A Lawrence clinic's success is a reminder of a national failure to provide health care for those who fall between the cracks.
Like millions of Americans, Larry and Tressa Bowers of Lawrence work hard and don't make as much money as they'd like, and from time to time, they and their two daughters, ages 6 and 2, get sick and need doctors.
And like an estimated 40 million Americans, they don't have health insurance but make too much money to qualify for the government's health program for the poor, Medicaid.
They had a rough winter. The kids got bronchial and ear infections, Tressa got the flu and Larry underwent treatment for Raynaud's disease, which causes painful spasms in the arteries of his fingers.
"And we are healthy people," said Tressa Bowers, 37, who runs a day-care center in her home. "We take our vitamins and eat properly. It's just that the bugs have been going around."
To get well, they have turned to Douglas County's only clinic for the uninsured, Health Care Access, at 1920 Moodie Rd. in Lawrence.
"There's no way I could have had all the treatments I've had without it," said Larry Bowers, 42, who works in construction.
Caught in the middle
The clinic, which opened in June 1989, has been a godsend for the Bowers and thousands of others who once had no source of health care other than the emergency room.
But Health Care Access is also a symbol of the nation's lingering and still unresolved health care problem -- the one President Clinton was unable to fix two years ago.
Since then, insurers have tightened their control of health care costs, but another 3 million Americans have joined the ranks of the uninsured.
Now, as another presidential election season unfolds, the uninsured remain snagged in a peculiar health care system that favors the poorest, the wealthiest and those with employer-paid insurance.
Millions of Americans, among them more than 9,000 in Douglas County, are caught in the middle without any form of insurance. They are retirees, the unemployed, the self-employed and low-wage workers whose employers do not pay for insurance.
While some employers and workers have seen their premiums drop or at least stabilize since 1994, those market-driven reforms haven't helped the uninsured.
"All the reform is really aimed at controlling costs for people who are already in the system," said Judy Eyerly, executive director of Health Care Access. "If fewer and fewer people are in the system, then we're failing. We're not doing anything to improve the access or to take care of the people who are already out of that system."
In a sense, Health Care Access is like a health maintenance organization for the working poor. Patients, who can't have insurance and must meet income guidelines that are less restrictive than Medicaid's, don't pay premiums. But they are asked to pay a $10 fee for each visit.
Primary care doctors and nurses do basic checkups and make referrals to volunteer specialists. They also limit the treatment they offer so the costs don't get out of control -- just like private HMOs watch their costs. For instance, Health Care Access doesn't provide dental care, except in emergencies.
Health Care Access is funded through the Kansas Department of Health and Environment as a result of state legislation that provides for community-based primary care. HCA also receives funding from the Douglas County United Way and through donations of supplies and services from local health care workers.
To those who say the nation should follow the lead of Oregon -- where health services for the poor are rationed but offered to more people -- Eyerly responds that without any government mandate, health care is already rationed in many states, including Kansas.
"Even in a private-pay system, care is rationed under managed care because there's a gate keeper," Eyerly said. "They decide what services you get and what services you don't get. In very real terms, we ration care here at Health Care Access. We have a limited amount of resources, and we have to decide how they go around.
"We often joke around here that we are a microcosm of what health care reform at this point in time is about."
Congress is working on bills to solve two of the biggest problems in health insurance: the denial of coverage to people with a pre-existing medical condition, and the ``job lock'' of workers who can't change jobs because they would lose health insurance.
But those bills won't help the Bowers pay the $500 a month that it would cost them to insure their family. Larry has faced occasional layoffs, and Tressa's day-care business has been slow. If things don't improve, they'll make less than $16,000 this year.
"There's a huge number of people who are working, have cars, but don't have enough to buy insurance," said Dr. Laird Ingham, a Lawrence internist who volunteers a few hours a month at Health Care Access. "If you're not employed with a company that can give you insurance, it's really tough. The bottom line is, in my mind, we've painted ourselves into a corner. We've got this great technology out there, but we can't afford it."
Last year 1,421 people made 4,237 visits to Health Care Access, where they were examined by the clinic's nurse practitioner or by 120 volunteer health professionals, including doctors, physical therapists and others.
While the number of patients was down slightly from 1994, 900 of them were new to the clinic, double the number of new patients the year before. Activity is up dramatically in the first two months of 1996. The 450 appointments in February alone is nearly 30 percent ahead of last year's monthly average.
Eyerly attributes the clinic's growth to rising demand -- linked in part to population growth in Lawrence -- and to wider recognition that the clinic is available.
To some extent, Health Care Access, and clinics like it elsewhere, can be seen as the solution to the health care crisis -- the place for those who have nowhere else to turn.
But it operates on a shoestring budget of $185,000 a year, offering only limited primary care services, not the type of ongoing preventive medicine that would keep people healthy in the first place.
"It's a Band-Aid," said Kay Kent, director of the Lawrence-Douglas County Health Department. "It really says that we don't make the provision of health care a real high priority in this country. Keep in mind that not every community has a Health Care Access. In Douglas County, I feel we're most fortunate to have this service. It was not easy when we didn't have it."
In the past, the Bowers avoided doctors altogether because they couldn't afford the bills.
"We don't like to live on assistance if we don't absolutely have to," Tressa Bowers said. "If we ever come into any type of money, we will give them back what they've given to us because they've kept our family healthy. We truly appreciate them.
"They are very kind people, and they don't make you feel uncomfortable when you can't pay. They don't make you feel like a lowlife or scum. They make you feel like decent people."