By Mark Zdechlik, MPR News

A few years ago, community health clinics routinely offered care to people with no health insurance. Today, offering care to people who have insurance — but still can’t afford care — is becoming more common.

At the Sawtooth Mountain Clinic in Grand Marais, Minn., more people coming through the doors have a health plan, as required under the Affordable Care Act. But the plans with the lowest monthly premiums tend to have high deductibles.

Clinic CEO Rita Plourde said that for many clients, the problem now is being underinsured. They have health insurance but cannot afford the out-of-pocket costs.

“So we’ve seen some pretty major drops in uninsured people, but we’ve actually at the same time seen an increase of our users who have very high deductibles,” she said. “So when they enter a facility they still have to have out-of-pocket costs.”

At Sawtooth Mountain and many other community clinics, government and grant funding subsidizes care, allowing the facilities to charge fees on an income-based sliding scale. The fees can be half what conventional clinics charge. The clinics have typically served the uninsured, but now help underinsured people with high-deductible health plans get care they can afford.

As a result, Plourde is convinced that community clinics will become more popular.

“I think that once individuals start shopping around, I think they’re going to realize that community health centers are a very good place to bring their families,” she said.

But community clinics need to do a better job promoting their services, she said. And some are trying to do that.

At a farmer’s market on St. Paul’s West Side, past the stands of produce, Angelica Diaz spreads the word about the neighborhood community clinic across town where she works, United Family Medicine.

“It’s a good resource to use that people don’t know that’s there,” she said.

Connie Walsh, the lead patient advocate at United Family Medicine, said her clinic isn’t seeing a big influx of insured patients struggling with high out-of-pocket costs yet. But she expects their numbers will grow.

“Their co-pays are so great or their deductibles are so great that they’re looking at community clinics as a good option,” Walsh said. “People are becoming very savvy at figuring out the best place for them to receive the quality health care that they need and deserve.”

In Coon Rapids, Nucleus Clinic gets some referrals from conventional clinics when patients are having difficulty with out-of-pocket expenses. Becky Fink, who runs the community reproductive health clinic, said that many patients with a high deductible health plan find it less expensive to bypass the insurance and pay cash.

“Typically, patients will prefer to use our sliding fee scale because it’s quite reasonable and within reach,” she said.

Even for clients with a relatively high income, Fink said, routine care of a urinary tract infection would cost a little more than $100. That’s a lot less than at nearby conventional clinics.

Price checks with HealthPartners and Allina indicate they’d charge at least $170 for the same care, plus lab costs.

Fink expects the growing demand for subsidized clinic services from people enrolled in health plans will continue despite the signature promise of Obamacare.

It’s frustrating to see insured people who can’t afford to pay for health care, Fink said. People need to know that the Affordable Care Act is pushing more people toward community health centers, she said, not decreasing the need for them.