Tucked into a corner of a former Mack Truck dealership, the Good Neighbors Health Center operates on the front lines of a growing problem.
As the cost of health insurance rises, more individuals here and across the nation are foregoing coverage or employers are dropping it altogether.
Patients who turn up at the health center in Buffalo, where a volunteer staff offers free care every Friday, illustrate how the uninsured often are left to fend for themselves.
Jacqueline Resto arrived recently before the doors opened. A Sunday school teacher with three children at home, she was worried about her high blood pressure and cholesterol.
She stopped seeing her regular doctor when the cost of the visits, tests and prescriptions was more than she could afford.
Then she stretched out what medications she had left and avoided other care. She hasn't seen a dentist in a few years.
"With a mortgage and utilities, we couldn't take on any more. Your money only goes so far," Resto told Dr. David M. Holmes as he examined her.
It's a predicament Holmes hears about from many patients.
Now, President Bush is proposing changes.
He wants to expand health savings accounts, which allow consumers to put aside money tax-free for medical expenses. But it is unclear whether the accounts, which come with high-deductible insurance policies, are the answer to covering the uninsured.
The number of Americans without health insurance rose to 45.5 million in 2004. In Western New York, there are roughly 200,000. And counting.
Resto faces a dilemma common to many, as four out of five of the uninsured come from working families.
Her husband's income fluctuates too high to qualify for Medicaid, the government health program for the poor. But the contribution at work for a family health insurance policy, which costs about $10,000 a year, is too expensive.
To go without health insurance often means rationing care.
>Unable to pay for care
It is the rare doctor who will see the uninsured. So they are less likely to get preventive care to avoid complications from diabetes, heart disease and other chronic conditions.
When they get sick, the uninsured show up in crowded hospital emergency rooms or depend on a handful of health centers in the community that offer discounted or free care.
Even then, they face the prospect of paying hundreds or thousands of dollars if they need prescriptions, specialists, diagnostic tests or surgery.
"We have a health system that will guarantee insurance if you need dialysis," Holmes said as he examined Resto. "But there's no insurance to get the care that might prevent diabetes from getting so out of control that you need dialysis."
Dissatisfaction is growing despite advances in medicine and large increases in health care spending. The rising expenses threaten many industries. Ford Motor Co. recently decided to cut up to 30,000 jobs by 2012, and General Motors Corp. is posting huge financial losses. Both companies pin much of the blame on health insurance costs.
Proponents of health savings accounts see them as a way to shift costs away from employers while making individuals more judicious users of care by having them pay more.
"Linking health care to employment is the problem. If you lose your job or get sick and don't have coverage, you lose access to care," said Susan Starr Sered, co-author of "Uninsured in America: Life and Death in the Land of Opportunity."
But Sered stands among those who say the uninsured are less likely to have money to stash in the special accounts and more likely to neglect care to save their income for other expenses.
"After you pay the rent or mortgage, the utilities, car payments and food bills, there is not much money left over," said Sered, a Suffolk University researcher.
>Church leases space
Good Neighbors is a small player in the safety net.
"We're a drop in the bucket, compared to the need," said Holmes, a family physician at Kaleida Health's Mattina Community Health Center and director of the University at Buffalo family medicine clerkship.
Good Neighbors, which Holmes helped start about a year ago at 175 Jefferson Ave., is not technically a health center.
It is the not-for-profit creation of a suburban congregation, Eastern Hills Wesleyan Church, which leases space in a building owned by Harvest House, a faith-based retreat in South Buffalo. Good Neighbors subleases rooms at no charge to doctors and others who want to provide free care.
Patients find Good Neighbors by chance or word of mouth. Some come attracted by the spiritual counseling, which is offered but not pushed. Others like the low-key atmosphere.
Tracye Curtis-Johnson, a special-education teacher, noticed the health center while driving to see a young client.
She stopped by for a physical exam needed for another job.
"It's scary. Anyone could be in my position. I'm not sick, but I don't want to have to skip stuff like mammograms," said Curtis-Johnson, whose coverage ended after a divorce.
Curtis-Johnson typifies how loss of insurance can follow changes in life -- divorce, layoff, sudden illness, self-employment, caring for a loved one.
Emily Vinette, a YWCA case manager for homeless women, cannot afford the insurance plan offered at work.
She knew of Good Neighbors because it is where she sends her homeless clients for health care until their Medicaid applications are approved.
"I wanted to work in human services and didn't care about the money. But if you don't have insurance, the money matters," said Vinette, who came in with a respiratory illness.
>'It's rewarding work'
Good Neighbors survives on good will.
Behind the small but modern offices, the unfinished parts of the building are crammed with donated equipment. Old exam tables share space with height-and-weight scales and a hodgepodge of used medical devices, some of them past their prime.
The tiny staff includes a medical student, sonographer, nurses, secretaries, opticians and optometrist. Harvest House provides free glasses.
Holmes is always searching for specialists willing to see patients at little or no charge. So far, it is a patchwork group comprising a chiropractor, an allergist, a podiatrist and an ear, nose and throat doctor. Gastroenterology Associates performs two free colonoscopies a month to screen for colon cancer.
If patients need medication, the staff directs them to pharmaceutical company prescription-assistance programs. These programs offer limited quantities of free or low-cost drugs.
As Holmes examined patients, workers carried in boxes of medications left over from a local medical group's charitable medical mission in Honduras.
Drug company representatives also leave samples, a convenient but controversial practice.
Patients get whatever is on hand. If they want to buy a drug they have sampled, patients find out to their surprise that samples are usually the newest, most expensive medications.
Business is picking up, but to expand hours, the center needs more primary-care doctors.
"It's rewarding work. You feel as though you're giving back to the community," Holmes said.
But there's frustration, too.
Four patients walked in near closing time on this day and had to be turned away. And Holmes is bothered by what happened to Resto.
A week later, she called the office, complaining of chest pain.
Holmes advised her to go to a hospital, but she resisted, fearful of getting a big bill.
Resto rushed to Good Neighbors, where the visit included some gentle scolding.
The medical student on duty told her, "Funerals are more expensive than emergency room visits."