Healthcare for the hard-up

A $40,000 hysterectomy: $700.

Basic X-ray: $10. Dental cleaning: $45. Intensive care unit: $600 per day.

The Access to Healthcare Network's prices sound like a doctor's bill from the 1950s or '60s. So it's not surprising that the Reno-based nonprofit -- which provides affordable, comprehensive healthcare to the uninsured working poor in Washoe County, Nev. -- has seen its membership swell to more than 2,500 people since it opened in 2007. Director Sherri Rice expects another 2,500 to join by the end of this year.

"We are in such a healthcare crisis in our country," Rice says. "Hospitals and the uninsured want to look for a new way."

The Access Network operates on one basic principle: shared responsibility. Its roots go back to 2004, when a group of local stakeholders, including two big hospitals and the county and state health departments, began looking for a sustainable way to provide service to some of the community's poorest people. According to Rice, they weren't interested in "another entitlement program" such as Medicaid, which relies on federal and state funding and doesn't require patients to put much money or effort into their own care.

Now, the two hospitals and more than 450 other healthcare providers have agreed to offer their services at low fixed rates. In exchange, the Access Network guarantees that its members will pay cash at the time of service. It pairs each member with a "care counselor" who ensures that medical appointments and follow-up care will be handled responsibly.

It's a good deal for the providers -- which range from pharmacies to acupuncturists, optometrists to cardiologists -- because it allows them to serve needy people with the assurance they'll get some payment without a protracted collection effort. The hospitals are also able to cut down on their charity expenses. (Patients who can't afford specialty services or coherent care often end up in emergency rooms, and hospitals are frequently stuck with the bills.)

"We put structure to a structureless population," says Rice. "We have proved that people at poverty line can pay."

Nevada residents who earn between 100 percent and 250 percent of the federal poverty level are eligible. Aside from the fixed rates they pay to providers, they pay a monthly fee to the Access Network: $45 for an individual, $90 for a family. Some small-business owners help employees by paying a portion of the fees.

Rice has only expelled 10 members for failing to pay. No one, she says, has asked for free service. "They ask to pay what they can according to income. They ask for their dignity. We give them both."

--Terray Sylvester

Developing to stop development

In 2001, Ted Harrison, working for the Trust for Public Land, acquired 1,400 acres of rabbitbrush and petroglyph-etched basalt boulders as open space for Santa Fe County, N.M. Nice accomplishment, but Harrison was frustrated: It was just a sliver of the more than 14,000-acre Thornton Ranch, which lies right in the path of Santa Fe's sprawl. And the Trust and the county couldn't afford to buy the entire ranch.

They did their best "to preserve discrete parcels," Harrison says, but "the real estate industry was washing away a lot of the effects."

So Harrison left the Trust and started the nonprofit Commonweal Conservancy. His group is now buying the remaining 13,222 acres of the Thornton Ranch south of Santa Fe, where it plans to create the Galisteo Basin Preserve: About 1,000 homes built on just 427 acres, with the rest set aside as open space.

Other developments in the West preserve more land, but typically they emphasize exclusivity and their open space becomes a "private refuge," Harrison says. Galisteo Basin Preserve is inclusive: No gates allowed, no golf courses and no country clubs -- and 10,000 acres of the open space will be open to the general public.

Ninety-five percent of the houses will be clustered in a 300-acre "village" that includes 30 percent county-approved affordable housing. There will be an environmentally oriented charter school and a commercial area to reduce the need for driving. Outside the village, some of the largest, most expensive lots are off-the-grid; their sales will help fund the rest of the land purchase. The village plan includes community gardens and a centralized rainwater-catchment and graywater-recycling center. Construction is slated to begin in 2010; a hundred-tree orchard has already been planted.

Harrison had to appease the residents of nearby Galisteo, who worried that the development would impact their water supply. He also reached out to include other nonprofits, from the Earthworks Institute, which is restoring arroyos, to the Quivira Coalition, which is fashioning a sustainable grazing strategy.

"Coming at this from a nonprofit perspective, part of the fun and craziness here is to see how many things we can fit together and really push the envelope," Harrison says. "If your goal is wealth maximization for a small group of investors, then these other social welfare ideas are not on the table."

Those ideas include a "memorial landscape" or environmentally friendly cemetery. "If we don't accommodate that," says Harrison, "well, of course, it's not a whole community."

--Jonathan Thompson

St. George, Utah, is building a community-owned solar PV field on city land -- homeowners make a one-time payment (less than rooftop solar) and agree to buy the electricity for 19 years.