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From the Middle Class to the Working Poor, Millions in U.S. Count on Free Clinics


United States

Pharmacist Brooke Kendall stocks medicines at Cape Fear Clinic in Wilmington, North Carolina, in October 2019. Free clinics, like Cape Fear Clinic, serve patients that find it difficult to access care by other means. (Photo by Donnie Hedden for Direct Relief)

The United States has several de facto medical systems, and the one a person accesses often hinges on how much money they have, or their employment benefits.

Those with the means to visit a hospital or private medical group often do. But for the nation’s vulnerable populations, a social safety net exists, in the form of Federally Qualified Health Centers, or FQHCs, where patients are able to pay for services on a sliding scale depending on their income, though no patient is denied services due their inability to pay.

Over 29 million people — which is about 8% of the U.S. population — access such care at more than 12,000 sites throughout the country, according to the National Association of Community Health Centers. The system is funded by a mix of federal and state sources, as well as private insurance and donations, in some cases.

Still, millions of people across America continue to fall through the cracks. For those who can’t afford their insurance,  don’t live near an FQHC,  need services not offered by an FQHC, or who are unaware of their eligibility to access care via an FQHC, a nationwide network of free and charitable clinics helps fill the gap.

“Free and charitable clinics are the net below America’s safety net,” said Nicole Lamoureux, President and CEO of the National Association of Free and Charitable Clinics (NAFC).

Receiving minimal to no federal or state funding, free clinics survive on the donations and volunteers from the communities in which they are based. There are more than 1,400 free clinics in the U.S and about 2 million patients received care at one of them in the past year, according to the most recent statistics from NAFC.

“One of the biggest misconceptions since the passage of the ACA (Affordable Care Act) is that everyone in America has insurance now or everyone has access to Medicaid now, and nothing could be farther from the truth,” Lamoureux said.

Kevin Stang, Care Coordinator sees a patient at a Cape Fear Clinic, Wilmington, NC.“I coordinate patient care amongst our higher risk, higher need patients. I work together with the providers, nurses and rest of our staff to provide the best outcome for our patients. I’ve always found more satisfaction in helping people. There’s a group of people that doesn’t often get recognized for needing help, especially in the medical field and mental health field— and these folks who are going through tough times, they still make the effort to say thank you and show appreciation. Every time something like that happens, I know I’m doing the right thing.” -Kevin Stang, Care Coordinator. Cape Fear Clinic, Wilmington, NC. Cape Fear Clinic provides compassionate and affordable patient-centered healthcare to low income individuals and families in the Cape Fear region regardless of ability to pay. Cape Fear Clinic has on site medical, pharmacy, and mental health services. Direct Relief actively donates medicine and disaster relief supples, and recently paid for a comprehensive back-up generator system that will allow Cape Fear Clinic to stay operational throughout power outages caused by hurricanes, flooding and other natural disasters or power complications.
Care coordinator Kevin Stang sees a patient at Cape Fear Clinic, a free clinic offering medical, pharmacy and mental health services in Wilmington, North Carolina. (Photo by Donnie Hedden for Direct Relief)

Reflecting this reality, more than 200 free and charitable clinics have been established in the U.S. since the passage of the ACA in 2010, according to NAFC figures.

Contrary to public perception, 83% of free clinic patients come from a working household, according to NAFC figures.

Dr. Ahmad Nooristani, who founded a free clinic in San Luis Obispo, said his average patient is “middle class.” He said they are often small business owners or people who recently lost their jobs, though exceed the income limits for Medicaid. These individuals can then face high deductibles and monthly premiums, which can make coverage options unaffordable, thus leaving them either literally or effectively uninsured.

Undocumented individuals, who are also unable to access Medicaid, might choose to go to free clinics over FQHC’s due to being afraid or unaware of their eligibility, according to Dr. Christian Espinoza, chief medical officer at MEND, a free clinic in Los Angeles.

A 2015 study published in “Risk Management and Healthcare Policy” reviewed literature from around the world on which issues were most prevalent in stopping undocumented immigrants from accessing care. The second-most cited reason, after legal and insurance-based issues, was fear of deportation.

Even with Medicaid coverage, patients often run up against logistical impediments to care, like finding a doctor who accepts new Medicaid patients and finding an appointment time within a relevant time frame.

Volunteers at free clinic Medspire, take a patient's vitals during a clinic day in Magalia, California. The free clinic was started to address unmet needs of vulnerable residents after the Camp Fire destroyed most of neighboring Paradise. (Mark Semegen for Direct Relief)
Volunteers at free clinic Medspire, take a patient’s vitals during a clinic day in Magalia, California. The free clinic was started to address unmet needs of vulnerable residents after the Camp Fire destroyed most of neighboring Paradise. (Photo by Mark Semegen for Direct Relief)

Lamoureux said that people with Medicaid can also face financial hardships related to medical care. Medicaid coverage varies by state and she noted cases where an individual who is covered by Medicaid loses their eligibility for certain pharmaceutical access programs and mental healthcare benefits. Further, less than half of states provide “comprehensive dental care,” according to the Centers for Medicare and Medicaid Services. Twenty-three percent of Americans lack dental coverage, according to the National Association of Dental Plans.

Coverage gaps also exist for Americans with lower incomes and who live in one of the 14 states that have not expanded Medicare coverage.

In all such cases, free clinics provide an alternative solution, particularly in underserved health care regions of the country.

“…There’s a big need within the U.S. and within this county,” said Nooristani about access to health care. He decided to start his clinic seeing an uninsured patient who had suffered a stroke and was having to cut his doses in half because he could not afford his medication.

“If you could only see the pain it caused him and his family,” Nooristani said.

The experience with this patient, who was the sole breadwinner for his two kids and wife, changed Nooristani and, by extension, his community. The free clinic he started, now called SLO Noor Healthcare Services, had over 6,200 patient visits from June 2018 to June 2019. It also offers specialist care, including from neurologists, nephrologists, orthopedic surgeons, general surgeons, and ophthalmologists — all of whom are volunteers.

The clinic also relies on donated medical equipment, sponsors, private donors—including people who have given him cash on the street —  and non-medical volunteers.

“Every time we have come across any kind of obstacle and we’re in need, somebody has stepped in, an angel has appeared,” he said.

“Free clinics are usually started by healthcare providers who see a need in their community that’s not being met by anybody,” said Aaron Katz, a principal lecturer at the University of Washington’s School of Public Health.

In addition to providing primary care, free clinics serve their communities by offering a basket of services. Much like the FQHC model— a civil rights-based approach imported from South Africa to the American South by Dr. H. Jack Geiger — free clinics address both acute problems as well the conditions that may have led to those problems, like malnutrition. To this end, patients can often access dental, vision, and mental health care, as well as be seen by chronic care specialists and nutritionists. Some clinics also have caseworkers, and provide specialized services, like care for people experiencing homelessness, and other essential programs, like food banks and free clothing.

Direct Relief's FQHC and Free Clinic partners (Direct Relief)
Direct Relief’s network of partner health centers and free clinics span the United States.

In times of crisis, these clinics can also be community hubs during disasters. Last October, when the Saddleridge Fire hit Los Angeles’s San Fernando Valley, MEND, a free clinic, offered free N95 masks and medicines for people whose conditions were exacerbated by the smoke, such as those suffering from asthma.

“It’s a simple thing, the masks, you can get them cheap, but they can’t afford this. It’s just something we are able to provide for them, until they figure out their next steps,” MEND’s Espinoza told Direct Relief in October 2019.

Lamoureux argued that providing access to care and essential health-related services for all people benefits society at large, even from a purely economic standpoint.

With an average emergency room visit costing $1,389 in 2017, according to a report from the Health Care Cost Institute, Lamoureux said that free clinics saved the nation about $2.8 billion in ER charges year while also freeing up resources.

“These patients don’t have insurance and don’t have the money to pay for their ER cost, and the ER is going to have to figure out how to pay for them or how to not pay for them,” she said. NAFC figures state that 53% of their member clinics operate on a budget of less than $250,000.

“We’re making sure people are using emergency rooms for emergencies, and not for the common cold or cough or chronic disease management,” she said

As the U.S. heads towards a presidential election later this year — with some candidates supporting Medicare-for-all — Katz said he would still expect an ongoing need for free clinics and FQHC’s if such legislation were enacted.

“Maybe in the long run, if the arc of history truly bends towards justice, maybe we won’t have the need to have such organizations, but I don’t see that at all,” he said, adding that, “issues of financing and inclusion are separate from the challenge of actually providing services.”

“The reality is we live in a society that has a deep-seated and wide gulf of inequality and inequity and, for the foreseeable future, there will still be a need for organizations that provide health services to parts of communities on the wrong end of the inequities,” Katz said about FQHC’s and free clinics.

Nooristani said he is ready to keep providing pro bono care — buoyed by the support he has found in his community.

“We’re saving life here, and who’s going to say no that?” he said.

— Additional reporting contributed by Amarica Rafanelli.

SLO NOOR received a Continuity in Care grant from a joint initiative between Direct Relief, BD, and the National Association for Free and Charitable Clinics. Since 2008, Direct Relief has provided $373.8 million in medical support to 863 free and charitable clinics, and has also provided more than $2 million in emergency grants and funding focused on chronic disease management.

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