Last week while lawmakers in Washington, D.C., were gnashing their teeth over what health insurance in the U.S. should look like, patients and providers in King County were wrestling with some of the same challenges they faced before the Affordable Care Act was in place.
On Friday at Seattle Children's Odessa Brown Children's Clinic in Seattle’s Central District, two young girls in bright head scarves ran up and down a staircase.
They were two of the last dental patients for the day — the same one on which the Republican effort to repeal Obamacare fell apart.
Dr. Ben Danielson said the dental clinic functions like a well oiled machine. It's a bright, tight room. At a thousand visits a month, the seven chairs packed in here are well broken in.
“When things are really hopping, this is a little symphony, this little dance of dental assistants navigating between interpreters and family members and the dentists. I don’t know how they do it in this small space," Danielson said.
Tooth pain is a major contributor to school absences and low self-esteem. Periodontal disease also contributes to heart disease and diabetes.
And in 2014, students in King County who are black, Native Hawaiian/Pacific Islander or American Indian/Alaskan Native were twice as likely not to have had a yearly dental check-up.
Danielson, a pediatrician and senior medical director at Odessa Brown, has been at the clinic for nearly two decades. The clinic opened in the 1960s to serve low-income families. Today patients have access to medical, dental, mental health and nutrition services. The clinic serves as a hub for patients with sickle cell anemia, a hereditary blood disorder that mostly affects people of African descent.
About half the patients who come to the health clinic are African American. Eighty percent used Medicaid or are low income — the people that Obamacare was designed to serve. Over the years, Danielson said, the clinic's demographics have been fairly consistent. But the neighborhood's demographics have changed a lot. Steadily since the '70s, it’s become much more white and affluent.
“That means a few important things." Danielson said. "One, that we're really working to stay to our mission of serving the community we originally intended to serve, but two, that families are coming from farther and farther away from this direct neighborhood in order to get to us. And that's a problem.”
Danielson says when families become geographically scattered they lose the benefits of community. It also means that transportation becomes a health care issue too.
Dr. Allison Cole is a clinician and researcher at the University of Washington School of Medicine. She thinks a lot about how to improve healthcare delivery. Her clinical work with patients at Harborview Medical Center’s Family Medicine Clinic often informs her research.
“We often see that they experience barriers to accessing care, identifying the health system," Cole said. "Just in terms of the logistics of participating in the health system, especially if they're coming from a country where health care was different, as well as financial barriers to accessing care and identifying ways to pay for their care.”
All of these factors contribute to missed health screenings, lack of care and ultimately poorer health outcomes.
Cole often considers her patient's life beyond the exam room to craft a treatment plan that makes sense. They might be homeless or living in a shelter, which makes refrigeration of certain drugs like insulin difficult. She starts every appointment by asking the patient if they'd be more comfortable using an interpreter.
“We know that patients who speak comfortably and feel comfortable that the doctor is understanding them are able to share better information about their health and also better able to understand information that they're receiving,” Cole said.
Cole says King County has a robust primary care and public health system, so overall the health of the county is good. But she cautions those numbers also mask disparities, both in outcomes and the quality of care. People of color have higher rates of asthma, diabetes, colorectal and cervical cancers, among other things.
And finding a place where you feel comfortable being treated is important.
At the Odessa Brown Children's Clinic, Dr. Danielson said the mission hasn’t changed since the 1960s, but the way care is delivered has changed.
When the geographic location became less central to where patients lived, Danielson said, providers branched out into schools and early learning centers.
But he thinks the challenges of poverty and health still make this geographic dispersion a big problem.
“Losing that connectedness means you're losing a resilient factor that really supports your community," Danielson said. "The other thing is that the solutions that were so smart and so right back in 1965 and '69 are a little bit more challenging now. You can't just put everything in one spot in the center of the concentration of poverty and then think people can just walk to you and get to you and it'll be fine."
These problems are not unsolvable, Danielson said. And programs like the ACA and Medicaid expansion are in their infancy.
We’re in the slow curve of moving a huge steamship, Danielson said, not the quick turn of the kayak.