When the Health Insurance Marketplace launched in 2014, millions of previously uninsured Americans gained coverage. But implementation of the ACA does not appear to have decreased the public’s reliance on free and charitable care.
U.S. Census Bureau data reveal that the number of people enrolled in health insurance rose from 86.7 percent in 2013 to 89.6 percent in 2014, presumably due largely to the launch of the Health Insurance Marketplace and the expansion of Medicaid in certain states. Despite the more than 11 million people who have recently enrolled in health insurance, however, gaps in coverage persist. By 2024, roughly 31 million non-elderly Americans are expected to remain uninsured, according to estimates from the Congressional Budget Office and the Joint Committee on Taxation.
“[The ACA] is a first step in providing health care for some Americans, but not for all Americans,” says Nicole Lamoureux, Chief Executive Officer of the National Association of Free & Charitable Clinics (NAFC). “One of the largest misconceptions that many have is that everyone in America now has access to health care and everyone is covered. There is nothing farther from the truth.”
The Role of Free and Charitable Clinics
The NAFC defines free and charitable clinics as “safety-net healthcare organizations that utilize a volunteer/staff model to provide a range of medical, dental, pharmacy, vision and/or behavioral health services to economically disadvantaged individuals.” An estimated 1,200 such clinics across the United States provide care to 2 million people, according to AmeriCares, a nonprofit organization that provides resources for free and charitable clinics and delivers other forms of medical aid globally.
Since the implementation of the ACA, several free and charitable clinics have closed their doors, but they are the exception. While 20 percent of the clinics associated with the NAFC have seen a decrease in volume since the ACA rollout, 80 percent have not. In fact, NAFC-affiliated clinics experienced a 40 percent increase in patient demand in 2015, while donations decreased by 20 percent, according to Lamoureux.
A Shifting Patient Population
Free and charitable clinics predominantly care for uninsured Americans — and for the most part, that hasn’t changed. However, clinics in many states, especially states that have expanded Medicaid, are seeing a new type of patient: people who have insurance through Medicaid or Health Insurance Marketplace-sponsored private plans but either can’t find a Medicaid-approved provider or can’t afford the high deductibles associated with their bronze-level plans.
Johanna Henz, Executive Director of the Lake County Free Clinic in Painesville, Ohio — a state that expanded Medicaid in 2014 — noted that the number of uninsured patients who access free care at the clinic has dropped from 90 percent of the patient base to roughly 80 to 85 percent, while the number of people with insurance who visit the clinic is increasing. Gregory E. Lang, PhD, Executive Director of the Good Samaritan Health Center of Gwinnett in Lawrenceville, Georgia, has observed similar changes. Georgia opted out of Medicaid expansion, but the clinic has seen more patients with private plans.
“Recently, a woman came into the clinic seeking services and complaining of her ‘worthless’ insurance,” Lang says. “She had a $6,300 deductible. If one requires a subsidy to afford a monthly premium, how could that individual be expected to pay 100 percent of the first $6,300, potentially after a single episode of care?”
To keep up with demand from insured but underserved patients, the Good Samaritan Health Center of Gwinnett has adjusted its business model. The clinic traditionally provided care only to uninsured individuals but now sees uninsured patients and those with individual deductibles higher than $3,000, with service prices averaging roughly 55 percent of market cost.
Filling Traditional Care Gaps
Despite the ACA’s efforts to provide insurance to all Americans, many people still lack basic coverage. The Greenville Free Medical Clinic in Greenville, South Carolina, provides free medical care to uninsured adults between ages 18 and 65 and has seen a stable annual average of roughly 4,000 patients in recent years. In addition to providing basic primary and dental care, the clinic specializes in the management of chronic conditions and offers patient education, free prescriptions and behavioral health services.
Since the ACA took effect, the clinic has partnered with two local healthcare systems to provide a medical home for uninsured patients with diabetes, hypertension and other chronic illnesses. According to Suzie Foley, Executive Director of the Greenville Free Medical Clinic, results from the partnerships are positive. Those with chronic ailments who seek care at the clinic have fewer emergency department visits and preventable hospital stays.
An ongoing need
Although care models and the types of patients served at free and charitable clinics may vary, Lamoureux, Henz, Lang and Foley all agree on one thing: There will likely continue to be a significant need for free and charitable care.
“There are always going to be people who fall through the cracks,” Henz says. “... Despite [any government program], there are always going to be people that it doesn’t work for.”