LOS ANGELES - When Maria Barrales' children got sick, she would drive two hours south from her East Los Angeles home to the Mexican border and spend two more hours waiting to cross so she could go to an affordable doctor in Tijuana.
Now, Barrales, who does not have health insurance, can walk a couple of blocks to Garfield High School and see a modestly priced physician at a new health clinic converted from an auto shop on the school grounds.
"This is something so necessary here. A lot of people don't have insurance, and they don't have the means to go to Tijuana," she said in Spanish.
The clinic is one of 14 new "wellness centers" that the Los Angeles Unified School District is rolling out this year at schools in impoverished neighborhoods in an initiative that expands the mission of traditional school-based health centers from treating only students into one that treats the general public, too.
While a smattering of school clinics across the nation have long been open to the public, more are looking to expand their patient base to reap revenue that can subsidize the care often given for free to youngsters as well as fill a dire larger need for community health-care access.
"The more folks you're seeing, the more revenue you're generating," said Tracey Schear, who oversees 26 school-based health centers for Alameda County Health Services Agency in Northern California. "We're trying to make more visits reimbursable."
About 1,800 school-based centers, which are usually run by a nonprofit or public health-care provider in school-owned buildings, operate across the country. They provide a combination of primary care, mental health counseling, dental and vision screenings, and health education and prevention to youth who may have grown up with few, if any, doctor visits.
Around since the 1980s, school health clinics received a shot in the arm from the federal Affordable Care Act, which earmarked $200 million from 2010 to 2013 to build and equip more centers and expand services. With fewer than half of public schools now employing school nurses, some districts have used the money to add health centers, which have traditionally been located in high schools, at elementary and middle schools and add mental health, vision, and dental care.
The federal funding, though, does not cover operational expenses, and more providers are looking to become financially sustainable in an era of shrinking public money and increasing competition for private donations that typically fund school clinics. Some clinics have closed in recent years.
The National Assembly of School-Based Health Care is now lobbying Congress to appropriate $50 million to help centers maintain their operations, said President Linda Juszczak.
With health-care reform approaching, school-community health centers are also ramping up to enroll people in public insurance programs that will become available.
"We're looking at long-term sustainable plans," said Maryjane Puffer, executive director of the Los Angeles Trust for Children's Health, a nonprofit that supports the school district's clinics.
One Los Angeles Unified school center that has served the community for a long time has been successful doing that, she noted.
About four school-based health centers have opened to the general public in California's Alameda County, and two centers under construction at schools in the Oakland Unified School District are being designed to serve the community as well as students.
Other clinics are choosing a more limited model that serves school staff, who have private insurance, and students' families.
In Oklahoma City, nonprofit community health-care provider Variety Care is rolling out its first school clinic at Capitol Hill High School that is open to the staff and student families, said Chief Executive Lou Carmichael. Although United Way donations help to cover expenses, how the clinic would be financially self- sufficient was a key issue, she noted.
"It's about building income so you can see as many people as you can," she said. "We don't need a big margin but we do need to be able to cash-flow this."
Carmichael said the agency already has a waiting list of schools wanting clinics, but she noted that she'll have to see how the first program works. "The need is so great, but how do you pay for it?" she said.
Advocates say the combo clinics make sense because neighborhood schools are convenient locations to reach underserved people, especially in rural areas, but accepting community patients has some caveats.
Safety is a concern because schools do not want strangers wandering around their grounds. A health center open to the public typically needs two entrances - one from the school for students and another street entrance for adults, and may require longer hours, as well as different equipment and staff, such as internist, to deal with adult health problems.
Security issues have prevented a number of clinics in Connecticut from expanding because they're located within older school buildings, noted Jesse White-Frese, executive director of the Connecticut Association of School Based Health Centers. The state has one school clinic open to the public in north New Haven.
Another key issue is privacy for adolescents, who may be seeking contraception, pregnancy tests or treatment for sexually transmitted infections and might shy away from going to a place where they could run into someone they know.
At Garfield High School in East Los Angeles, the clinic is installing a partition to divide the center into two areas after realizing students could feel the waiting room was a little too open, said Rafael Gonzalez-Amezcua, medical services director for Bienvenidos, the nonprofit health-care agency running the center.
"It's a little tricky," he said. "The staff will keep the two groups separate. We want the kids to enjoy true privacy."
Experts say the combo clinic is an efficient way of delivering low-cost health care, but note that the school-based health center's primary mission is kids. School clinics often serve a role in student health education and even provide professional role models for kids who lack exposure to career paths , said Julia Lear, senior adviser to the Center for Health and Health Care in Schools at George Washington University.
"Historically, the health care system has not treated children well because the truly interesting money is in adults. These programs were driven by that gap in care for kids," she said. "You don't want to lose that."
For working-class immigrant communities like East Los Angeles, where many people work in jobs that do provide medical insurance, residents said the Garfield High School clinic was a welcome relief for families.
Kids said they'll now be able to try out for school sports teams because they'll be able to get the required physicals their parents can't afford, while parents said they can get help for asthma, diabetes and general stress without worrying about how they'll be able to pay.
Mariela Ortiz, who has no medical insurance, said she's planning to get tetanus shots for her two kids. "Everybody was waiting for this," she said.