthcare reform is implemented, the need for clinics will diminish. For now, they provide a step up to people until they get more education, get papers, and get a better job with insurance.

Clinicas’ Mecca location is basically a rural family practice, providing primary care. They have a complete clinic with 12 consultation rooms, plus a complete lab with x-ray equipment. They employ ten bilingual medical assistants, a lab tech and a referral coordinator.

Dr. Gibbs says the clinic mainly treats people for chronic diseases like diabetes, hypertension and arthritis. If people need urgent care, Clinicas works them into the schedule rather than packing them off to the emergency room. They make time for acute cases because many of the patients have no car so they can’t drive to the closest ER (20 miles away in Indio). Sometimes patients just give up and forgo treatment.

Romero laments the fact that the government has slashed funding for chiropractic services, which were heavily in demand at the clinics among farm workers. She also says they also lost funding for podiatry, which is crucial for many diabetics.

Low-income patients generally pay $30 per visit. X-rays, trauma care, and sutures are included. For a diabetic, that $30 would cover a blood sugar test and a urine sample and x-rays, but the patient would still have to pay for the outside lab work.

“If we weren’t here,” Dr. Gibbs says, “the ER would have to serve as the family doctor and the cost would be much higher.”

Clinicas has been working hard to cut down on the waiting lists by bringing in more providers to Mecca, Galvez says. “But when we expand services, more patients pour in. We serve a large population of undocumented workers who tend to come out only when they really need something.”

They refer people to outside doctors all the time, Romero says, but the wait time can be long. “They’ve got waiting lists of up to six months for specialties like ophthalmology, nephrology, endocrinology, gastroenterology, and obstetrics.”

Clinics that primarily serve low-wage farm workers also have to overcome significant challenges. Romero says that patients miss a lot of appointments, especially for trips to specialists, because they have problems getting a ride or they can’t afford to take a day off and pay for 2-3 buses. So, the clinic’s referral coordinator tries to help patients arrange for transportation. Riverside County does provide one van that goes from Indio to the County Medical Center in Moreno Valley each day.

Sometimes the doctors have to convince people to try modern medicine in place of the traditional remedies. Mexican traditions teach that you should drink Jamaica or chamomile tea or use cinnamon or honey, or eat lemon for high blood sugar. “People are taught by their parents. But at certain point you understand that you have to see a doctor because you need to get better, “ says Galvez.

A patient’s immigration status is irrelevant to the clinic, Gibbs says. “We don’t ask that. A patient is a patient to me.”

Dr. Gibbs says he recently saw a 70-year-old diabetic who came in with a gangrenous foot that looked like it might have to be amputated. She was reluctant to come in or take medication, thinking that treatment would cost too much. After a week of antibiotic injections, they convinced her to go to the ER at JFK Memorial Hospital in Indio and get admitted. So far, she hasn’t lost her foot.

Gibbs says many of his patients can’t afford the procedures, so they go across the border to get things done in Mexico. They pay cash for dental work, MRI’s and x-rays, then bring the reports back to him for interpretation.

The clinic also treats a great many migrant workers who travel between the Coachella Valley and Bakersfield. The doctors will often give patients a three month supply of medicine to tide them over until they come back.

“Lots of people have their home base in the valley,” Claudia Galvez says. “They live here and travel 2-3 months out of the year to Bakersfield or Guadalupe to continue the grape season. Some of them go all the way to Washington and come back here. By October most of them are back to pick the vegetables. In February they start on the grapes here and then move up to the Central Valley by May.”

However, Mecca is starting to see more migrant farm workers stay year-round, because it’s too expensive to travel and maintain two residences. Often the wives and children will opt to stay behind even if the men follow the work. As a result, the need for clinic services has increased in the valley compared to other places.

The new school complex on Avenue 66 in Mecca has attracted many families who now live here year- round, Galvez says. The parents’ desire to get a good education for their kids has created more permanent population in Mecca.

As a result, the Mecca clinic is looking for another doctor, ideally someone who is bilingual, with family ties to the area. According to Dr. Gibbs, “If we have another good family doctor we’ll be good. We need someone who has an interest in the community and will stay.”

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