Over the past month or so, Hospital District trustees, one by one, have gotten a very different view of Indian River Medical Center – the view from dilapidated houses half-hidden by a wild overgrowth of vegetation in a four-block pocket of extreme poverty just across and down the road from the hospital.

Julianne Price, head of the Health Department’s PACE program for environmental health, has in separate trips taken trustees Allen Jones, Ann Marie McCrystal and Tracey Zudans over the rutted dirt roads of Gifford and West Wabasso in her minivan to show them conditions in the neighborhoods where many of the hospital’s indigent patients live.

As the hospital inches forward in the partnership process with Cleveland Clinic, the Hospital District Board – which exists to provide public funds for indigent healthcare – is beginning to ponder its own future mission.

And as board members debate their dollars-and-cents commitments to various agencies that provide healthcare to the poor, stepping out of the boardroom into the worst of the county’s poverty cannot help but bring a sense of urgency.

The debate centers on this question: If Cleveland Clinic takes on greater responsibility for indigent care in Indian River County, should the Hospital District cut taxes to reflect a reduced need for taxpayer funded care? Or should the District use the money it has to expand care for the poor?

The decision is complicated by the fact that Cleveland’s takeover of IRMC is not yet a done deal, leaving the details of what indigent care it will provide unclear, even as the District comes up on the deadline for putting next year’s budget in place.

Price has been taking board members on tours to help them understand what is at stake as they wrestle with the complicated budget situation.

Few outsiders ever penetrate these neighborhoods that Price is intimately familiar with – certainly not most residents of the barrier island, a bridge away, or Grand Harbor, a mile away.

On nameless roads that don’t show up on county maps, the elderly live out their days amid addicts and prostitutes – all of them in need of healthcare. They are some of the poorest people in the county, surely some of the sickest, and too often, the hardest for healthcare to reach.

Economically, they are as far down the scale as anyone could be from the affluent residents Cleveland hopes to lure to its state-of-the-art centers of excellence, but they too are patients Cleveland will soon be treating – if all goes well with the planned acquisition of Indian River Medical Center.

The disparate groups are physically close in terms of geography but from separate worlds when it comes to health and healthcare. As proof: the life expectancy of the residents of Gifford and Wabasso is a decade shorter than their neighbors across the bridge on the barrier island.

At its other hospitals, Cleveland Clinic offers free emergency care to uninsured people earning up to 250 percent of poverty guidelines, and discounts for those earning up to 400 percent of guidelines, provided patients are residents of the county where the hospital is located. As in Vero, patients at Cleveland Clinic are screened for Medicaid eligibility.

That is a more generous policy than the Hospital District’s and if Cleveland Clinic takes on more of the burden of caring for the indigent across the board, the Hospital District will be in a position to reduce taxes or expand programming.

But a definitive agreement is now past due from Cleveland Clinic negotiators, and the delay has frustrated Hospital District trustees who want to see and mull over the specifics of the Cleveland’s charity care policy before setting a final tax rate, or committing to requested increases from the agencies it funds, or inaugurating new programs such as the Mental Health Association’s program on school violence.

The issue of program expansion first arose in May when the Hospital District began looking at raising the income level it uses to define the medically indigent from 150 percent of the federal poverty level to 200 percent, potentially adding 3,000 poor patients to the 4,000 the District currently helps care for. The move would cost another $2.4 million, and that estimate is believed to be conservative.

In June, the Hospital District Board agreed to let Treasurer Allen Jones research ways to better serve the Gifford community by expanding services at the Gifford Health Center, questioning whether the Hospital District-built-and-owned center was being utilized to its full potential.

But at the same June meeting, there were questions about whether to fund Indian River Medical Center’s full request for indigent care since Cleveland Clinic could take over at least partial responsibility for those costs midway through the fiscal year.

At its July 25 meeting, the District approved a tentative budget that hikes the tax millage rate to a maximum of .9405, despite an increase in property values expected to bring in close to $1 million more than last year with the current millage rate of .8894. The .9405 rate means property owners would pay 94 cents for each thousand dollars of taxable real estate value to provide healthcare for the poor.

“I would point out that the biggest amount of increase in this is for IRMC,” Jones told the board. “They had a $1.2 million increase over what was budgeted a year ago. That’s a total of $7.5 million for indigent care. If that turns out to be $5 million, this millage rates falls to .78, and if it turns out  to be less than that, then it falls even further.”

While the maximum millage rate of .9405 can be cut before the budget is finalized, the tentative increase has already led to grumbling.

“I would caution us not to be making these kinds of decisions hastily,” said trustee Zudans at that May meeting. “To jump from 150 to 200 percent costs us conservatively $2.4 million? I mean, our taxpayers . . .”

“Well, you can ignore that [the need] exists [even though] it’s been brought to our attention by United Way big time and every other agency,” said trustee McCrystal. “You can ignore it and forget it . . .  or you can address it, and just bite the bullet and fork it out. It exists out there, and you know the people that are affected.”

Trustee Zudans, who was appointed by Gov. Scott to the District Board and faces a challenger in the November election, made clear she is not eager to put the burden of healthcare for the poor on taxpayers.

“Some of the programs that exist are better funded by philanthropy,” she said last week, reached on a vacation with her family.  “We have an amazing philanthropic community and I feel they would love the opportunity to be more informed about these programs and be able to participate.

“I am concerned about the talk of expansion of programs when they’re going through this great transition, this huge transaction, until it’s complete and we’ve ironed out all the wrinkles,” Zudans went on. “I think programming [changes] should be based on what the Hospital District will become after the transaction.”