The current debate over health care reform is confusing to most Americans, yet it affects everyone. The Times wants to help Alexandrians gain a better understanding of the current state of health care in the city. Toward that end, the Health Care Alexandria series focuses on different facets of the citys system. Last week the series examined various aspects of what is known to many as concierge medical care or direct medical care.

The series continues this week with a look into options for the citys uninsured and underinsured population.

Done for the work day, Roger Torres and a few coworkers from his construction job made a trip to Arlandria Tuesday afternoon to see about making a doctors appointment.

Like his companions, Torres, 23, didnt appear sick but said he had been nursing a cough for about a week. Also like his companions, Torress health insurance was limited to their work site.

With his soon-to-be 3-year-old daughter in mind, he found himself waiting in line at the Arlandria Health Center, where he saw his best available, most affordable way of securing health care not that he wouldnt like to have the protection of comprehensive health insurance.
I had just heard about this place, so this is my first time here, Torres said of his trip to the clinic, the flagship location for Alexandria Neighborhood Health Services where the vast majority of clients are uninsured, according to the clinic.

Although his previous job provided more complete health insurance, he had yet to see a doctor since emigrating from Honduras a couple of years ago. It didnt really bother him until a conversation the day before led him to personal reflection.

I would like to get some [health insurance] because I had it before, Torres said, explaining that it simply costs too much to keep up on his own. I was talking about it with my girlfriend yesterday. Id like to get it for her and my daughter and me. It would have to be all three.
Such concerns are likely shared by many of the 82 percent of the clinics clients without some form of health insurance, according to its website, and the 18.2 percent of Alexandrians without health insurance, according to the U.S. Census.

For people in Torress situation, uninsured but looking for care, options are often limited by financial circumstances or by choice. But various alternatives to insurance-based care do exist in Alexandria.

Beyond the Arlandria-based health group, which meets standards for an exceptional federal designation that includes federal funding, the Queen Street Clinic in north Old Town, and the Minute Clinic at the Monroe Avenue CVS Pharmacy in Del Ray provide different levels of as-needed discount health care to individuals without insurance.

While lower rates are key to basic care for many each facility has a different fee scale sometimes an amount that may seem offhand to some is a barrier to others in the community.

Many people who dont have health insurance are also very low income [residents] and they would have difficulty paying cash, even as little as $100, so it all depends on individual circumstances, said Dr. Lisa Kaplowitz, director of the Alexandria Health Department.

Thats really the challenge here, she said. Its not that they cant access care, but they cant pay for care and that certainly limits their options.

Previously, the citys Health Department, an outpost of the states health department that gets financial support from the city, had been able to administer first-hand care to adults. But with budgets being pared everywhere, it too is dealing with a declining resource base.

In the past, the Alexandria Health Department has been able to actually provide some primary care services, Kaplowitz said. We still do provide some pediatric services and some adult general medical services. However, we have to completely re-evaluate this with our budget cutbacks.

And as taxpayer-based health services are affected by local, state and federal revenue droughts, the citys social safety net grows increasingly critical and stressed.

The Alexandria Neighborhood Health System is a key part of that primary care safety net, Kaplowitz said, but in some ways its too popular for its own good, with demand pressuring the services available to the point that patients can face lengthy waits to get medical attention.

We are really operating under duress in terms of our ability to take care of the number of people who need service, said Kristin Langlykke, the clinics executive director. We are limited by our space and we just cant fit any more services into the space that we have.

If its a new patient for a routine visit, if someone wants to establish care and doesnt have an urgent problem, its about two months to get an appointment, said Langlykke, adding that a triage procedure exists if patients come in with an immediate, serious medical issue.

We see everyone, regardless of where they live or their ability to pay, Langlykke said.

As health care facilities go, the Arlandria Health Center is about as flexible as it can be, with a sliding-scale fee for exams ranging from $10 to $50, depending upon income any lab work costs an extra $25 and those in the highest income bracket pay a slightly higher price, according to Langlykke.

The health center also helps individuals like Mabincy Jabbie, a 69-year-old city resident with diabetes, asthma and cholesterol issues, obtain their medication at much cheaper rates.

Jabbie said that even with Medicaid her prescriptions cost hundreds of dollars each month, but are now a fraction of that, making it possible for her to afford the medicine she requires.

Since becoming a federally qualified community health center in 2003, the Arlandria clinic and its five smaller satellite locations have seen the number of patients increase nearly four-fold to 32,025 visits in the last fiscal year.

When the health centers comprehensive services are not sufficient, it turns to outside organizations and local specialists that agree to provide pro bono or significantly discounted services. In the direst of circumstances, the center will send patients as far away as Charlottesville to receive treatment at the University of Virginias public hospital, one of just four in the state, Langlykke said.

People get excellent care once they get there and its been a real life saver for some, Langlykke said of the work they coordinate with the UVA hospital. The Inova health system has also been very generous with providing significant charity care primarily for diagnostic testing and imaging.

Alexandrias Minute Clinic, tucked away in the corner of the Monroe Avenue CVS, is one of a handful in the area but the only one in the city. It administers basic primary care to people with and without insurance, employing family nurse practitioners in Virginia.

The CVS Minute Clinics, open seven days a week, take care of flu shots and school physicals for $30, while minor illness or injury treatment costs start at $62 and can rise above $100 depending upon tests or additional prescriptions.

Beth Pickering, on a break from her job at nearby National Airport, was waiting to receive her flu shot. Pickering decided to capitalize on the facilitys convenience and quick turnaround the main draw she cited in talking about Minute Clinics.

I guess if my doctor wasnt in on a weekend I might take advantage of it, Pickering said during her 10-minute wait, adding that she only comes about once a year for the vaccination. There are a lot of things they do here.

The Queen Street Clinic, founded in 2001 by Anne Boston Parish, a family nurse practitioner who is at once the owner and main care provider, caters to the uninsured with low-cost medical treatment.

A basic office exam costs $75 and additional services vary in price, but all must be paid at the time of the visit, according to the website, and does not accept insurance, Medicare or Medicaid as payment.

The clinic was t
emporary closed during the reporting of this article, but in an Alexandria Times article published last April Parish said, What
I saw when I saw this building was a haven for sick people. I saw a clinic that would be in the city so the inner-city population would have access to health care.

Still, there are others like Jabbies daughter, Rugie Mansaray, who considers herself really pretty healthy and gets by without health insurance.

I dont have health insurance because its just too expensive. I cant afford it, Mansaray said. When she needs care, Mansaray said she goes to the emergency room and pays the bill when it comes.

And yet, even with the ongoing health care debate across the Potomac and the ever-increasing pressures on Alexandrias health care safety net, those who find themselves in the uninsured minority maintain at least some health care alternatives within the city limits.