Naked City

City Council members have promised us a fight over a consultant's recommendations to trim and consolidate services in the city's public health clinics, but the tightened budget the council approved last week guarantees that patients are going to feel a pinch. Council members did forestall the proposed closure of the South Austin Dental Clinic for at least six months, but a dozen clinic positions were lopped off by the budget ax, including four social workers and a nutritionist -- positions health advocates say are more important than ever as clinics handle ever-greater numbers of hepatitis C and diabetes patients. City contributions to the Federally Qualified Health Center system, meanwhile, were more tightly capped as well, leaving the clinics more dependent on iffy federal subsidies and other risky revenues for survival.

City staff defended the FQHC budget they placed before the council as compatible with cutbacks recommended by Goggio & Associates, the firm hired last year to make the clinics more financially efficient. But Goggio consultant Kathleen Music, currently acting as head of primary care for Austin/Travis County Health and Human Services, says her team has had to work inside budget constraints more severe than they expected.

City Manager Jesus Garza withdrew all General Fund support for the clinics this year, and although the 1999-2000 FQHC budget includes about $1 million more than the clinic system spent last year, the bulk of that increase is from projected additional patient fees and Medicaid payments. A four-year FQHC budget forecast prepared by Goggio shows city contributions to the system remaining flat while operating expenses climb by about $3.5 million through 2003. What little additional revenue the clinics are forecast to draw in would come from treating more patients covered by Medicare, Medicaid, and the new Children's Health Insurance Program. However, all those patients can choose where they receive care, and no one can predict if they'll use the public clinics more frequently in the future.

A cynical observer might say that city officials are setting the clinic system up for failure. Outside consultants report that Goggio can't do much more to improve efficiencies, so the question has now become whether the city even wants to manage a public health care system, streamlined or otherwise. The vibes given out by the City Manager's office -- manifest in especially chilling terms by the fact that the office will charge the clinics $325,000 more this year for city administrative support and maintenance without a comparable increase in the FQHC budget -- aren't encouraging.

The recent focus on clinic cutbacks, meanwhile, is taking its toll on the morale of clinic employees. Although patient traffic may be light in some clinics, others, such as Rosewood-Zaragosa, have two-week waiting periods, and staff say losing more social workers means less assistance getting to the root of the domestic complications that keep patients coming back -- poor diets, stress, and family abuse. Staff, meanwhile, are in limbo, with posted vacancies in clinics staying up for weeks at a time.

"Most people who work in this area do so because they have a great interest in a public commitment to public health," says East Austin clinic physician Brendan McDaid. "It does tend to be demoralizing that there's this constant trend toward cutting back."

Goggio's final report on clinic system cutbacks is expected this week, and over the next six months council members will decide how many of Goggio's recommendations -- which include closing the Northeast, Oak Hill, Jonestown, Montopolis, and East Austin clinics, as well as consolidating pharmacies -- will be implemented.