“Doctora, por favor,” a middle-aged woman in a lilac shawl followed me into my clinic in South Los Angeles on a recent morning. The woman explained that she and her sister had been waiting outside our door since 5 a.m. for a chance at an appointment. But when the clinic finally opened at 8:30, she was turned away at the door. At my free clinic, we had to close to new uninsured patients a few weeks ago. We are out of money. It does not say free anywhere in the name of my clinic, but we are part of a small network of clinics that accept uninsured patients. There are some who say that we are considered a clinic of last resort. “I hope you like working with poor people,” the medical director said to a recent interviewee. But it is more than just economics that brings people through our door. “Por favor, Doctora,” the woman implored me. The woman was a patient of ours, and she had brought her diabetic sister for a chance at medical care. I checked the sister’s blood sugar, which was normal, made sure that she had enough medication, and scheduled her for an appointment in July, when our state and federal funding renews. The crumbling economy has intensified the need for free healthcare in Los Angeles. Although we have not tabulated our data, other clinics in the area report a 30 percent increase in demand from just one year ago. At my clinic, the line outside the door has grown steadily. When I send letters to patients with abnormal laboratory results, I see addresses from miles away while I used to see addresses only from the surrounding blocks. For a city without a comprehensive public transit system, that is notable. A complex mix of Medicaid reimbursement, federal grant, and state programs for the uninsured pay for the medical care we deliver. It is never enough. To combat the yearly shortfall, we request donations from patients, occasionally charge small fees for services, and hold community fundraisers. But the bulk of the deficit is covered by private grants and philanthropic donations. This year, the donations came up short. And so, at our last management meeting, our CEO declared us closed to uninsured patients who are new to the practice. Poverty draws patients into our clinics, but we witness a need more profound than simply money. Just in the past week, I have seen a 49-year-old Mexican dwarf who has never been to a doctor; a transient Honduran AIDS patient with a brain infection; a crack-addicted woman with three days of sobriety for a physical to enter rehab, and then her 15-year-old daughter to treat an STD. “La Mama,” who always refers to herself in the third person, brought her six asthmatic children in for yet another asthma flare triggered by the cold that passed quickly through the family in their studio apartment. In the face of such need, we want to throw open our doors. We have prioritized access above all, at the expense of medical supplies, medications, support staff, computers, infrastructure. We have stripped every luxury from our budget, and then some. Our patients wait for hours in a crowded and uncomfortable waiting room. And we, myself included, accept perhaps more than we should to preserve our “free” health center, open to all. It is easy to see why some might consider us the option of last resort. You have to really need something to come through our doors. President Obama has embarked on a national conversation to reform healthcare. There are two starting points from which to begin—increase access with universal healthcare, as Massachusetts has done, or reduce healthcare costs to bring healthcare within reach of more people, which is President Obama’s proposal. Here in Los Angeles, we confront that balance on a daily basis. We are just starting to see federal stimulus money filtering into our system. State programs have allocated more funding to our service area in Los Angeles, and there is the promise of federal aid to hire more physicians, to implement electronic records, and to build new buildings. As we discussed areas for potential growth at our last management meeting, my CEO commented, “Wow, I haven’t had a conversation like this in 10 years.” One morning last week, I was waiting with my clinic manager for the lab to open. A woman who was also waiting took advantage of the rare down moment to complain about the lengthy delays at our clinic. “Every time I come, I spend the whole day. They are always so behind. Who will watch my children for a whole day? But, I can’t complain so much. I have no insurance, and I have no money to pay a doctor. Here they always attend me very well,” she said. “Where else can I go?” Ellen Rothman, HMS ’98, practices at a community health center in Los Angeles. The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.