THE SETTING FRANKLIN COUNTY

Virtually the prototype of rural New England, Franklin County is the most sparsely populated county in Massachusetts, with 26 towns and a total population estimated at 70,806 in 1999.5 Since the 1700s, Franklin County’s social and economic life has been organized around its many densely populated, socially tight-knit industrial villages (each town, a jurisdictional entity, typically includes several of these historic villages) surrounded by a produc-tive agricultural countryside.

Skilled employment in the major local industry of the 20th century, toolmaking, reached the tens of thousands in its heyday during World War II, declining rapidly in the 1960s and 1970s. The postwar period also brought a rapid decline of the county’s agricultural sector. Many Franklin County residents are from former farming families who inherited their land and a way of life that has become less and less sustainable.

The county’s population numbers reveal trends of both out-migration and in-migration. With shrinking opportunities for skilled industrial employment and fam┬Čily farming, changes in the county’s demographics reflect a relative loss of younger working-age adults and a relative increase in the population segments living in poverty at the extremes of age.
Asian, former-Soviet, Latina(o), and to a lesser degree African American segments of the population, while still in smaller than state and national proportions, are increasing rapidly through migration from the nearby urban centers of Worcester, Springfield, and Holyoke. Unlike their postwar counterparts who benefited from federal agricultural price supports and from land values at bottomed-out post-Depression levels, today’s immigrants face low-paid employment and a dearth of affordable housing. Service jobs in today’s growing tourism sector rarely supply a living wage or employer-paid health insurance.

ACCESS TO HEALTH CARE

As much as 15% to 20% of the adult population in Franklin County is estimated to lack health insurance or an income adequate to pay for needed medical care. Health insurance has become increasingly unaffordable for Franklin County employers. Small employers, most of whom are themselves struggling, often forego health insurance altogether, not only for their workers but also for themselves and their families. Since 1996, welfare reform has exacerbated the usual “churning” effect of rapidly alternating Medicaid eligibility and disenrollment among the poor, with people now covered by Medicaid for shorter periods of time, interspersed with periods of no health insurance coverage.

Prior to the existence of the Health Links program, traditional charity care and the community hospitals emergency department were the only points of access to medical care for uninsured or underinsured Franklin County residents. The hospital (privatized in 1986 from its longstanding status as the only public hospital serving the county) had never had an outpatient primary care department, nor was there a community health center serving the area. Thus, apart from federally funded family planning and other similarly narrow clinical public health services offered by nonprofit agencies, the Health Links program represented the first time in the community’s life that ambulatory general medical care was offered to the population at no cost to patients.