My grandmother died in 2019 because she waited too long to seek care, and I've spent my career since then asking what healthcare access really means. That's why I was at Riverside Community Health Center at 6 AM on a Tuesday in August 2040, watching staff prepare for the flood that would hit two hours later.
Westside had made a different choice in 2037. With $2.5 million to invest in healthcare infrastructure, they'd renovated the old clinic to withstand climate disruptions rather than distributing care through mobile units. The building was elevated four feet, mechanical systems moved to the roof, backup power installed for two weeks of operation. The investment was massive, but the assumption was clear: when people are sick, they need a place with doctors, equipment, and resources that can't be replicated anywhere else.
Three years later, I wanted to see if that assumption was holding up.
By 8 AM, water was rising outside, but inside the clinic, morning appointments ran on schedule. The backup generators hummed. The lab processed blood tests. The pharmacy filled prescriptions. A diabetic patient whose insulin pump malfunctioned got immediate care. A child with a severe asthma attack received nebulizer treatment. An elderly man with chest pain got an EKG within minutes.
None of that would have been possible without the clinic's infrastructure—the diagnostic equipment, the climate-controlled environment, the trained medical staff, the reliable power and water systems.
By noon, though, the access problems were becoming obvious.
Mrs. Rodriguez had called three times trying to reach the clinic for her daughter's epilepsy medication refill. She lived six blocks away, but those six blocks were under two feet of water. The clinic was open, fully staffed, perfectly functional—and she couldn't get there. A staff member eventually arranged for a volunteer with a high-clearance vehicle to deliver the medication, but it took four hours.
Here's what Westside's choice comes down to: The clinic provides sophisticated medical care that distributed models can't match, but only for people who can reach it. And climate disruptions are making that harder.
The clinic serves 5,000 residents and costs $1.8 million annually—about $360 per person per year, roughly double a distributed care model. Funding comes from insurance, sliding-scale fees, and increasingly uncertain grants.
"We stay open during every flood, every heat wave," the clinic director told me, reviewing the patient list. "But staying open doesn't solve the access problem."
The clinic's supporters argue the costs are justified. The diagnostic equipment alone—lab analyzers, imaging machines, monitoring systems—represents hundreds of thousands of dollars that require climate-controlled, secure facilities. The staff includes experienced physicians, specialists, and nurses whose salaries reflect their training. The building's resilience features need ongoing maintenance and upgrades.
During the August heat wave, the clinic became a cooling center, its industrial air conditioning running even as the grid struggled. Elderly residents without transportation, though, faced dangerous conditions traveling there. One woman collapsed from heat exhaustion walking to the clinic and ended up in the emergency room instead—exactly the expensive outcome the clinic was supposed to prevent.
The clinic's physician, Dr. Martinez, was frank about the limitations. "We can provide excellent care to people who make it through our doors," she told me between patients. "But we're losing people who can't get here. And I don't know how to fix that without fundamentally changing what we are."
Some residents have stopped trying to reach the clinic during disruptions. I met a mother whose son has asthma who now drives fifteen miles to a hospital during floods because "at least I know they'll be open and I can get there on the highway." The clinic is closer and provides better continuity of care, but accessibility trumps quality when your child can't breathe.
The clinic has tried to adapt. They've extended hours, added telehealth appointments, partnered with a volunteer transportation network. Telehealth requires reliable internet, which many residents lose during storms. The transportation network depends on volunteers with appropriate vehicles, and there aren't enough of them.
During the September floods, the clinic treated patients for four days straight while staff slept in the break room to maintain coverage. The generators performed perfectly. The supply room never ran low. The building protected everyone inside. Patient volume dropped by 60% because people couldn't reach them.
"That's the paradox. We invested $2.3 million to create resilient infrastructure, but resilient infrastructure doesn't help people who can't access it."
—Clinic coordinator
The clinic is now discussing whether to use some of their operating budget to fund a peer health worker program—essentially adopting elements of the distributed model they rejected in 2037. That would mean reducing clinic hours or cutting staff positions, undermining the very capacity that justified the centralized approach.
The residents I spoke with were divided. An elderly man with heart disease told me, "I need real doctors and real equipment. I can't trust my health to someone from the neighborhood with a tablet." A young mother said, "What good is the best clinic in the world if I can't get my kids there when they're sick?"
The clinic's resilience is real. During the heat wave, during the floods, during the wildfire smoke events, the building's systems kept functioning. The staff stayed. The care continued. Resilient infrastructure doesn't equal resilient access, though, and Westside is learning that distinction matters.
Three years after choosing a climate-resilient clinic over distributed care, the neighborhood is facing questions about whether they made the right choice. The clinic provides sophisticated medical care that mobile units and peer workers can't replicate. It provides that care primarily to people who can reach it during good weather, and good weather is becoming less common.
The flood receded after three days. The clinic had never stopped operating. Mrs. Rodriguez's daughter had missed two doses of her epilepsy medication because her mother couldn't reach the pharmacy. A diabetic patient's blood sugar had spiked because he'd skipped his appointment rather than risk the flooded streets. An elderly woman with COPD had struggled through the heat wave at home because she couldn't make it to the cooling center.
The clinic was open. The doctors were there. The equipment was working. For many residents, it might as well have been fifteen miles away instead of six blocks.
"We built this place to last. We just didn't solve the problem of getting people here when they need us most."
—Dr. Martinez
Westside lives with this uncertainty now—their clinic can withstand climate disruptions, but can a clinic that withstands disruptions matter when the disruptions prevent people from reaching it?