This past June, MediCal stopped reimbursing Sage Femme Midwifery, the Mission-based birthing center, for the babies it was delivering for MediCal patients. Actually, MediCal stopped paying Sage Femme for everything. “We weren’t put on the “suspend payment” list , like the others,” says Judi Tinkelenberg, Sage Femme’s founder.“They just stopped paying.”

When the state budget was delayed for over three months this summer, physicians still received payments. They were protected by federal law, which requires MediCal to reimburse them within 30 days. California’s community health centers had no such protections. They were left to left to fend for themselves and continue to struggle months after the budget was finally approved.

Judi Tinkelenberg, the nurse midwife who founded, and runs Sage Femme, initially supplemented the delayed payments with her own savings. When those ran out, she had to ask her employees to go without pay. The MediCal payments began trickling in again in late September, but the debt has yet to be paid in full. All told, California owes the state’s community health centers $857 million. Sage Femme is owed about $20,000. The full amount may never be paid – MediCal’s own rules state that if it is billed for a service that was performed six months ago, it only has to reimburse 75 percent of the cost. If MediCal is  billed for a service that was performed over a year ago, it doesn’t have to pay at all.

Some 53 percent of Sage Femme’s patients are on MediCal. Three years ago, each pregnancy  used to net the center about $1,700. After three years of 10 percent  cuts by MediCal to its reimbursements, the center now gets $1088 for eight prenatal care visits, plus delivery – the reason that many nurse midwives, and the only other birthing center in the Bay Area – Sacred Birth Place in Oakland, do not take MediCal.

Tinkelenberg says that she opened Sage Femme largely because the dot-com boom of the late 1990s, which left her with a patient base that was living in smaller and smaller spaces, with roommates and next-door neighbors who were unnerved by the sounds of – well – a human being giving birth to another human being.

Facilitating homebirth in such conditions was, as Tinkelenberg describes it “not terribly fun.” In addition, poor clients (to qualify for MediCal, a patient needs to make 200 percent or less of the federal poverty level) were more likely to live far away from a good hospital. A clinic building just five minutes away from San Francisco General made good sense.

In many ways, Tinkelenberg, and other clinics, are trying to hold on until  2014, when changes made to federal health care law by the Obama administration will redirect a substantial amount of federal money into small clinics, turning them into  into major players in regional health care. It will also require states to reimburse licensed midwives.  Currently, a nurse midwife needs to attend every MediCal-subsidized birth, which is how Tinkelenberg, as the only nurse midwife on staff, has already attended 100 births this year.

Meanwhile, Tinkelenberg’s associates haven’t so much tried to persuade her to stop seeing MediCal patients. Instead they make pointed hints about how perhaps she should take on fewer MediCal patients.  Tinkelenberg refuses to do so.

Before she became a midwife she spent ten years working in hospitals where it was entirely possible to have a natural childbirth.  Before epidural and c-section rates began to rise dramatically, and issues of consent around these procedures blurred.

Until then, Sage Femme is looking for the sort of funding that would allow it to keep going even if MediCal continues to be erratic in its payments. Most grants are oriented towards non-profits and turning a for-profit clinic, however unprofitable, into a nonprofit is a complicated, not always possible process.

At the beginning of her ten-year stint in hospitals, she says that it was entirely possible to have a natural pregnancy. Today, one in three children in America is born by c-section and many of Tinkelenberg’s patients come to her less out of ardor for natural childbirth, and more out of a terror of involuntary, unnecessary surgery. “How do you say to a person? Based on your financial issues…how do you say that only people who can afford it can have access to a midwife?”

Good question. A simple “No” might suffice. But Tinkelenberg carries on with business as usual — waiting ’til 2014, and trying to get bills paid in the meantime.