The ACA ushers in era of rapid change at free clinics

The waiting room is modest, but staff at Pilsen Homeless Health Services, a free clinic on Chicago’s west side, have spruced up the florescent-lit space with motivational posters. Some are uplifting: “Never Give Up!” Others are cautionary: “If you aim for nowhere, that’s just where you’ll go.”

Behind the intake desk, an equally humble exam room is brightened by cream walls and natural light streaming through large east-facing windows. This is where patients meet with Maria I. Brown, DO, who co-founded the free clinic more than 20 years ago. Now a community institution, Dr. Brown’s clinic facilitated about 1,300 patient visits last year.

With her warm smile and affable laugh, Dr. Brown’s positive attitude ripples through the clinic, touching not only its volunteer medical students and nurse practitioner, but also its patients, including Sheldon Gayton, who visited recently for a tuberculosis test.

Talking to Gayton as if he were an old friend, Dr. Brown said, “Let’s see your arm. Look at this arm! Very strong, and these are great veins.”

“Thank you,” Gayton said, laughing.

“What’s your favorite thing about coming here?” Dr. Brown asked. “Is it hanging out with the wonderful staff here?”

“Hmm … It’s free,” Gayton answered.

“You can’t beat free,” Dr. Brown said.

Across the nation, free clinics are helping meet the health care needs of millions of Americans who don’t qualify for insurance coverage under the Affordable Care Act.

Clinics like Dr. Brown’s provide much-needed care for those whose incomes do not meet the threshold for purchasing insurance through ACA marketplaces and those who live in states that have not expanded Medicaid programs.

Despite playing such a vital role in helping to care for the underserved, many free clinics have faced hardships, including decreased funding and patient populations, since ACA coverage kicked in last year.

The ACA and free clinics

Most free clinics were created to assist underserved patients who faced a major barrier to receiving care: lack of health insurance.

The ACA was the government’s attempt to lift that barrier for Americans, and it succeeded in facilitating coverage for some. The number of uninsured U.S. adults under age 65 fell by more than 30% from 2013 to 2014, according to The New York Times. In low-income neighborhoods, the number of uninsured people fell one-third, the article reported.

Although Dr. Brown says roughly 20% of her patients at Pilsen Homeless Health Services were able to sign up for ACA coverage, she notes that health insurance is still out of reach for her patients who are severely mentally ill, homeless or undocumented immigrants.

“Every time we survey our population and review our charts, we find that about 85% of our patients are either mentally ill, substance abusing or dually diagnosed,” says Dr. Brown, who is also an associate professor of family medicine at Rush University Medical Center in Chicago. “That’s a tough population to insure and we really don’t see any signs of that changing with the Affordable Care Act at this point.”

Some free clinics have seen a decline in the number of patients seeking care since ACA coverage took effect. Heritage Community Clinic in Athens, Ohio, treated roughly one-third fewer patients last year than it did in 2013, according to Kathleen Trace, MHA, RN, who runs the clinic and serves as director of area health education center and community health programs at the Ohio University Heritage College of Osteopathic Medicine.

Last year, an insurance navigator joined Trace’s clinic to help patients sign up for coverage. Over roughly six months, the navigator helped about 1,600 people get health insurance.

Many of those patients are now getting care elsewhere.

Despite the decreased volume of patients, Trace says the need remains for services the clinic provides. “There are always going to be people who drop through the cracks,” she says. “They make too much to sign up for Medicaid, but they may not make enough to sign up in the marketplace for one reason or another, or they may sign up and then realize that they can’t afford the medicine.”

Fewer patients, fewer dollars

As a result of declining patient numbers, many free clinics are grappling with decreased funding levels. Although Trace reports that funding at her clinic wasn’t affected last year, she plans to apply for less money from at least one grant this year.

“We have multiple grants, and believe me, the granters are asking,” she says. Funders want to know whether the clinic is seeing fewer patients now that many have obtained ACA coverage, she says, adding that one granter has already asked the clinic to increase the level of community education it provides as a result of the drop in clinical services.

Joining the ranks of many other free clinics across the nation, Heritage Community Clinic is also considering beginning to bill Medicaid for newly insured patients.

“I surveyed some of the health care providers in the community, and they said, ‘If you’re seeing people and they have Medicaid, you should bill Medicaid,’ ” she says. “You also run into the fact that there may not be enough providers to take Medicaid patients.”

Trace points out that some of the clinic’s newly insured Medicaid patients prefer to continue receiving care at the clinic rather than find a new physician’s office because they are already established with a health care professional they trust.

Medicaid expansion

On the other side of the Rocky Mountains in McCall, Idaho, Sarah Jessup, DO, runs Community Care Clinic, a free clinic for low-income and uninsured patients. Since last year, patient visits have dropped about a third, from around 60 to 40 per month, she says.

Dr. Jessup runs a lean operation; she and her staff of 20 part-timers all work on a volunteer basis. So far, the ACA hasn’t affected her funding, and the lower patient volume has given her and her staff some breathing room to spend more time with patients. But she says many of her patients were not helped by the ACA because Idaho elected not to expand Medicaid coverage.

“The Medicaid options in Idaho are extremely minimal,” she says. “If you’re not pregnant, you basically need to have a dependent child and make around $300 per month or less, so that’s a tiny fraction of people at the poverty level. The rest are left without any coverage under the ACA in this state.”

Right now, 28 states have expanded Medicaid coverage, while five are considering expansion and 17 are not, according to The Advisory Board Company. States that expanded Medicaid decreased the number of uninsured residents from nearly 15% to about 9% on average, while the number of uninsured in nonexpansion states went from about 18% to nearly 14%, The New York Times reported in October 2014.

Although Illinois did expand Medicaid coverage, Dr. Brown says her clinic has not seen any fewer visits despite the fact that roughly one-fifth of its clients have obtained health insurance via the ACA. Her now-insured former patients have left an opening for more uninsured people to get care.

“There always seems to be somebody there to take the place of the insured patients, at least at this point,” she says.

ACA pitfalls

While she is ultimately in favor of the ACA, Dr. Brown notes that the working poor often fall through a coverage crack when seeking insurance through the exchange. One of her patients, a man with a full-time job whose income is about $20,000 per year, earns about $4,000 too much to qualify for Medicaid in Illinois. But the only plans he can afford are those with a $6,000 deductible.

“A $6,000 deductible with a $100 premium will nearly bring him back down to the poverty line,” she says. “It doesn’t make sense. For the working poor, especially the people who are above the poverty level but still low-income, we really have to ask ourselves, ‘What truly is affordable care?’ ”

Plans such as these aren’t primary-care friendly, notes J. Wesley Cook, DO.

“These plans are catastrophe-friendly,” says Dr. Cook, who volunteers at CommunityHealth Chicago, a free clinic on the city’s West side. Although high-deductible plans protect patients from financial ruin in the event of an emergency, they don’t necessarily facilitate access to preventive and primary care, he notes.

While acknowledging that the law wasn’t designed to address everyone, Dr. Brown says homeless people and severely mentally ill people have not fared well under the ACA.

“There’s just a tremendous need for comprehensive case management and wraparound services,” she says, adding that case management programs vary by area and aren’t available in many parts of the country.

When undocumented, homeless and other underserved patients receive primary and preventive care, everyone benefits, Dr. Brown says. Patients who receive free care at a clinic won’t have to wait until a health problem is so serious that they need emergency or hospital care, which is exponentially more expensive.

Trace agrees.

“When people get the care they need and it’s quality health care, it really does decrease total health care spending,” she says.