After 39 years in existence, a rural network of health care providers is in serious trouble.

MACT Health Board Inc. operates multiple health care facilities in the four counties of Mariposa, Amador, Calaveras and Tuolumne, hence its name. While its services are targeted to American Indians and their family members - the health board is composed of representatives from the American Indian Council of Mariposa, Calaveras Band of Me-Wuk Indians, Ione Band of Miwok Indians, Jackson Band of Mi-Wuk Indians and Sierra Native American Council - the majority of its clients come from the general public, according to long-time board member Sam Baugh, a cultural resources representative for the Jackson band.

But with the state budget impasse setting new records for delay with each day, a network that provides care to thousands of people who couldn't otherwise afford it has entered uncharted waters.

"We are closing several clinics because of the state budget and some of them are permanent closures," said MACT Health Board executive director Nancy Ehlers. "This is the first time we've ever had to do something like this."

Of the 13 clinics MACT was running - three of which are located in Amador County - the medical and behavioral health clinics in West Point and Sonora closed last week, as did the dental clinic in Sonora. The Jackson dental clinic will only handle emergency cases now, and the Jackson medical clinic next door won't offer any services until a budget is passed. Other clinics are holding out as long as they can, but money is running out and more closures are expected after Oct. 1 without a new budget.

MACT officials tried to put up the $3 million clinic in Mariposa for a $1 million bank loan to pay back vendor debts, but that fell through. Ehlers is now hoping for half that. "Any bank that's willing to step up for a short-term loan, we'd love to hear from them," she said. "Our vendors are being very kind to us."

When Ehlers spoke to the Ledger Dispatch last week, MACT's staff of 130 employees had been slashed. "We're at 73 and going deeper," she lamented last Friday.

Rebecca Patterson, a medical assistant at the Jackson clinic, estimated she was losing an average of three co-workers a day. When she spoke Monday, the dental clinic next door had just dismissed half its employees. "It's our skeleton crew right now," she said. "Mariposa shut down today. All of behavioral health is gone. ... We're losing people like crazy because of this budget."

She contacted the Ledger Dispatch in the hope the public would register its concerns with state representatives. In MACT's case, that would be Republican Sen. Dave Cox at 223-9140.

More troubling are the patients being turned away. There were 91,000 patient visits at 13 MACT clinics last year, and Ehlers said the program has been averaging about 5,000 visits a month through 2008. Seventy-three percent of the patients clinic staff sees are Medi-Cal recipients who often struggle finding care elsewhere because Medi-Cal reimbursement rates are so low, Ehlers said. Medi-Cal pays less than half of the cost to provide care to their patients Marshall Medical Center's Jim Whipple said in a recent press conference with Gov. Arnold Schwarzenegger.

MACT also operated the only behavioral health clinic for foster children in Amador County, at least until it was forced to close its doors last week.

As for why many MACT clinics won't be able to reopen, there are multiple reasons. The cost of doing business in the more remote areas is so high that there would be no way to recoup the losses the program has already endured. And the ones that do reopen will probably take at least a year to fully recover.

The fixed rates of some insurance providers - like Healthy Children - don't pay as well, especially when it comes to dental costs, Ehlers explained. She remembered one of her dentists giving a child an $800 crown the insurer only paid $5 toward. MACT absorbed the loss. "We always go above and beyond and that's probably why we're in the place we are now."

Baugh, a member of the Sierra Native American Council, has been on the MACT board for 15 years. "Where are they going to go?" he wondered of the patients. "It's all because of that damn state budget."

Ehlers expects many patients to turn to expensive emergency room care now that their clinics are closed or else flood remaining clinics.

"We expect that we're going to be inundated with people that don't even have Medi-Cal or CMSP," said Terry Lindsey, a physician's assistant who splits his time between clinics in Plymouth and Pioneer.

CMSP stands for County Medical Services Program, a medical assistance program for those no longer eligible for Medi-Cal, explained Jackie Steele, director of the county's social services department, which processes applications for Medi-Cal and other forms of health insurance. The recent crisis has revived thoughts of a universal health care plan for Steele. The governor's plan to insure every Californian collapsed amid intractable factions last year.

"These are hard times, aren't they?" Steele said.