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Budget cuts are nothing new to local public health departments, but this time it’s different, Dr. David Fleming told his staff at Public Health — Seattle & King County on Thursday.

Facing a shortfall of $15 million per year for the next two years, Public Health is proposing to close up to four of its 10 public health clinics, said Fleming, director and public health officer. The clinics provide family planning, and maternity and infant support services for patients with income, language, social or mental difficulties who have trouble getting help elsewhere.

For 200 to 300 workers, layoffs loom, as do cuts to key efforts to prevent communicable diseases and chronic conditions, Fleming said in interviews this week.

For now, change is most likely to occur for patients at clinics in Seattle’s Northgate and Columbia City neighborhoods. There, primary care and some other services may shift to a private provider. In addition, four other clinics may close.

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Final decisions won’t come until late this year, after the County Council approves a budget. But county Budget Director Dwight Dively said: “The problem is so severe we need to talk to people now.”

The funding gap has climbed over the years as population, inflation and labor costs have risen. And while many of Public Health’s 200 income sources have not kept pace, a particular problem has been the steady decline of federal money for administrative costs of helping Medicaid patients navigate coverage.

Cutting the budget mostly means losing people, said Dively, noting that 75 to 80 percent of the budgets around the county go for salaries and benefits.

For Public Health, that means clinic support staff and professionals, many with particular expertise.

Fleming is particularly worried about the prospect of losing 40 percent of support services for pregnant women and infants. Looking decades ahead, he sees potential social and financial costs of unhealthy newborns — hospitalizations, lifelong health problems, even deaths.

Nearly 40 percent of the pregnant women in King County are eligible for Medicaid, and the vast majority of those get maternity support services from Public Health clinics.

Provided by public health nurses, dietitians, behavioral-health specialists and community health workers, the services include social, emotional and physical support for expectant and new mothers — critical to helping ensure babies are born healthy, Public Health says.

Health and economic status are inextricably intertwined, Fleming said. “We can’t make any reductions without creating more health disparities.”

In addition, he worries about cuts to disease investigations. “We are the eyes and ears of what’s happening in our community,” he said. “It would be foolhardy to sort of gouge your eyes out.”

Still, neither Dively nor Fleming offered a solution.

Fleming knows that the federal Affordable Care Act is changing the landscape, making room for new models of integrated care, and he’s glad for it.

To that end, this budget crisis may bring opportunity. “We’re trying to think as creatively as possible around a transition,” Fleming said.

The agency has partnered with Neighborcare Health, a nonprofit community-clinic organization that plans to close its Greenwood Medical Clinic and build a new clinic on the site of Public Health’s Northgate-area clinic.

The two agencies may work out a similar arrangement in Columbia City in South Seattle, where they already share a building.

The four clinics that may close have not been identified.

At the new Northgate-area clinic, named the Meridian Center for Health, Neighborcare will provide primary care, while Public Health will continue other services, including dental.

Such clinics are needed more than ever, because most primary-care medical practices severely restrict the number of Medicaid patients they take, said Mark Secord, Neighborcare’s executive director and CEO.

Unlike the clinics run by Public Health or his organization, he added, “most private doctors’ offices aren’t well set up to meet the complicated needs of homeless or immigrant or persistent mentally ill populations.

“Our goal is to assure continuity of services so we don‘t skip a beat,” Secord said. “So when Public Health closes, we’ll be there to pick up the services.”

But Secord, aware of Public Health’s budget problems, says the timing may not work. The new clinic won’t be completed until fall 2015, and Fleming says it’s unclear what the 2015 budget will support.

Years of cutting back

For years, Public Health — Seattle & King County has been cutting and refocusing services as funding dwindled.

“This is an ongoing chronic problem that has affected not only our public health department, but is a problem around the country,” Dively said.

In the wake of the recession, Fleming pared and eliminated services, including immunization clinics, TB treatments, laboratory testing and street outreach to pregnant substance abusers — the very services he argues reduce overall costs to society.

Meanwhile, Fleming has solidified his case that public health, with its new understanding of the underlying causes of poor health, could improve life and save money for county residents for years to come. With private money and new partnerships, he has begun to try some innovative ideas.

But these ideas aim toward community-level work, he noted.

Individual services to patients are more expensive and less likely to attract private funding.

Much of Public Health’s current $365 million budget is funded by grants, levies and fees, and won’t be affected by cuts — with money dedicated, for example, to jail health services or emergency medical services.

At risk is that part of the budget that goes to prevention and Community Health Services, which includes the 10 clinics.

For the clinics, the primary source of funding has been Medicaid reimbursements for direct patient care. But another stream of Medicaid money is causing a budget problem, Fleming said. The money that pays for administrative services to help Medicaid patients has fallen drastically, from $14 million in 2008 to under $7 million last year.

State Medicaid Director MaryAnne Lindeblad said the state and the Center for Medicare Services are negotiating over the federal formula.

“It’s not a done deal,” she said, but she doesn’t expect a return to 2008 levels.

Carol M. Ostrom: 206-464-2249 or On Twitter @costrom

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