When Clare Ross couldn’t afford her $300 health insurance premium on top of her student loan payments, she turned to the Santa Cruz Women’s Health Center.

The safety-net clinic was founded in 1974 to serve only women, many of whom, like Ross, couldn’t get care elsewhere. But the center is now expanding its services in order to serve a wider demographic and receive federal funding under the Affordable Care Act.

Policy experts say health centers like this one will be instrumental in implementing the federal health law. Some of these health centers were founded decades ago to serve certain populations — such as women, ethnic minorities and LGBTQ people — but they are changing under health reform. While many see the expansion of services as beneficial, others worry that these centers could lose the ethos they were founded upon, potentially alienating the populations they were originally designed to serve.

“A lot of people are asking, ‘Are you losing your roots? You’re changing so much,’” said Leslie Conner, executive director of the Santa Cruz Community Health Centers, an umbrella organization for the women’s center and its new clinic that also serves men.

“It is tricky to navigate,” she said. “We have changed dramatically. On the other hand we’re very clear on our mission: Access to healthcare is a human right. Our roots are in empowerment, advocacy and social justice.”

Changes due to federal laws

The Santa Cruz women’s center has changed significantly this year. It was founded four decades ago by University of California Santa Cruz students as a feminist women’s health collective. It offered counseling, pregnancy tests, transportation to Oakland for abortions and support groups on women’s health issues at a time when the county had no female gynecologists. The center has been gradually growing over the years to accommodate the shifting needs of the community, adding bilingual providers and accepting children, for example.

In May, the center built a new clinic, the 9,000-square-foot East Cliff Family Health Center, also in Santa Cruz. The center can now see twice the number of patients, many of whom are men. It opened to men for the first time in 2012 when it became a Federally Qualified Health Center. The center also accepts children.

A combination of federal funding for health centers through the Affordable Care Act, more patients becoming insured and support from hospitals and donors is helping to grow the network of health centers that primarily serve low-income people. The Santa Cruz center, for example, hopes that many of its remaining 40 to 45 percent of uninsured patients will get coverage this year, bringing in additional revenue.

Hospitals throughout the state are also contributing to health center expansions, which provide primary care for low-income patients who might otherwise end up in their emergency rooms.

One of the biggest sources of funding for these expansions is $11 billion in federal funding for health centers through the Affordable Care Act. The U.S. Health and Human Services Department says health centers are often veterans in coordinating providers and delivering care that is culturally appropriate and high quality.

Federally qualified centers receive higher reimbursement rates than other California providers when they treat low-income patients. However, the clinics must also abide by federal laws that prohibit discrimination, which means they must be open to all. And with the federal funding comes more regulation and oversight.

“It’s not an easy decision, these boards wrangle with it, but I’ve not met one health center that regretted it,”” said Carmela Castellano-Garcia, president and CEO of the California Primary Care Association that represents almost 1,000 community clinic and health centers in the state, about 600 of which are federally qualified centers.

Expanding services and clientele

The additional funding allows centers to design new programs, Conner said. She’s excited about group medical visits the center has started to offer, which will address issues like anxiety, nutrition, pain and chronic conditions.

The new East Cliff clinic equips the organization with 15 more exam rooms, three behavioral-health counseling rooms, double the providers and social workers, and new staff members who can enroll people in health insurance and assist with legal, housing, transportation and food needs.

It was the providers and an ability to have a more intimate relationship with her doctors that attracted Gloria Nieto to the center five years ago. She switched from Kaiser, where she said visits felt rushed and she often didn’t get personalized care. She got away with neglecting her health until a heart condition required two stents. A day after that surgery she was back in the hospital needing her gall bladder removed.

“When I walked into the women’s health center I was a mess,” she said. She also has diabetes and a long list of other health problems. But center providers listened to her and gave her the community, support and knowledge to turn her life around, she said. She now sits on the center’s board.

While Nieto said she’s sensitive to concerns that the center could lose its focus with the expansion, she thinks it will continue to provide the same level of care.

“There’s still an expertise in providing services to women,” she said. “Nothing gets taken away from those skills by opening the doors to men and children.”

Trying to preserve some specialization

Health centers across the state are facing similar expansion issues. WellSpace Health Inc. in Sacramento started in 1969 as a free substance abuse clinic, but it has dramatically shifted its focus to primary care. Since becoming a Federally Qualified Health Center in 2009, it has grown from fewer than 4,000 patients to 27,000 last year. It now serves mostly children.

It has found ways to preserve some specialization, CEO Jonathan Porteus said. Clients who are dependent on opiates, for example, may be seen on certain days or have a separate waiting room. Or they may have specialized clinics close to more full-service ones.

Jo Kenny, an early founder of the Santa Cruz women’s health collective, and Nieto’s partner, celebrates its evolution to serving a broader group of people and its expanded capabilities such as better integration of behavioral health services.

If a provider has a patient suffering from depression or domestic violence, a staff social worker can now step into the exam room immediately to provide support, Conner said.

“You can’t talk about being physically well if you’re going home and getting beaten up,” Kenny said. “Having that kind of counseling help onsite has incredible ramifications, especially for people in abusive relationships who don’t want their partners to know they’re seeking help,” she said.

While very supportive of the new center, Kenny hopes the original center downtown can be preserved for women. Even 40 years after its founding, women’s health is still marginalized, she said.

Reserving that center for women will depend on whether the new East Cliff site can accommodate all the men seeking services, Conner said.

Ross, 27, who came to the clinic when she was uninsured, enrolled in a health plan this year through Covered California, the state’s insurance exchange. She appreciates the fact that the center was there to help her when she needed it and that she was treated with compassion. Ross said she’s not concerned that the clientele has now expanded to include men.

“Guys totally deserve that same care,” she said.