Think the fight over the stimulus or the bank rescue package or the climate bill was gnarly and mean? Then brace yourself for the great health care reform debate.

The realm of the abstract is in the past. How the nation cares for the sick is — very literally speaking — personal, grinding down to the passion-producing subjects of the doctor-patient relationship, as well as the quality of the U.S. health care delivery system and society's moral obligation to insure the uninsured.

Health care reform is also, of course, about reeling in costs.

And, just how much is at stake? According to the Kaiser Family Foundation, a nonpartisan policy group, expenditures in the United States on health care rose above $2.2 trillion in 2007, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980. Also, in 2007, U.S. health care spending accounted for about 16 percent of the nation's gross domestic product or, put another way, about $7,400 per resident.

Medicaid, a combination of state and federal programs designed for those unable to pay for health care services, is the nation's largest health insurance program. According to the Department of Health and Human Services, it covers some 60 million poor people, or about 1 in 6 Americans. The program pays for around 37 percent of all births in the United States and helps pay for some 60 percent of patients in nursing homes.

And, as a local program shows, it also pays for the dental care of indigent children.

The local example, the Sarrell Dental Clinic, could provide a blueprint for attacking health care reform, those involved with it say — something Congress would be wise to pay attention to.

"I've been involved in medicine for 45 years, and I've never seen anything like this," said Dr. Warren Sarrell, a retired Anniston cardiologist who helped get the clinic started in 2005. "If Congress is smart, they will look at what we have achieved here. I honestly don't understand why this isn't being replicated all over the country."

The nonprofit Sarrell Dental Clinic has gone from having 8,500 appointments in 2005 to 30,000 in 2008; it is projected to have 55,000 in 2009.

The main office, which also houses the much smaller Sarrell Eye Clinic, is on the ground floor of the Medical Arts Building at 10th Street and Leighton Avenue. But since 2005, the clinic has expanded to include nine other offices from Cherokee County to Coffee County. The clinic has a staff of 14 full-time dentists, seven residents from the University of Alabama at Birmingham, 38 dental hygienists, and 28 clinical and support staff.

While these numbers might be interesting, the relevancy to the health care debate is how the clinic is run and how this, a program serving the poor, actually has profits to manage while keeping costs down.

The business side of the house — accounting, booking appointments, human resources and so on — are completely separated from the medical side. The dentists have nothing to do with the business side, and the business managers have nothing to do with the medical side. Its only source of revenue is Medicaid reimbursements and those from the associated state-run programs, such as All Kids, and Blue Cross Blue Shield's Child Caring Foundation. The clinic also takes some cash payments, mainly from Spanish-speaking clients.

The result, says Jeff Parker, the CEO of the Sarrell Clinic, is that the clinic is able to use managed profits from these programs to expand into other parts of the state, serving more and more children each year, while paying the dentists and support staff competitive wages.

The clinic has done this, he adds, by saving Medicaid and the health care system, or better put, the taxpayers, money.

The clinic, Parker says, started out charging an average of $328 per patient visit in 2005. That cost has now been reduced to $125. And that, Sarrell says, "saves a hunk of money."

And it proves something, Parker says.

"We have proven that a dental practitioner can operate a successful business on current Medicaid funding," said Parker, who also serves as a professor of business at Jacksonville State University.

Parker explains that the clinic has no debt, uses the most modern technology, is expanding and that it pays competitive wages.

Parker is a businessman, having served in leadership roles at a number of multi-national companies in the past, including Bryant Foods. He doesn't know the ins and outs of dentistry, he readily admits. His talents are in running the business.

"Dentists are not taught business in dental school," he said. "In our model, the dentist practices dentistry. They don't have to worry about payroll, scheduling, paper work; all they have to do is perform great dentistry."

His side of the office, his accountants, and schedulers and support staff, they take care of all that, he says.

This frees the dentist up, says veteran dentist Dr. Edward Lindsey of Gadsden, to practice without worrying about the business end.

"This is a new model," said Lindsey, who is on the board of directors of the Sarrell Dental Clinic. "This is not what dentists are used to. They usually run overhead at around 60 percent and don't have that kind of volume."

John Rutkauskas, the CEO of the American Academy of Pediatric Dentistry in Chicago, agrees the clinic's model seems to be working.

"The Sarrell Clinic appears to us to be very successful," he said. "The partnership with UAB and the way the program is working is clearly creating a dental home for a lot of kids. We support it and think it could be used as a model."

The Sarrell Clinic has a couple of advantages that help the bottom line. One is that Regional Medical Center leased the ground floor of the Medical Arts building to the clinic for $1 a year. It also benefited early from foundational support from the Community Foundation of Calhoun County, although it runs without that support now.

The other advantage is the partnership the clinic has with UAB School of Dentistry and its pool of residents.

"We were approached about coming over," said Dr. John Thornton, a dentist and associate dean at the UAB dental school. "We had the expertise they needed here, and we didn't particularly want to be involved in the business management end of it. So it was a good fit."

The model, Thornton went on, "is that we are out of the business part of it. Jeff Parker is a business man; he has a solid business model. He's got a lot of experience, and his expertise allows us to concentrate on what we're good at, dentistry."

Thornton agreed that the clinic could serve as a model for health care reform. "I've seen a lot of different models," he said. "I've never seen anything that worked as well as this one. Congress should have a look at this."

Part of what makes the model work, says Thornton and Parker, is getting people to show up for appointments and getting them to return for follow-up appointments. The Sarrell Clinic has a 90 percent show rate and part of that is because some staff at the clinic call patients frequently to remind them and encourage them to arrive.

When they do come, they are treated with respect. In the waiting room, for example, the equivalent of a maître de can be found tending to the wants of parents and children, explaining delays, if there are any, and answering questions. It also helps that the Sarrell Clinic is open six days a week.

From the start

Discussions about opening a clinic of this size in Anniston started taking place several years ago, according to Wayne Carmello-Harper, the president and CEO of the Community Foundation of Calhoun County.

"When we first started talking about the need for a dental clinic here," he said, "we discovered that about 2,800 kids in Calhoun County didn't have a dental home. All of the Head Start kids were bussed once a year to UAB and only three dentists in the county took Medicaid. It was a problem."

Sarrell, a member of the board at the time, threw his effort into the project as did a number of local dentists, especially Don King of Oxford and Bruce Cunningham of Jacksonville.

"These guys really had a passion for getting this done," said Carmello-Harper. "They never gave up on it."

Since then, the clinic has not only grown to serve more children — who can be as old as 20, if they qualify — it has also started producing a lot of revenue.

In 2008, the Sarrell Clinic had revenue of a little more than $4 million. Next year, CFO Burt Arthur says, that number will be closer to $6 million.

That might seem to be some big money for a nonprofit, says Sarrell, a well-respected retiree who has become an icon of volunteerism in and around Anniston. But, he stresses, it is put to good use and that includes Parker's salary of $146,000 a year.

That's a figure, Sarrell points out, that was approved unanimously by the clinic's board, and amounts, Parker adds, to about half of what he paid in federal taxes when he was in the for-profit business world.

"When I first started working here in 2005, I was paid $28,000 a year," Parker says.

Additionally, CFO Arthur says, the clinic is audited regularly by Anniston-based Edgar and Associates, and the public is welcome to scrutinize the clinic's tax returns by either viewing them online at www2.guidestar.org (free registration is required for viewing) or by dropping by the office to have a look.

Also, as Carmello-Harper points out, nonprofit "doesn't mean you have to be impoverished. It doesn't mean you have to have a zero balance at the end of the year. It just means you are exempt from paying federal income taxes. There are plenty of hospitals that operate under the same rules."

If there is something more that could be done in the realm of dental care in Calhoun County, says Carmello-Harper, it is with adults. He explains that there are solid revenue streams that will fund children's dental care, but virtually nothing that will help with indigent adult care.

An example, he says, is a dental clinic Cunningham is running at the other end of 10th Street that serves adults on precious little funding.

As for the greater health care debate, the people at the Sarrell Clinic think they have something to add as well.

Sarrell, for example, who's still going strong at age 85, doesn't want the dental or the eye clinic to be the stopping place. He sees the potential for expanding into health clinics.

"We tried it once before in Talladega," he said. "It was just a miserable failure. But we've learned a lot, and we have a model that will work. Can it be carried over into general medicine, into regular medical clinics? Well, I'm already thinking about how to do that."