It was only after the death of her husband in 2018, a year after their children sponsored their immigration to the U.S. from Venezuela, that Tatijana Kowalchuk began paying attention to the dizziness that made walking a challenge and shaking hands that made her writing a mess.

And so did the staff at Richmonds Health Brigade free clinic, who found a nearly quarter-inch tumor pressing on her brain.

The staff at Richmonds Health Brigade free clinic found a nearly quarter-inch tumor pressing on Tatijana Kowalchuk's brain. The clinic continues to offer her care and support.

She did not have the money to do anything about it and these days, Virginias free clinics are short of the resources they need to help people who, like the Kowalchuks, fall between the many cracks in the American health care system, which is why Del. Betsy Carr, D-Richmond, and state Sen. Barbara Favola, D-Arlington, are asking the General Assembly to lend a hand.

At the clinic, once staff found treatment for the usual explanation of dizziness middle ear problems was not helping Kowalchuk, they quickly arranged for a neurologist to examine her, free of charge, as well as for the MRI scan that found the tumor.

It was big; the surgery would cost a lot, Kowalchuk said. Health Brigade stepped in again, working long-nurtured connections with surgeons and hospitals to arrange the operation, again free of charge, and to negotiate a discount and payment plan for Kowalchuk to afford follow-up scans.

Tatijana Kowalchuk and medical case manager Robert Key talk at Health Brigade in Richmond on Feb. 13 about how much they mean to each other. Kowalchuk calls Key her guardian angel.

As new, if elderly immigrants, sponsored by their children, the Kowalchuks could not get Medicare and from what they had heard about the cost of health care here, doing something about Wladimiro Kowalchuks cancer scare was a frightening prospect.

Robert was my husbands angel. His guardian angel. He is my angel, said Kowalchuk, referring to the clinics veteran medical case manager, Robert Key, who took the lead helping the couple navigate his cancer treatment and later her surgery.

Virginias 60-plus free clinics provide care to some 75,000 people a year, amounting to some $114 million in 2022. It is a distinctive kind of care, too: focused on all of the needs a patient might have including some that do not always come to mind when people feel they need to see a doctor.

Kowalchuk saw the difference several months after her surgery. She had come back from a trip to her attic with a painful rash on both hands.

I called dermatologists and they said they could give me an appointment in two or three months, she said. The pain is really strong, Id say, but it didnt make any difference.

A visit to a hospital emergency room prompted a suggestion to see a dermatologist. She stumped three doctors at a local doc-in-a-box.

I finally came to Health Brigade, she said.

The nurse looked at my hands and said; Thats an infection the ER doctor said it wasnt that, Kowalchuk said. She said, Ill give you an antibiotic; if it is not better in two days come back and well figure it out. The first day I was a little better; the second day, a lot better.

It is paying attention, maybe even more than being able to offer free access to care, that is the key to what free clinics provide, said Karen Legato, Health Brigades executive director.

We look at the whole person," said Karen Legato, the executive director of the Health Brigade free clinic. "Its not the transactional model."

We look at the whole person ... its not the transactional model, she said.

That means, for instance, making sure a patients electricity is on and that they have enough food. Health Brigade will arrange connection with food pantries, for instance, and can help people access emergency help with utilities to make sure they are warm enough in winter and not overheating in a summer hot spell. If transportation is a problem, case managers and social workers figure out ways to deal with that.

Health Brigades distinctive outreach efforts, like its syringe exchange program, take similar extra steps, when staffers offer COVID-19 and flu vaccinations, clothing in the winter, and assessments of other medical or dental needs as well as a path to getting them treated.

But that whole-person approach, especially in the wake of COVID-19, is swamping Virginias free clinic network.

Coverage through Medicaid was expanded, and all of a sudden, people who werent insured were coming in, Legato said. We had people who didnt know what they had, and we were finding complex, chronic conditions ... and now that Medicaid is going away for them, theyre on our rolls and were taking care of them.

The free clinics compete with hospitals and private practices for physicians, nurses and other medical staff. Staffing accounts for about 80% of Health Brigades budget, for instance free clinics do get a bit of a break on the biggest driver of medical cost increases in other parts of the health care system: prescription drugs.

It takes a big heart to do this, but people need to be paid, Legato said. Even so, a nurse practitioner here may be making 30% less than in private practice.

Theres been a squeeze, too, on the heart of the free clinic model: the volunteers.

COVID-19 kept many away, as clinics tried their best to make sure they did not become hotspots. Statewide shortages in some specialties behavioral health is a particular problem mean many volunteers who used to pitch in cannot find the time and relief from their own patients demand to spare.

That has meant larger paid staffs than had been the pre-pandemic pattern.

Rufus Phillips, CEO of the Virginia Association of Free and Charitable Clinics, said budget amendments proposed by Carr and Favola would offer some relief.

Virginias free and charitable clinics are the backbone of our Commonwealths health care safety net, Carr said in a statement.

With Medicaid unwinding and the end of pandemic relief as well as increased economic pressures disproportionately affecting underserved communities, the need to sustain free clinics has never been greater, she said.

The amendments call for a $5 million-a-year bump in state funds for the clinics, for an annual total of $10.3 million. The current $5.3 million a year was set in 2016, with the idea of covering about 30% of the clinics costs. It currently accounts for about 18%, Phillips said. The clinics operating costs since then have climbed 170%.

If you look at clinics in 2016 and now, youll see big differences, too, Phillips said. Theyre adding dental care, wraparound supports for the social determinants of health; food pantries, even delivering food and showing people how to cook unfamiliar food.

Tatijana Kowalchuk relies on a free clinic Richmonds Health Brigade for care and for support.

And in the end, it is the staff paid and volunteer and the way they see the people who need their services, that make a difference.

So in spotting a concern in Kowalchuks once-every-six-month lab tests for a kidney issue last December, her nurse asked her to come in for another test last month, and with that suggested an every-three-month schedule just to be sure my kidneys are still OK, Kowalchuck said.

You know, they also have a mental health service, she said. Theyve been a real help after my husband died ... I can get down ... I have my daughter and her husband, my neighbor shes very nice but I really dont know many people here.

Brianne Chapman, center, holds up sign near members of the Kekoa Virginia Militia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

Philip Van Cleave, president of the Virginia Citizens Defense League, speaks during a Second Amendment Rights rally on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

Demonstrators march toward the General Assembly building at the state Capitol in support of various bills on Lobby Day, Monday, Jan. 15, 2024. The march was organized by New Virginia Majority.

Demonstrators put down signs before entering the General Assembly building at the state Capitol in support of various bills on Lobby Day, Monday, Jan. 15, 2024. The march was organized by New Virginia Majority.

Demonstrators enter the General Assembly building at the state Capitol in support of various bills on Lobby Day, Monday, Jan. 15, 2024. The march was organized by New Virginia Majority.

Demonstrators enter the General Assembly building at the state Capitol in support of various bills on Lobby Day, Monday, Jan. 15, 2024. The march was organized by New Virginia Majority.

Demonstrators put down signs before entering the General Assembly building at the state Capitol in support of various bills on Lobby Day, Monday, Jan. 15, 2024. The march was organized by New Virginia Majority.

Demonstrators wait to enter the General Assembly building at the state Capitol in support of various bills on Lobby Day, Monday, Jan. 15, 2024. The march was organized by New Virginia Majority.

Assaddique Abdul-Rahman, and organizer with New Virginia Majority, leads a chant during a demonstration in support of various bills outside of the General Assembly building at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

Assaddique Abdul-Rahman, and organizer with New Virginia Majority, leads a chant during a demonstration in support of various bills outside of the General Assembly building at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

Demonstrators enter the General Assembly building at the state Capitol in support of various bills on Lobby Day, Monday, Jan. 15, 2024. The march was organized by New Virginia Majority.

Young demonstrators attend a gun safety rally at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

Demonstrators attend a gun safety rally at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

Speaker of the House Don Scott, D-Portsmith, speaks to a crowd during a gun safety rally at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

Demonstrators attend an afternoon gun safety rally at the Bell Tower in Capitol Square on Lobby Day on Monday.

Speaker of the House Don Scott, D-Portsmith, speaks to a crowd during a gun safety rally at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

Young demonstrators attend a gun safety rally at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

Demonstrators attend a gun safety rally at the state Capitol.

A demonstrator holds a sign at a gun safety rally at the state Capitol on Lobby Day, Monday, Jan. 15, 2024.

During the Omega Psi Phi Lobby Day session, Senate President Pro Tempore Louise Lucas, D-Portsmouth, responds to questions from Fairfax County resident Robert Fairchild, right, about her priorities for the 2024 General Assembly.

Philip Van Cleave, president of the Virginia Citizens Defense League, speaks during a Second Amendment Rights rally on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

A flag is waved during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

Virginians on both sides of the gun debate make their case during Lobby Day at the state Capitol on Monday. Brianne Chapman holds up a sign near members of the Kekoa Virginia Militia during a Second Amendment rights rally hosted by the Virginia Citizens Defense League.

A demonstrator, who goes by Rustpit, stands in front of the Supreme Court of Virginia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day on Monday, Jan 15, 2024.

Cam Edwards of Farmville speaks at the state Capitol during a Second Amendment rights rally hosted by the Virginia Citizens Defense League.

Del. Delores Oates, R-Warren, speaks during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

Brianne Chapman holds up sign near members of the Kekoa Virginia Militia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

A demonstrator holds up a sign during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

Members of the Kekoa Virginia Militia hold guns during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day at the state Capitol on Monday, Jan 15, 2024.

Demonstrators hold flags in front of the Supreme Court of Virginia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day on Monday, Jan 15, 2024.

Demonstrators stands in front of the Supreme Court of Virginia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day on Monday, Jan 15, 2024.

A demonstrator holds up a sign at the state Capitol on Lobby Day during a gun rights rally hosted by the Virginia Citizens Defense League.

Jason Hazelwood holds a flag in front of the Supreme Court of Virginia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day on Monday, Jan 15, 2024.

Eddir Garcia, a Republican Senate candidate, speaks to demonstrators in front of the Supreme Court of Virginia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day on Monday, Jan 15, 2024.

A demonstrator, who goes by Rustpit, stands in front of the Supreme Court of Virginia on Monday during a Second Amendment rights rally hosted by Virginia Citizens Defense League.

Jason Hazelwood holds a flag in front of the Supreme Court of Virginia during a Second Amendment Rights rally hosted by Virginia Citizens Defense League on Lobby Day on Monday, Jan 15, 2024.

Jess Bookout, left, and Leslie Floyd attend Lobby Day to talk about early childhood education.

Virginians stand in the lobby of the General Assembly Building on Monday.

Virginians gathered for Lobby Day at the Virginia General Assembly include People wearing Guns Save Lives stickers in the lobby of the General Assembly Building.

On Lobby Day, Madison Brumbaugh, second from left, vice president of the Speech-Language-Hearing Association of Virginia, speaks with lawmakers, including Del. Michael Jones, D-Richmond, left; Del. Chris Obenshain, R-Montgomery; and Del. Wendell Walker, R-Lynchburg.

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VA's money-squeezed free clinics offer a vital helping hand - Richmond Times-Dispatch