Subsidized health centers welcome surge of Medicaid patients

Kathleen O'Brien reported this story as a project for the National Health Journalism Fellowship, a program of the University of Southern California’s Annenberg School of Journalism. This article was originally published by Other stories in this series can be found here:

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What comes to mind when you hear the term "clinic"?

A storefront in the low-rent side of town, with plastic chairs in a crowded waiting room?

A cramped examination room with just a curtain for privacy, where worried relatives hover in the hallway?

That's exactly what the old "Dover Community Clinic" looked like a quarter-century ago when it was founded by a newly retired urologist who wanted to treat the poor.

Now the Zufall Health Center occupies a renovated bank smack in the center of town, its three-story stone façade conveying solidity and permanence. It has a fancy new name - a Federally Qualified Health Center - and "clinic" is a word consigned to its past.

Instead of plastic chairs, patients will find a spacious waiting room with pastel walls adorned with local art work. Photos of all the doctors are displayed along with their professional credentials.

"During the recession, patients would walk in embarrassed as all get out and say, 'I never thought I'd end up in a place like this,' said Eva Turbiner, director. "And I'd think, 'What kind of place do you think this is?"

New Jersey was one of 28 states that opted to accept federal money to expand Medicaid under the Affordable Care Act. That expansion has added almost 400,000 people to the public health insurance program - without necessarily adding more doctors to see them.

The overflow may well find themselves getting treatment at the 20 federally funded clinics in the state that offer basic medical care to all. Nationwide, the federal government pours $2.8 billion annually into centers that provide care for nearly 22 million patients.

"They're a really important part of the safety net, and have been since the 1960s," said Joel Cantor, director of the Center for State Health Policy at Rutgers University. "Frankly, without them we'd have a serious problem with access for Medicaid patients.

They enjoy broad bipartisan support, he said: Foes of big government are happy to provide some way to treat the poor without resorting to national health insurance, while those who favor more government support of health care like that centers treat needy populations.

The number of patients seen at these clinics has marched up steadily, year after year, so that by 2014, roughly a half-million New Jersey residents got their health care this way, according to the U.S. Department of Health and Human Services. About a third of those visits were for dental work.

While many private physicians resist treating Medicaid patients because the payment is too low, health centers welcome Medicaid patients. That's because they help the bottom line more than the uninsured, who pay only sliding scale fees that start at $20 or $25. (Dental work can be costlier, but centers offer payment plans.)

In Lakewood, an old Jamesway discount store has been renovated to become the ever-expanding Center for Health Education Medicine & Dentistry, or CHEMED. In 2013, it served nearly 20,000 patients. Last year that jumped to 21,000, and given the addition of onsite mammography, ultrasound, and bone density screening, the number is expected to continue to grow.

What began as a small referral agency soon had founders convinced the uninsured had woefully few options, said Dovid Friedman, the CEO of CHEMED.

"They were seeing adults and children whose teeth were completely neglected for lack of proper dental care, and uninsured adults who did not see a doctor at all when sick, sometimes leading to heartbreaking results," he said.

CHEMED's dental director, Joseph Tricarico, used to have a private practice, and later worked as an assistant commissioner within state government. Now he oversees about a dozen examining rooms where 3,500 patients get dental work each month.

Alycyne Fumosa, of Toms River, is 25 and waitressing to put herself through college. She'd come to CHEMED for the first time to get some dental work - another area where the community need is great.

"It's pretty difficult to find a dentist who takes Medicaid," she said. "It's not as popular as you think. They have waits that are really long." At CHEMED, however, they could give her an appointment in a few weeks instead of a few months.

A young Spanish-speaking couple with a premature baby brought him in for his check-up, monitoring wires still attached to his chest. They'd asked around, said the father, Magdaleno Jimenez, and heard they could get treatment here.

Staffers at CHEMED are also urged to avoid using the word "clinic" to describe their facility.

"This isn't a clinic - this is a quality medical facility," Friedman said. Senior staff members are encouraged to use the services for themselves and their families. "If you don't use it yourself, are you really standing behind your product?" he asked.

More than half of their patients are on Medicaid. Lakewood has a burgeoning population of both Hispanics and Orthodox Jews, and the waiting rooms of CHEMED reflect that mix.

Reflecting the needs of the Orthodox population, the center keeps hours that reflect the religious requirements of the community: It's closed on Saturdays, the Sabbath, but open Sundays. The Friday afternoon closing time is linked to sunset, so varies through the seasons.

In order to be designated a Federally Qualified Health Center, the facility must set up shop in a needy area or region. Along with federal money come other benefits: its physicians get a break on both malpractice insurance and their student loans.

In return, these centers treat everyone, regardless of insurance or immigration status.

"They don't ask," said Cantor. "It's not their concern whether someone is here legally." Patients not in this country legally pay a sliding-scale fee; they are ineligible for Medicaid.

Treating them was precisely Robert Zufall's intent when he and his wife started their tiny clinic 25 years ago. He was a newly retired doctor, she a nurse, when they traveled to Peru to provide medical care to needy villagers.

The experience was so gratifying his wife proposed returning there for a second trip.

"I said, 'Listen, there's a lot of poor Hispanics in Dover. Which is closer?'" recalled Zufall, now a 90-year-old Parsippany widower who still serves on the center's board of directors.

They set up shop one night a week in a local community organization, using a tiny exam room separated by a curtain. "It was kind of grungy....not very fancy," he said. They started out giving free care, but gradually realized they needed to charge something to cover their modest costs. They started at $5, then moved to $20.

Eventually they expanded to a church gymnasium, then to a rented storefront. With further growth, that storefront became the center's dental clinic, and the main operation moved into the renovated bank in 2012. Zufall now runs centers in Morristown, Hackettstown, Flemington, Somerville, and West Orange as well.

When they qualified for federal health center status in 2009, they served about 10,000 patients. By last year, that number had risen to 26,000. Unlike CHEMED, which has a lot of Medicaid patients, Zufall has more uninsured - although that has dropped, because of the Affordable Care Act, from 69 percent to 57 percent of its patients.

The recent expansion of Medicaid didn't produce a flood of new patients showing up, said Turbiner. "They were already all our patients," she said. "It's not like a whole bunch of new people moved here."

Then, as now, the majority of its patients are Hispanic, many of them recent immigrants who d entered the country illegally. (Medicaid doesn't cover them.)

"They're good people," said Zufall, who had always envisioned them as the pool of people he wanted to treat. "They're hard-working people, they're family people, they're nice."

Cantor said the federally-supported health centers have three drawbacks: They don't offer the full array of services because they rarely have specialists on staff. So patients who need surgery, for example, will have to get seen by a doctor elsewhere. And because of their popularity, they can have long wait times.

In addition, the visitor's experience might differ from center to center. "Do they feel like clinics, or do they feel like doctor's offices?," he said. "They do vary, although they've gotten a lot of expansion money and I think they've tried to make themselves patient-friendly." (Most are open evenings and weekends, for instance.)

Still, he said, "these are the go-to places for a lot of people who would not have any other options."

Photo Credit: Patti Sapone | NJ Advance Media for