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Model Cities Health Center in St. Paul, Minn., defies the image some may have of such facilities as overcrowded, worn and barely scraping by on meager resources.

The clinic, which serves mainly low- and moderate-income patients who are uninsured or on Medicaid, is newly renovated. It is buzzing with new patients and offering an enhanced menu of services. The waiting area is spacious and comfortable. Artwork covering the walls reflects the diversity of its patients, most of them African-American and Southeast Asian, but also white, Latino and West African.

"We want our patients to come to a first-class physical plant because we feel we have first-class doctors," said Executive Director Barton Warren, who oversaw the purchase and remodeling of the clinic's new facility, which opened in August 2001.

The renaissance under way at Model Cities and other St. Paul clinics offers a snapshot of the aggressive expansion and improvements being pursued by many health centers around the country -- a trend fueled in large part by a surge in federal funding.

Washington is putting more money than ever into the federal grant program that subsidizes community and migrant health centers, as well as homeless-, public housing- and school-based health centers. Nationwide, these facilities now number more than 3,300 sites. More will be added. Last year Congress and the Bush administration agreed to an initiative that would accelerate health center expansion by doubling the program's funding over five years. The goal is to build or expand 1,200 health center sites by 2006.

"Community-based health centers are the backbone of our nation's health care safety net, and we are committed to doubling the number of patients they serve," Health and Human Services Secretary Tommy Thompson said earlier this year.

Health centers received their largest-ever funding increase this year. As a result, an additional 1.25 million patients will be served, for a total of more than 12 million, according to HHS' Health Resources and Services Administration.

For fiscal year 2003, the Bush administration has proposed increasing the program's budget by $114 million, to $1.5 billion. This would enable health centers to serve a million more patients. But the facilities and their supporters in Congress are pushing for a $200 million increase, which they say is necessary to keep the five-year funding initiative on track.

Health centers, in turn, are busy upgrading and expanding their facilities, building new ones, adding sites and focusing on delivering quality care on par with any other clinic.

Model Cities even boasts of attracting patients with private insurance coverage who choose the clinic because they like the doctors. "We have patients who have the capability of going anywhere in the Twin Cities for care, but they come to us," said medical director, Fred Lewis, MD.

Its new facility has doubled Model Cities' square footage, providing space for more exam rooms and allowing the clinic to offer mental health services for the first time, add specialist physicians and expand its in-house lab.

In turn, patient visits have jumped -- from about 23,000 in 2001 to 56,000 visits projected through the end of this year, said Warren. The increase is due in part to the addition of a second site in St. Paul that resulted from a recent merger with a nonfederally qualified health clinic.

Enhanced federal funding has been critical to the center's growth, said Warren. "We wouldn't be expanding if there wasn't the expectation of ongoing federal support."

Build it and they will come

Across town from Model Cities, in the heart of St. Paul's historically Spanish-speaking neighborhood, West Side Community Health Center badly needs additional space. "We're about ready to explode," said Executive Director Mavis Brehm.

Thanks in part to the federal funding boom, but also to aggressive fund-raising from other sources, West Side is planning to break ground in October on a new building that would triple the size of its main site, La Clinica, and increase the number of exam rooms from 20 to 36.

Staffed with bilingual and bicultural doctors and nurses, La Clinica draws Latino patients from throughout the Twin Cities metropolitan area and beyond. Patient visits have climbed from less than 45,000 in 1993 to nearly 63,000 in 2001. This year, the number is expected to hit 80,000 -- in part because West Side last fall added a site in Minneapolis that is reaching out to Latinos.

Many West Side clinic patients are recent immigrants who have limited English skills, little money and no insurance coverage -- all significant barriers to accessing the health care system.

Latinos are the fastest growing population in Minnesota and are more likely than any other group to be uninsured and to be in fair or poor health. They have few places to turn, other than La Clinica, for health care that is comprehensible, culturally sensitive and affordable, said Miguel Ruiz, MD, an internist and native of Spain who has worked at the clinic for five years.

"The needs are overwhelming," said Dr. Ruiz, who decided to join the staff at La Clinica when he realized that many Latino patients were falling through the cracks of the Twin Cities health care system. It can be frustrating to care for patients with needs so great and resources so few. "But at the end of the day, you know you've helped people who have nowhere else to get help," he said.

Finding physicians

The building of larger facilities is improving community health centers' ability to meet growing patient demand, but they cannot function without adequate numbers of physicians, nurses and other staff.

Physician groups have been trying to get this point across as Congress considers funding levels for the National Health Service Corps and health professions program. These programs make it financially possible for many physicians to work in medically underserved areas.

Physicians such as Dr. Ruiz, who invest much of their career working in community health centers, help provide the health care safety net.

As of 2000, more than 4,800 doctors were working in community health centers nationwide, but more are needed, said Dan Hawkins, vice president of the National Assn. of Community Health Centers in Washington, D.C.

Work-force supply is one of the most critical issues facing community health centers today, said Hawkins. They rely heavily on the NHSC and the health professions program, which provide scholarships and loan assistance to health care professionals who agree to work in inner cities and rural areas.

At Model Cities, most of the physicians on staff have come through the NHSC, including its medical director, Dr. Lewis, who has worked at the clinic for 20 years. Dr. Lewis fulfilled his NHSC obligation long ago, but said he has stayed at Model Cities out of a commitment to the ideal that all patients, regardless of their income, are entitled to high-quality medical care.

That sense of purpose drives many physicians who make the decision to take low-paying jobs in community health centers. "We believe health care is a right," said Dr. Ruiz.

But while Congress and the Bush administration have made a firm commitment to send more money to community health centers, the future is less clear for the programs that provide the clinics with physicians and other health care professionals.

This year, the Bush administration has proposed increasing the NHSC budget by $44 million, to $189 million. The Senate Appropriations Committee also has approved a package that would do the same.

The House appropriations panel is expected to take up its own measure this month.

But considering that the NHSC has been underfunded for years, even running out of money in 2000, this year's proposed funding increase is "barely adequate," said Hawkins.

More troublesome is that the health professions program is slated for a cut of more than 70%, or $280 million, under the president's budget proposal for fiscal year 2003.

The Senate Appropriations Committee approved in July a $120 million cut in the program's funding, which would be less devastating. But physicians are left wondering how community health centers are supposed to continue improving access to care in medically underserved areas if they can't afford to staff them.

A coalition of health care groups -- including the American Academy of Family Physicians, the Assn. of American Medical Colleges and the American Academy of Pediatrics -- has warned Congress that deep cuts in the health professions program would limit the supply of physicians on which community health centers depend.

Onward and upward

Despite these worries, community health centers continue with their ambitious plans.

Barely a year has passed since Model Cities moved into its new facility, with more space and better equipment, but the staff at the health center is looking ahead to what more can be done to serve the community.

Director Warren has a long list of improvements he'd still like to make -- getting an electronic medical records system in place and adding specialists, such as a cardiologist, rheumatologist and endocrinologist. And the dental care department, although larger than before, still struggles to keep up with demand.

But Model Cities has come a long way since it was founded in a church basement more than 30 years ago. So has the entire system of community health centers, which rose out of the War on Poverty and the civil rights movement of the 1960s.

As long as there are 40 million Americans who are uninsured -- and many more who are underinsured or face geographic, economic or other difficulties getting access to care -- community health centers will continue to expand.

Talk to almost any physician who works at one, and they will tell you the same thing: The need is great and there is much to be done.

"We have patients here who don't have anything," said Dr. Ruiz. "Doctors want to help."

Budget boost

After several years of moderate growth, appropriations for community and migrant health centers are slated to double between fiscal years 2001 and 2006.

1997   $802 million
1998   $825 million
1999   $925 million
2000   $1.0 billion
2001   $1.1 billion
2002   $1.3 billion
2003   $1.5 billion*
2004   $1.7 billion*
2005   $1.9 billion*
2006   $2.2 billion*

*Note: Growth is projected for fiscal years 2003-2006. Appropriations must be approved by Congress each year.

Source: Health Resources and Services Administration.

Patient boom

The number of patients served by federally funded community health centers is expected to grow rapidly between 2001 and 2006.

1996   8.10 million
1997   8.30 million
1998   8.70 million
1999   9.00 million
2000   9.60 million
2001  10.30 million
2002  11.55 million*
2003  12.55 million*
2004  13.75 million*
2005  15.10 million*
2006  16.45 million*

*Note: Estimates for 2002-2006 based on fiscal year projections. All other figures are based on calendar year totals.

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