At the Open Door Health Center, a charity clinic in Mankato, the staff is turning away 100 patients a month.

At the Dorothy Day Center in St. Paul, the number of people sleeping on cots and mats shot up 40 percent last year.

At metro area food shelves, visits jumped by 21 percent last year, to 1.2 million, prompting the Greater Twin Cities United Way to raise an emergency cash infusion of $1 million. Statewide in 2008, Minnesotans made a record 2.26 million visits to food shelves, up nearly 15 percent, the advocacy group Hunger Solutions Minnesota said Monday.

Across Minnesota, more and more people are slipping through the public safety net, a web of programs that has grown thin with budget-cutting over the past six years and may face further cuts in this year's state budget crisis.

As a result, more and more are landing in the state's private safety net -- including food shelves, emergency shelters, community clinics and hospital emergency rooms -- and this network, too, is starting to fray.

State data tell the story. The number of Minnesotans receiving food support (formerly food stamps) and on medical assistance is climbing steadily. But the number of families collecting cash assistance has dropped by 20 percent in the past five years, even though the number living in poverty has risen by 20 percent.

The number of people getting subsidized medical coverage through MinnesotaCare has fallen by 25 percent, even though the number of uninsured Minnesotans is rising. The share of jobless workers who receive unemployment benefits is dropping, even as the job market suffers its worst recession since 1982.

"The formal safety net of government programs is getting pretty tattered," said Arnie Anderson, who directs the network of 28 Community Action Agencies that links Minnesotans in trouble with services to help. "When that happens, people squirt through the cracks and end up in crisis. We're seeing far more intact families -- people who are angry, scared and don't know how to work the system."

A system under pressure

During Minnesota's last fiscal crisis, in 2003, the stakes for budget-cutting were comparatively low. The state was entering a period of prosperity, and fewer people were turning to the government for help. Legislators cut eligibility for MinnesotaCare, cash welfare and other core strands of the public safety net.

Now Minnesota is in the worst recession in at least two decades, and lawmakers are gearing up for a new round of austerity.

People on the front lines of social trauma -- visiting nurses, job counselors, food shelf clerks -- are seeing the symptoms at every turn:

• A visiting nurse in Minneapolis stopped to see a poor woman with a sick child -- and found that 13 relatives ejected from a foreclosed apartment building had moved overnight into her one-bedroom apartment.

• Authorities report that bedbugs are making a comeback in many neighborhoods, the result of more families crowded into substandard housing.

• In February, Catholic Charities in St. Paul said, 22 people with depression were on its waiting list for psychological counseling -- for as little as $1 a session -- more than double the number from January.

• About 12 percent of Minnesota children live in poverty, up one-third since 2000. Last year, children also made up 42 percent of food shelf users.

Minnesota's safety net is "stretched, and we need to find out how badly stretched," said Rep. Paul Thissen, DFL-Minneapolis. He intends to explore that in the House Health Care and Human Services Policy Committee, where he is chairman.

Stepping toward the net

In Brooklyn Park, the fragile economy already has claimed the jobs of Benjamin Matswa, 43, and his wife, Christin Liwa, 35. Now he worries that it might claim the town house they bought two years ago.

Immigrants from Sudan in 2003, they had started to carve out their place in the American dream, working first at a hotel, then at a company making eyeglasses. They were laid off late last year. They have applied for welfare benefits but probably will not qualify. If turned down, they will get health coverage from MinnesotaCare, the subsidized program for lower-income workers. But because Matswa sometimes makes more than $150 a month working through a temp agency, the family doesn't qualify for emergency food support. Now, with two daughters -- an infant and a 3-year-old -- they're just trying to survive.

"This is very difficult," Matswa said before joining a line of job applicants recently at one of the state's 47 WorkForce Centers. Last month 21,400 people sought help there, up 5,000 from a year earlier.

"We have worked very hard. We almost lost our house until we borrowed from our credit card, but I must find work soon," Matswa said. "A job with health insurance."

The neediest cases

The way visiting nurse Nancy Hickerson sees it, those in her profession offer "the very bottom rung of the safety net." They see the signs of economic pressure on their clients, the poorest of the poor. For more than a century, the Minnesota Visiting Nurse Agency has served unwed mothers, immigrants, people with mental and physical illness, families caught in generations of welfare.

As the agency's staff members gathered recently, talk turned to the latest economic indicator -- bedbugs.

"They used to be rare, and now we routinely arm ourselves with bedbug kits," said Laura Stolpe, a supervisor.

"It's getting bad," said Hickerson. "People get tossed out of their apartments by foreclosure and end up crowding into substandard housing with roaches, which you can kind of control, and bedbugs, which you can't.''

The budget reality

It's the 380,000 or so uninsured Minnesotans that concern officials at the state's hospitals and clinics. Last year, hospitals provided $600 million in unpaid care, up from $324 million in 2003.

Budget-balancing proposals that would cut state reimbursements to hospitals and other care providers "will lead to more layoffs, fewer physicians and elimination of vital hospital community services," Lawrence Massa, Minnesota Hospital Association president, warned legislators recently.

Mankato's Open Door clinic, which last year provided medical and dental care to about 3,000 patients, routinely turns away 100 dental patients a month for lack of staff.

"People think of dental care and they just think of clean teeth, maybe fillings," said Sarah Kruse, executive director. "But good dental care prevents a lot of infections and other health problems."

Critics of Gov. Tim Pawlenty's budget have seized on his proposal to cut dental care from state health programs for the needy as a symbol of "balancing the budget on the backs of the poor."

Not so, said Human Services Commissioner Cal Ludeman, who noted that the governor would increase health and human service spending -- but slow the rate of increase so it "doesn't overwhelm the budget with unsustainable growth."

The governor also proposed cutting about 113,000 people from MinnesotaCare, the state health program for lower-income workers. He dropped the idea for now, a condition of getting more than $1 billion in federal stimulus money.

For those in charge, the choices are not pretty.

"To balance the budget, we have to do some cutting and it will hurt," said Rep. Tom Huntley, DFL-Duluth.

"The thing is, we have to preserve the integrity of the safety net. We could make some drastic short-term cuts to save our butts now, but it's a lot smarter to give people good care now to prevent very expensive crisis care later."

Jake Grovum, a University of Minnesota student reporter on assignment for the Star Tribune, contributed to this report. Warren Wolfe • 612-673-7253