As the complex debate over health-care reform rages, local government hasn't really been figured in.

While lawmakers in Washington at least considered the impact of sweeping Medicaid expansions on state budgets, and debated where responsibility for designing health insurance exchanges should lie, virtually no one thought of the uninsured problems or runaway costs as issues local government should address. And that, says Jeff Downes, Montgomery, Ala.'s deputy mayor, was a big mistake.

"Every region - every city - has a unique situation," says Downes. "It's hard to paint health reform in a broad brush across the entire nation." Instead, Downes believes that metro regions must develop local solutions to local problems. Over the past two years, that's precisely what Montgomery has done with an unusual communitywide effort. Last December, the effort reached its first milestone: The city secured funding to break ground on a state-of-the-art health clinic that will serve 25,000 low-income residents each year. Montgomery's experience illustrates how effective cities can be in addressing urgent local health needs.

The story of Montgomery's efforts to address the health needs of uninsured residents goes back to a dark event in the city's history: The 1983 Todd Road incident, in which the police raided a house in a black neighborhood after spotting a suspicious individual who was actual a mourner at a funeral. The incident severely strained local race relations, but it also gave birth to a program known as Leadership Montgomery. Initially nothing more than an educational experience for civic leaders, the program eventually grew into a pragmatic group - led by well known architect and urban planner Gianni Longo - that crafted a vision centered on education, race relations and economic development.

But it wasn't until the spring of 2007 that the new group, Envision 2020, focused on health care. That's when Jim Ridling, chairman of the board at Jackson Hospital, one of Montgomery's two big medical systems, came to Mayor Todd Strange with a problem: Uninsured patients were overwhelming his and Baptist Memorial Health Care Corp.'s emergency rooms, endangering the economic viability of Montgomery's largest employers and the lives of citizens in need of swift trauma care.

Envision 2020 Executive Director Lynn Beshear, a registered nurse by training, immediately took up the problem. A study of local health-care providers convinced her - and local leaders - that "we did not have a system of health care - no way, no how was it a coordinated system." So the city, the county, the chamber of commerce and others raised $150,000 to hire a consulting firm to help conduct an in-depth analysis of the region's problems and to help them find a solution. It found that roughly one-quarter of the people in the region were uninsured or "medically indigent" and desperately in need of a medical provider. While the consultants concluded that the two area hospital systems "are in no immediate financial danger," it did note that their facilities were old.

Despite the fact that emergency room overcrowding didn't pose a mortal threat to hospital balance sheets, civic leaders thought it was unfair that hospitals were being forced to bear such a large burden. Some solution was needed. To retired Judge William Gordon, chairman of Envision 2020's health committee, it was clear what that solution should include.

"[I]f you wanted to get people out of the ER," Gordon says, "the one thing we had to have was someplace for them to go." So one day, Jackson Hospital President and CEO Don Henderson picked up the phone and called Bernell Mapp, CEO of Health Services, Inc., one of the nation's oldest federally qualified community health centers. Henderson learned that Mapp and his board had plans to expand, but they'd been unable to procure funding to realize it. In short order, the two men agreed to work with Envision 2020 and others on an application for a federal stimulus "bricks and mortar" grant, with which they hoped to build a new federally qualified health clinic.

To sweeten the grant proposal, Jackson Hospital agreed to donate a parcel of land on its campus (valued at $1 million) to the new clinic. Last December, community leaders learned they'd been awarded an $11 million grant. Local leaders hope to open the facility in 18 months, and plans are already afoot to secure funding for another new health clinic to serve the southeastern section of metro Montgomery.

Montgomery's new health clinics promise to provide much-needed services to an underserved population - while also relieving the pressure on Jackson Hospital. (It's no coincidence that the new clinic is on its campus.) However, the plan stops short of providing residents with what health-care reform could (if it works as envisioned) - namely a choice of providers. Nonetheless, officials in Montgomery seem to prefer their incremental step to health-care reform's reach for a sweeping solution.

Mapp, who supports sweeping health-care reform, puts it differently: "I don't know what's going to happen in Washington, D.C.," he says, "but I have seen real reform in this city."