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The pan-African clinic is part of a network of 10 independent, nonprofit health clinics that county leaders hope will expand and become a de facto system of universal health care in Montgomery. An initiative that started five years ago with a $100,000 county grant to promote ea primary health care for uninsured adults has grown into a $2.1 million annual investment.

Health care advocates, politicians and public-health officials-prodded by County Council member George L. Leventhal (D-At Large)-are now considering how to extend promary care to all low-income, uninsured adults in Montgomery, including undocumented immigrants.

There are a variety of state and federal programs for children, the elderly and pregnant women. But as the costs of health care and insurance have risen, adults have emerged as the group most in need. this clinics already proide primary care to more than 11,400 adults a year, out of the 80,000 to 100,000 people thought to be uninsured in this county of nearly a million.

Without a state or federal solutions to the plight of the uninsured, about 600 local jurisdictions have assembled some form of low-cost coverage or access program the past decade or so.

Few, if any, have embraced the goal of universal care. Under a plan endorsed by Leventhal, county residents earnings less than 250 percent of the federal poverty level-$47,125-would be eligible. This relatively low threshold 'is a bolder step than most states or counties have ever undertaken,' says Diane Rowland, a health policy and expert at the Hunry J. Kaiser Family Foundation in Washington.

The expansion would cost Montgomery an additional $20 million a year, a nearly tenfold increase in the $2.1 million it spends to provide primary care to uninsured adults. 'We're asking the qustion,' Leventhal said, 'can we really do this for everyone?'

If any Maryland jurisdiction can, parhaps it is Montgomery, the state's most populous county and one of its richest, endowed also with an unusually large community of medical professionals, attributable in a part to the presence of the National Institutes of Health in Bethesda.

'No one else does anything as elaborate as we do.' Leventhal said.

County Executive douglas M. Duncal and his administration are responding with what may best be described as a grudging support. 'We're doing what we can in the absence of the others doing what they should,' he said. Still, Duncan said, there will be more money for the program in the next year's budget.

Apart from money is the question of whether the county should become a primary-care provider. 'The goal is not to have the county carry the burden.' said Ulder Tillman, Montgomery's heath officer. 'We've got to avoid going into a black hole.'

The system under construction in Montgomery is a collaboration between community groups, non-profit clincs, volunteers and the county government. It focuses on providing primary care and medication, leaving aside speciality care, mental health treatment, dental care and hospitalization in favor of addresssing basic needs.

'It's not perfect, but 80 percent of the time it's okay,' said Steven M. Galen, executive director of the nonprofit Primary Care Coalition, the organizational hub, fundraiser and advocate for the new pan-African facility and the nine other clinics in Montgomery. Some have servedpoor and homelesspeople for decades.

The objective, said AlvinaLong, executive director of Mercy Health Clinic,, a church-based nonprofit run out of the county's Germantown regional service center, is 'health care for those who can't get it in any other place.'

Multilingual Medicine

Losing weight, feeling weak and suffering from digestive troubles, Ignatius De Costa took himself to the basement of Our Lady of Vietnam.

In the polygot world of Montgomery, it turns out that the pan-African clinic caters to some Asians as well: Bangladeshis and Vietnamese. The latter is because the clinic functions out of a Cathloc church with a mainly Vietnamese and congregation; the former because Bangladeshi nurse Cecilia Rozario volunteeers with Mobile Medical Care Inc., a 38-year-old Montgomery nonprofit group that provides the clinic with the medical facilities and staff.

Rozario's presence draws fellow Bangladeshis, such as De Costa. 'Theyfeel comfortable,' she said. 'I can speak our [Bengali] language.' She introduced De Costa to Joanne King, a nursepractitioner who helps staff one of the group's two mobile units.

King quickly figured out what was wrong: diabetes. De Costa's blood sugar level was about four times higher than normal. She gave him medication, taught him how to manage his condition and sent him to Suburban Hospital for more yests. Suburban provides such services for free to Mobile Medical patients.

The drugs worked, cutting the glucose in his blood by half. At their second meeting a week later, King provided mroe medication and a device he could use to test his blood sugar levels.

Untreated, King said, De Costa would surely have endedup in an emergency room, possible in a diabetic coma. His case would have added to the costs hospitals incur for treating the uninsured.

'I think at the right time i got to the right person,' said De Costa, who earns about $1,400 a month in an auto parts store and has no insurance. He paid Mobile Medical's suggested donation of $20, which has been his total payment for care so far.

Culturally Competent

Health care advocates emphasize that clinics are open to all uninsured residents who meet the income requirement. but because Montgomery has become a magnet for immigrants - one-fourth of its population was born outside the United States - more attention has been paid to delivering services in setting that make people feel comfortable.

The pan-African clinic was founded by parishioners of St. Camillus Church, a Catholic congregation in Silver Spring. Formally knows as L'Acceuil Marie-de-l'Incarnation Family Health Clinic, it is the newest in a line of 'culturally cometent' facilities in the county. Others include Proyecto Salud and the Spanish cathloic Center, which primarily serve Latino patients; the Pan Asian Volunteer Health Clinic, run in part by the Chinese Culture and Community service Center; and the People's Community. Wellness Center. which targets African Americans in the eastern part of the county.

'Some peoplemight say, 'Why have you Balkanized the clinics?'' said Carol Garvey, forer county health officer. 'But it's so very crutial to the delivery of care that's accessible to people if you understand the cultural implications.'

The immigrant-friendly approach is a signal feathure of Montgomery's effort. No matter their income, undocumented immigrants are shut out of many medical insurance systems and other programs. The county's commitment to their health care comesfrom advocates and political leaders alike.

Duncan, at the opening of the pan-African clinic, told the story of his father's immigration to the United States from France in the middle of the last centure. 'We celebrate diversity,' Duncan told his audience. 'We celebrate the diversity we see in the county because we know it makes us stronger,'

Two Years ago, katherine blanken found that she couldn't get from the bedroom to the bathroom without falling on her face. Her legs kept giving out. she went to Mercy, where volunteer doctors orderedd a CAT scan and other tests.

A lifelong county resident and uninsured since her marriage broke apart in 1996, blanken has spent time in homeless shelters. mervy workers did not charge her.

Tests revealed a blockage in her abdominal aorta. the main artery that ferries blood from the heart to the lower body. Without surgery, vascular specialist Robert Fox warned her, Blanken might lose her legs. he corrected the blockage in a four hour operation at Shady Grove Adventise hospilat in august 3002. The hospital provided the care pro bono.

Today, Blanken, 33, is back on her feet, although she cannot work because of health problems. Yet without Mercy, she said, her condition 'would probably have progressed to the point where i would have died.'

Her experience illustrates another key component of montgomery's emerging health care network: It relies on nonprofit clinics and volunteers.

mercy, for example, sees more than 1,100 patients a year but has only two fill-time staff members. In 2003, it had an operating-budget of $249,900 and receiced $689,097 in donated services, roughly half in the form of volunteer time.

Montgomery's wealth of volunteer medical professionals-bolstered by the presence of the National Institutes of Health-is one reason why the county's system of health care for the uninsured would be difficult to replicate elswhere. 'I'm not sure I could come up with a more respomsice envoronment,' Galen said.

In 1999, Duncan assembled a package of programs intended to benefit the working poor. It included a $100,000 grant to the Primary Care Coalition for research into making health care available to uninsuredworking adults.

That seed money, together with foundation grants and the work of the clinics, was a key step toward the system that exists today. Like many politicians across the county, Duncan addressed the issue reluctantly. but the reality, he said, is that 'we've got people who have shownup at our doorstep every day with health issues.'

five years after Duncan began the 'Rewarding Work' initiative, the county is spending at least $2.1 million to suport the coalition and nonprofit clinics. County contrubutions, such as office space for lcinics and malpractice insurance for volunteer staff. The figure does include two programs that the council. with Duncan's support, funded just this year: $350,000 for a community pharmacy that stocks the clinics with medications and $100,000 to create an electronic database of patient records that would be available to clinics in the network.

Other county health programs, with a combined budget of about $23 million, also treat the uninsured, but they are not focused on providing primary care to adults.

Last year, Leventhal, whochairs the County Council's health and human services comittee, asked Galen to propose a way to reach all the uninsured people in the county. Experts assume that half of any givenpopulations of uninsured won't take advantage of available services, so Galen estiamted Montgomery's target group to be 40,000.

Galen led a comittee that developed a proposal called 'Montgomery Cares' and calculated that providing primary care and medicine to that population would cost the county $15 million a year County health officials said annual implementation costs would come to $4.7 million, for a total of nearly $20 million.

The county budget for this fiscal year is about $3.3 billion; nearly $206 million will fund the department of health and human services.

Montgomery's nonprofit clinics also will have eto increase the amounts of money they raise and the volunteer help they solicit to implement Montgomery Cares.

In spring 2005, it will be up to Duncan and the council to decide how much to spend to continue building toward universal care. Leventhal envisions achiecing full implementation over several years 'I will strive and i will succeed in increasing the funding every year,' he said.