March 23, 2014 Updated: March 23, 2014 at 2:16 pm
Mission Medical Clinic cared for roughly 600 people last year - all uninsured, all seeking free care.
But by March 1, nearly three-quarters began seeking care elsewhere because they could get Medicaid coverage under the Affordable Care Act - essentially.
"I thought it would be a large number, but I didn't think it would be so soon," said Barb Cronin, the clinic's executive director.
As more Coloradans sign up for free or subsidized health insurance through the Affordable Care Act, clinics like Mission Medical - which once catered largely to uninsured patients - have begun grappling with a difficult question:
What purpose do small safety-net clinics have in an age of expanded access to health care?
The four small safety-net clinics in the Pikes Peak region are finding the answer in new or revamped strategies, because, in spite of the law's goal of extending coverage options, deep needs still exist - particularly among area's undocumented immigrant community, officials running each clinic say.
Clinics also are focusing on people who are covered, but who still can't pay their medical bills.
"We're really looking at what 'underinsured' means," said Peggy Herbertson, director of SET Family Medical Clinic.
Each of the city's four has proceeded differently.
Mission Medical has chosen, in part, to focus on a new demographic: undocument immigrants.
SET Family Medical Clinic recently began accepting Medicaid, the state-run, federally-funded program, which expanded under the Affordable Care Act to cover people in the lowest income brackets. The clinic shied away from seeking that funding source in the past because it didn't have an electronic health records system.
That recently changed. The move is largely meant to help the clinic's finances, Herbertson said, but it's also a nod to the growing number of people covered by Medicaid.
The clinic still plans to serve low-income, uninsured residents, as well as undocumented immigrants.
Dream Centers of Colorado Springs, a New Life Church program, plans to expand its women's clinic in the coming months by focusing on insured people who still need help with their medical bills.
It also will continue helping undocumented immigrants.
"The need is still tremendous," said Matthew Ayers, the clinic's executive director. "A lot of their deductibles are way too high to pay."
Open Bible Medical Clinic is taking a more cautious approach. Program leaders will gauge the needs facing Colorado Springs' uninsured and low-income residents before deciding whether to continue the clinic in 2015.
"If that's not a need in our community anymore, that's something we would celebrate and we would move on to finding new ways to helping our community in a different capacity," said Jeff Martin, the clinic's executive director.
In late February, Mission Medical chose to open its doors to undocumented immigrants - it's first public effort to reach that patient base. The clinic traditionally shied away from publicly accepting undocumented immigrants because it was at capacity treating people here legally who did not have insurance, Cronin said.
That changed quickly.
Seventy percent of its patients signed up for Medicaid when it expanded in Colorado on Jan. 1, Cronin said. Nearly everyone earning 138 percent of the federal poverty level or less - roughly $16,000 a year - became eligible for the program this year.
"We lost a lot of clients," she said.
With space to fill on its patient rolls, the nonprofit is trying to reach out to the largest group left out of Colorado's Medicaid expansion.
Little is known about the Pikes Peak region's undocumented immigrant community - how many there are, how much they spend or how often they seek health care. Challenges mount, however, the moment they walk into a hospital or clinic, said Rene Ruelas, Mission Medical's admission's director and a client advocate at Memorial Hospital. He also serves as the staff's interpreter.
For example, Ruelas never began a patient visit at Memorial Hospital by asking people to lie. But when some people flat-out refused to say anything - a name, an address, a date of birth - he found himself in a tough spot.
"I would say 'Here's the deal: This has nothing to do with INS (Immigration and Naturalization Service),'" Ruelas recalled. "'This is just to get your information.'
"'If you don't want to give me your exact name, date of birth, information - that's fine. Make something up," Ruelas continued. "'The only thing is that when you come back again, and you're allergic to a certain medication and we don't know that because you're not telling us ... then that's going to be a problem.'"
Undocumented immigrants' options for health care are few. Often, they seek care in emergency rooms, even if the problem concerns dental or mental health.
Advocates also rely on Peak Vista Community Health Centers - a massive organization specializing in low-cost care - for help.
"I send all my clients to Peak Vista," said Sandra Hernandez, director of Centro de la Familia, an organization that offers mental health care, counseling and parenting classes, largely to immigrants. "That's what a lot of our clients do, because they know they won't be turned away."
Peak Vista does not keep statistics on the number of undocumented immigrants who seek care at its clinics, said Pam McManus, the federally qualified health center's chief executive.
When incoming patients can't supply identification - such as a driver's license or birth certificate - they are referred to the nonprofit's sliding fee scale. She did not say how many of those bills go unpaid, but said in 2012, the nonprofit gave out about $15 million in care at a reduced cost through the sliding fee scale.
So far, Mission Medical's new focus has been slow to start. Instead of an influx of undocumented immigrants, the clinic has largely treated people who remain uninsured, or who can't afford the high deductibles on their newly-purchased plans.
Still, Cronin doesn't mince words. She said her clinic's decision to cater to undocumented immigrants merely reflects the region's options for care.
"They're here, they need medical care, and we serve the underserved," Cronin said.