The benches outside of the county health clinic in Chapel Hill are filled with people waiting for the bus: a college graduate with a criminal background who got her license taken away; a self-employed hairdresser who can’t afford a car; a disabled man who can’t drive.
Those waiting for the bus at Southern Human Services represent the dynamic reasons that lead patients to seek primary health care services from the Orange County Health Department.
With one clinic in Hillsborough and one in Chapel Hill, health services are stretching the budget.
Members of the Orange County Board of Commissioners are starting to ask where costs can be cut and whether reducing services to only one county health clinic might make the most long-term sense.
They could decide as early as June to give up the dental clinic in Carrboro when its lease in Carr Mill Mall is up, in October 2011, and shift all dental services to Hillsborough.
But the question of consolidating primary care is more long-term.
With patients arguing for access to health care services and county officials arguing for cost efficiency, the future of the health department is up for debate.
The role of county health
Megan Hucks spent most of January and February in rehab for a heroine addiction.
With a criminal record related to her drug abuse, Hucks said she can’t find a job worthy of the degrees she received two years ago from the UNC-Greensboro.
“I wish I had insurance and a job with benefits. But especially as someone with a criminal background and as a recovering addict, I can’t even volunteer.”
People like Hucks — adults who don’t have children or a disability and therefore don’t qualify for Medicaid and have outgrown their parents’ insurance — often seek free and reduced services at county health clinics.
County health departments are mandated by the federal government to assure that citizens have access to primary care services, and in rural areas like northern Orange County, the county itself often takes on the role of provider.
“The mandate is not that the county necessarily provides primary care; it’s that they insure that people have access to primary care, which may be through them as a provider of last resort,” said Becky Slifkin, director of the N.C. Rural Health Research and Policy Analysis Center.
In northern Orange County, there are fewer primary care physicians who will see uninsured or Medicaid patients than in the southern part of the county.
“Typically there is less access to primary care in rural communities. It’s sort of all the obvious things you would expect when you have low population density … where highly trained professionals might not want to go settle,” Slifkin said.
But Slifkin said these issues could be hugely affected by the federal health reform bill, and people like Hucks could qualify for Medicaid.
Slifkin said that when Medicaid expansions take effect during the next four years, people like Hucks might not have to depend on county health providers, and the county might not have to provide for her.
“What about in four years when health reform is fully implemented and the number of uninsured drops drastically? It’ll be interesting to see what happens to community health centers.”
Choice means everything
For now, having two health department locations in the county has helped make things a little bit more convenient for Hucks.
Born and raised in Chapel Hill, Hucks visited Southern Human Services to get subsidized birth control when she was in high school, but she said it was always too difficult to get an appointment.
“It’s kind of a lottery,” Hucks said about the Chapel Hill-based clinic.
So Hucks chose to go to the Whitted Human Services Center in Hillsborough for her gynecological check up last year. She said the staff was more attentive, and she could get an appointment the day of.
“It’s hell to get to Hillsborough,” she said. Hucks has asked friends for rides, so far avoiding the bus that drops off patients blocks from Whitted.
“If they did what they do in Hillsborough here, it’d be easier,” she said.
Transportation is a key access question for patients, county officials and health care providers.
Wayne Sherman, personal health services director for the county, said public transit has made it easy to access services in Chapel Hill and harder in Hillsborough.
“The southern part has a bus service that goes directly to the front door of the building,” Sherman said. “But the bus between Chapel Hill and Hillsborough drops people off far away from Whitted.”
Mary Vilane is an Air Force veteran who lives and works in Chapel Hill but finds it difficult to get to Durham, where the veteran clinic is.
Self-employed and without a car, Vilane is considering switching her health care to Southern Human Services, which has a direct bus line to and from downtown Chapel Hill, instead of heading to Durham.
“It’s easier to come here. Hillsborough is just too far away. But another problem is social services is in the same building,” Vilane said, adding that she’s worried about how much more congested social and health care services could get if the county chose to consolidate.
“Two clinics would be more convenient with the amount of people in Chapel Hill. Every city should have its own location,” she said.
County strapped for funds
“Projected revenues for next year are about $4 million less than they were this fiscal year, and the expenses are somewhere in the number of 8 to 10 million anticipated dollars more,” said Orange County Manager Frank Clifton.
County commissioners are looking to cut a little bit everywhere.
The health department has compiled the numbers of where people live in relation to the clinics they visit to determine which clinic is most utilized and whether one can be cut.
While 3,732 people visited Whitted between July 2008 and June 2009, and 4,290 people visited Southern Human Services in that same time period, the data points toward the trend that the county is successfully reaching its population.
Sherman said he hopes that if the county does eventually consolidate services, it wouldn’t reduce patient access to care.
“The county has supported the two-site service model for years. But in light of current economic conditions, it would be more cost-efficient to pay for one site,” he said.
“We’re waiting to see where (the commissioners) want to go,” Sherman said, adding that he hopes the ultimate decision will not cut services.
“If we were to go to a one-clinic site, would we be able to keep the same staff and services? Serve the same amount of people?” Sherman asked.
One size does not fit all
Another question is whether other, non-county-run clinics accepting low-income and Medicaid patients can provide primary health care in place of the county itself.
UNC Hospitals is looking at opening a branch in Hillsborough, which would likely involve some level of charity outpatient care, potentially offsetting the need for clinical services from Hillsborough.
In the Chapel Hill area, Piedmont Health Services, a federally funded community clinic, serves low-income and Medicaid patients. The Student Health Action Coalition, a free clinic run by medical and dental students, provides free clinics. Both offset some of the need for county health services.
Clifton said the health department has been in touch with other public health providers to figure out where services do and don’t overlap.
From a cost perspective, it makes sense to collaborate, Clifton said.
“The people of Orange County have an array of services available that a lot of counties don’t have. We’re open to any of those kinds of partnerships — any method that delivers quality services in a quality manner.”
Contact the State & National Editor at stntdesk@unc.edu.
