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Cleveland used to take medicine to those who needed it, and should again

In 1981, Cleveland launched an ambitious and innovative project to provide health care to those who needed it most, by taking the services to them. The program's "office" was a 33-foot converted medical van, not unlike a Winnebago. John Booher, a physician's assistant, piloted the mobile office from its home base at the Shaker Medical Center Hospital to Cleveland's inner-city communities.

"The people we met had not seen anyone medical unless they were in crisis," recalls Booher, who now lives in Florida. "They used emergency rooms when they had to, but by and large, they just didn't have care. Most of the hospitals, like Mt. Sinai and Huron Road Hospital, had clinics that the patients could go to, but for many, the biggest problem was getting to the clinics. It made the mobile medical units an ideal delivery tool."

Inside the van, Booher and other staff members could conduct physical exams and screening tests, and draw blood that could be taken back to the Shaker hospital for analysis. Some of the patients suffered from chronic diseases like uncontrolled hypertension and diabetes; if they were already under a doctor's care, the mobile staff would forward its findings to that physician. But many clients received no other care.

"We saw a large variety of general medical problems," says Booher. "But I think that the best thing we provided was the consistency of coming back every two to four weeks. We could examine the patients, draw blood, provide immunizations and manage the routine medical issues. If necessary, the patients could be hospitalized at Shaker. It would have been better if we had a network that involved the local hospitals where the patients could have been hospitalized in their neighborhoods. But we never got to that level of coordinated services."

The mobile medical unit operated for roughly a year and a half, receiving most of its funding from Medicare and Medicaid. But that didn't last, and neither state nor local resources could be found to fill the gap. So the program was abandoned and largely forgotten. And that's a shame because, as Booher asserts, "There was no question that the unit brought health services to folks who weren't seeing a doctor."

A 1981 Plain Dealer article about the program quoted Shiv Aggarwal, then executive vice president of Shaker Medical Associates, as saying, "The need [for mobile services] is so great."

Today, the need is far greater. In the U.S., the only industrialized nation not to recognize health care as a human right, at least one in every six citizens is uninsured. And the number of uninsured has increased each of the past seven years.

The insured are suffering as well. In Ohio alone, health premiums have grown almost nine times faster than wages, contributing to more out-of-pocket medical payments, not only for workers but also employers. This leads to a domino effect where economic constraints — along with skyrocketing health premiums — cause small businesses to fold, leaving even more people jobless or limited to jobs that do not provide insurance.

Cities across the nation are helpless, bound at the wrists and weighted down in the murky waters of health care oblivion. In a recent poll of mayors, all respondents indicated that they were unable to meet the demand for health services necessary for their communities to thrive, partly because of eligibility restrictions for public programs such as Medicaid. Cleveland has a poverty rate of around 30 percent, much higher than the national average of 12.3 percent. As far back as 2004, nearly 25 percent of Clevelanders were neither insured nor recipients of Medicaid, placing them at a higher risk for untreated chronic diseases, which cause seven of every 10 deaths in the U.S.

In 2005, chronic diseases swelled the health-care tab to 75 percent of the nation's $2 trillion health-expense deficit. Heart disease, diabetes and stroke are the most prevalent chronic diseases, and they are also the most preventable ­— provided that care is available. For tens of millions nationwide, it often isn't. And what little is available for the uninsured often goes unused. The Bureau of Primary Health Care estimates that only one in six of the underserved population will actually seek treatment at a community health clinic. One possible cause of this gap: lack of transportation.

For these reasons alone, Cleveland should revisit the past, redirect city funds, and reinstitute a mobile medical initiative.

In 2007, San Francisco established medical "homes" throughout the city to provide universal health care to its residents. The program, Healthy San Francisco, is designed to offer preventive care and primary medical services, regardless of the patient's ability to pay. Fees are based on income, and residents who fall below the poverty level are not required to pay at all. The program is financed by the redirection of funds from the city budget and supplemented with aid from the federal government.

If San Francisco can do it, why can't Cleveland? Granted, Cleveland has suffered more from forces like the decline of manufacturing jobs and the foreclosure crisis. But priorities are also part of the equation. In Cleveland's 2008 budget, only 1 percent went to public health, compared to 8 percent for parks and recreation, and 10 percent for "other" — which includes city council, the mayor's office and community relations. Those functions may well be important, but they do not offer the potential of greater tax revenues down the road.

Statewide, an estimated $43 billion in taxable revenue is lost annually to chronic illnesses. So diverting public funds, even by a fraction of a percent, to support programs that manage and prevent chronic disease would create its own financial life-support system. One 2007 study concluded that greater efforts to prevent and manage chronic diseases could save Ohio $40 billion in spending by 2023. And that doesn't include the greater tax revenues that could result from regaining the productivity lost to illness.

So by spending money to decrease the incidence and prevalence of chronic disease, the state and city could reap even greater rewards. With local and federal funding, mobile medical units like the one that patrolled Cleveland in the early '80s could provide life-saving — and money-saving care — where it's needed most.

"Basic care, to be effective, needs to be accessible," says John Booher, who still works as a physician's assistant. "I think that even in our current environment, if we could reach out to people who can't get the care and/or can't afford the care, we could make some inroads. How we did it [back in 1981] was the smallest part of the equation. Feeling like we made a difference was the important part."

Nicole McFall will earn a master's in June from Kent State University's Adult Nurse Practitioner program. She is also a registered nurse at University Hospital.


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