Introduction by Croakey: More than 27 million people in the United States do not have health insurance, and another 109 million adults are estimated to be underinsured, meaning they do not have affordable access to healthcare despite having insurance.
Non-profit clinics are helping to address the needs of these patients. They rely on healthcare professionals working as volunteers to provide a range of services for no cost or for a nominal fee.
The potential for this safety net model to help deliver care to the uninsured in countries all over the world will be discussed at the 17th World Congress on Public Health in Rome in May, writes Associate Professor Julie S Darnell, from Loyola University Chicago. Her scholarship is focused on strengthening the capacity of the primary care safety net to provide high quality care.
Her article below is published as part of the #WorldInTurmoil series, a collaboration between the World Federation of Public Health Associations and Croakey Health Media in the lead up to the World Congress on Public Health.
Julie S Darnell writes:
‘Cynthia’, in her late-50s, works part-time at a retailer outside Milwaukee, Wisconsin, USA, where she lives. She has no savings and relies on the generosity of her oldest daughter to help her with her basic needs, like food and housing costs.
In the United States, those basic needs can also include healthcare, because unlike many other advanced democracies, universal health coverage (in which everyone – regardless of the ability to pay – has access to essential health services) is not guaranteed.
In the United States, employers – not the government – are the largest source of health insurance coverage. Most Americans get their health insurance as a “fringe benefit” of their job.
But Cynthia’s job – like many jobs in the US, especially part-time positions – does not come with free employer-provided health coverage. She would have to pay at least $US126 (Aus$186, €115)/month in premiums for the private health insurance offered by her employer, but Cynthia declined coverage because it cost too much, given her $US12.38 ($Aus18.32, €11.39) hourly wage and annual salary of about $US18,000 ($26,640, €16,562).
Cynthia’s premiums are also higher, because in the US, her employer is permitted to charge her higher rates (up to 50 percent more) because she smokes cigarettes.
It should be noted that, owing to the USA’s federalist system of government, power over healthcare matters is shared; powers not enumerated to the federal government are reserved for the states. As a result, access to healthcare can vary considerably from one US state to another.
Limits of Obamacare
This sharing of power is illustrated pointedly in the implementation of the Patient Protection and Affordable Care Act, otherwise known as Obamacare. The “Obamacare” law enacted in 2010 constituted the largest expansion of insurance coverage in the US since the creation in 1965 of two government health insurance programs: Medicare and Medicaid.
Medicare is a federal government-administered health insurance program mostly for people aged 65 and over and is financed through payroll taxes, general revenues, and by Medicare beneficiaries themselves.
Medicaid is a government health insurance program for low-income persons. Uniquely, Medicaid is structured as a partnership between the federal government and the states.
The 2010 “Obamacare” Affordable Care Act was designed to expand insurance coverage principally by expanding eligibility for Medicaid to 138 percent of the income threshold defined as poverty (and also by providing subsidies to help lower income people buy insurance through a state health insurance marketplace).
However, the Medicaid expansion became optional for US states in 2012 when the US Supreme Court ruled that the Affordable Care Act could not require states to expand Medicaid; to date, 11 states have not expanded Medicaid.
Unfortunately for Cynthia, her state, Wisconsin, is one of those states. Though the US Supreme Court upheld the Affordable Care Act’s individual mandate to purchase insurance, the mandate became optional after President Trump signed into law the Tax Cuts and Jobs Act of 2017, which repealed the requirement that individuals must have health insurance or face a tax penalty. This change effectively made the mandate for health insurance optional.
Recalling that Cynthia, with an annual income of $US18,000 ($Aus26,640, €16,562), lives in Wisconsin, one of nearly a dozen US states that has not expanded Medicaid to 138 percent of poverty, Cynthia is instead bound by Wisconsin’s Medicaid eligibility rules. It turns out that her annual salary is well above the state’s maximum income of $US14,580 ($Aus21,578, €13,418) to qualify for Medicaid as an adult. In the US, states can – and do – set different household income eligibility standards for adults and children.
Though Cynthia was offered insurance coverage by her employer, she was reluctant to sign up for it in part because she knew that her employer’s health insurance plan would charge her for more than her monthly premiums at the point of care. For example, she realised that every time she went to the doctor that she would have to pay a co-payment, a fixed amount for services, unless they were just for preventive services like immunisations or screenings for chronic conditions.
For instance, her plan includes a co-payment of $US25 ($Aus37, €23) for a visit to the doctor for, say, a sore throat, or a sprained ankle. She also was aware that she had to meet a $US2,750 ($Aus4,070, €2,530) deductible, an amount that she must pay for healthcare services before the insurance company would begin to cover things like laboratory tests or x-rays.
Because her employer offered health insurance in compliance with the American tax authority’s (the Internal Revenue Service’s) affordability threshold, Cynthia is not eligible for coverage from the Affordable Care Act’s health insurance marketplace, which makes available private health insurance that is subsidised for lower-income Americans.
Adding to her financial worries, Cynthia is still paying off a visit to the hospital emergency room for chest pain, which she was grateful to discover was indigestion and not a heart attack. Nevertheless, she still has $US2,200 ($Aus3,256, €2,024) in remaining medical debt that she pays down in $US200 ($Aus296, €184) monthly instalments that she negotiated with the hospital after they sent her bill to collections.
Besides the emergency room visit, Cynthia has not seen a doctor in almost three years. She had considered going to a community clinic that charged uninsured patients, like herself, a sliding fee scale based on her income. But even that charge, $US25 ($37), would be beyond her budget.
So instead, on the advice of a friend from her church, Cynthia made an appointment with a local free clinic to see a doctor.
During Cynthia’s first medical visit at the free clinic, the physician, whom she learned was a volunteer, spent over an hour talking with her and performing the exam. For the first time that Cynthia could remember, she did not feel rushed during a doctor’s visit.
She also was struck by the number of helpers – whom she later learned were mostly medical students – around the clinic. There was, for instance, a medical student taking notes on a computer during her face-to conversation with the doctor. Another student helped her with the paperwork at the front desk when she first checked in.
The clinic performed a range of tests (that – unbeknownst to Cynthia – were donated by a major laboratory) and scheduled a return visit for the following week, at which time she learned she had diabetes.
This was bad news, of course, but a better outcome than if she had not gone to the free clinic that day; she would still have had diabetes, but would not have known. Cynthia was prescribed insulin, which was stocked (through a donation by a pharmaceutical company) at the clinic.
Before leaving the clinic, Cynthia met with a pharmacist (again, a volunteer) who counselled her about living with diabetes and explained the insulin therapy. Cynthia was never asked to pay for any of her care, but noticed a donation box in the waiting room and dropped in the contents of her wallet, about $US15 ($22.20, €14).
Since her initial visit, Cynthia has had two follow-up visits, with tests showing an improvement in her diabetes management, and has another follow-up visit scheduled in three months. She also plans to return to the clinic the next time they host their monthly mobile farmer’s market, and may also join the clinic’s drop-in cooking class.
Once she became a patient at the free clinic, Cynthia felt a weight lift from her shoulders and could not wait to share the news with her daughter that she finally felt secure about and in control of her health.
An intractable problem
It has been more than decade since the plight of the uninsured – people like Cynthia – have made the headlines in the United States. The number of uninsured has fallen from its peak of 48.6 million (16 percent) in 2010, the year that the Affordable Care Act was signed into law, to its lowest number ever recorded of 27.3 million (eight percent) in 2022.
This is a great achievement to be sure, but as evidenced by the more than 27 million uninsured, Cynthia’s story, though fictional, is all too common.
Besides the uninsured, however, an additional 109 million adult Americans are estimated to be underinsured, defined as not having affordable access to healthcare despite having insurance.
It is documented widely that people who are uninsured or underinsured have less access to healthcare and experience worse health outcomes, including higher rates of morbidity and premature death.
Minorities are particularly affected. People of colour suffer negative outcomes, disproportionately in part because they are at significantly higher risk of being uninsured or underinsured.
The fact that even after the achievements of Obamacare, two in every five residents in the US are either uninsured or underinsured is probably hard for people in many other advanced industrialised countries to imagine – and should provoke a public outcry in the US. That it does not suggests that the status quo of the USA’s health insurance system will persist in the foreseeable future.
This reality does not mean that meaningful improvements in healthcare outcomes and healthcare equity are out of reach, even for the uninsured, a particularly vulnerable population, through efforts designed to strengthen the safety net.
While not a substitute for insurance coverage, safety net organisations are shown to fill important gaps in access to essential health services for uninsured and underinsured persons.
It must be acknowledged that the uninsured receive their care from disparate sources, including: private physicians’ offices (through formal and informal charity care and bad debt), safety-net hospitals and affiliated outpatient clinics, and government-supported community health centres, which serve approximately 29 million patients annually, including six million uninsured, at their nearly 14,000 service delivery sites, aided by nearly $US6 billion ($Aus8.88 billion, €5.5 billion) in funding annually from the federal government.
Free clinics, the place where some two million mostly uninsured US residents – like our fictional Cynthia – receive care annually deserve to be more widely acknowledged and better supported as an essential element of the US healthcare safety net.
Free clinics are non-profit entities that have a sizeable reach among low-income uninsured, are dependent on private donations, and rely on volunteer licensed healthcare professionals to provide a range of healthcare services to low-income uninsured and underinsured patients at no cost or for a nominal fee. They serve patients who are disproportionately members of racial and ethnic minority groups.
Shining a spotlight on this lesser known member of the safety net could stimulate notice from non-traditional funders and uncover innovative and cost-effective solutions that can be supported, tested, and spread across safety net settings, both in the US and in other countries where gaps in healthcare coverage are observed.
Among the USA’s 1,400 known free and charitable clinics, those that charge a nominal fee are sometimes called “charitable” clinics but for purposes of this discussion the term “free clinic” will be used to denote both those clinics that charge no fees and those that charge a small fee.
Free clinics are able to charge little to nothing for patient care because of private donations of cash, goods (for example, medications, supplies), space, and volunteer time. In this respect, the differ markedly from health centres, which receive most of their funding from government and third-party insurance payers such as Medicaid.
Free clinics have evolved from highly individualised entities to a more centralised collection of organisations over their more than 100-year history. A majority have become members of the National Association of Free and Charitable Clinics (NAFC), the US voice of clinics, and/or members of similar state-level associations, such as the Illinois Association of Free and Charitable Clinics in my own home state.
Recently, greater centralisation and coordination at the national and state levels have raised the visibility of clinics and have facilitated improvements in the quality of care at free clinics.
Roadmap to Health Equity
For instance, the Roadmap to Health Equity initiative is a national collaborative co-led by NAFC, Americares, a humanitarian aid organisation that has become a major resource for free clinics, and Loyola University Chicago.
Involving more than 150 leaders representing clinics and state associations across the US, “Roadmap” has developed a national data repository of 15 clinical quality outcomes, such as blood pressure control, alongside patient-level characteristics. Pairing clinical quality outcomes with patient-level data permits detection of differences in clinical outcomes by sex, race, ethnicity and language spoken.
Preliminary findings suggest the free clinics’ overall outcomes on some measures are similar to their more resourced counterparts, government-sponsored health centres, but also reveal that inequalities exist. No longer hidden from view, the inequalities can be addressed by clinics.
The advent of Roadmap shows the maturity and ingenuity of free clinics, but the fact that this initiative is supported exclusively with private sources of funding exposes vulnerabilities in its sustainability and introduces constraints in scaling up.
Free clinics, which once eschewed government funding, now support efforts by the NAFC and US states to attract federal and state appropriations. To date, however, successes have been very limited. One of the biggest achievements at the federal level is a $US1 million ($Aus1.48 million, €924,000) appropriation that allows free clinics (but not charitable clinics) to obtain federal medical malpractice liability protection for volunteer health professionals, among others. At the state level, a handful of states have earmarked an appropriation for free and charitable clinics, with funding ranging from $US500,000 ($Aus740,000, €462,000) to nearly $US10 million ($Aus14.8 million, €924 million).
With half of free clinics reporting cash operating budgets below $US200,000 annually ($Aus296,000,€185,000), additional funding is a top recurring need. To fill funding gaps, free clinics rely on donated goods and services (especially volunteer time) to be able to deliver care to uninsured persons at no cost or for a small fee.
Free clinics report, on average, about 6,000 volunteer hours per clinic per year, an amount totalling more than eight million volunteer hours across all clinics. Indeed, volunteerism is in many respects the essential sine qua non that allows America’s free clinics to exist. Determining volunteers’ impact on organisational performance and uninsured patients’ health outcomes are promising areas of future research. Past research measuring the impact of volunteerism on hospital performance offers a starting point.
Among volunteers, students (from medicine, nursing, dentistry, psychology, and social work) are vital inputs in free clinic operations as they help expand capacity. By involving students, free clinics have become important clinical training sites.
The literature shows that from experiences in free clinics, students: 1) learn systems-based care, 2) are more satisfied and perceived to be better prepared to work in low-resource settings, 3) are more likely to practise in underserved areas, and 4) more likely to choose primary care specialties. These studies underscore the potential upstream benefits of supporting student involvement in free clinics.
Costs, opportunities and lessons
Cynthia’s case illustrates the deficiencies of the costly, fragmented, and inequitable health system in the United States.
But, more encouragingly, her experiences at a free clinic hint at some unappreciated opportunities and lessons that merit closer examination because they might stimulate new and better ways to organise, finance, and deliver care to the uninsured in countries all over the world that, while not being as extreme as the United States, nevertheless experience inequities in access to healthcare.
The upcoming World Congress on Public Health offers a unique prospect to launch this examination as it brings together disparate groups who are motivated to achieve a common goal: promote health for all, not just those who are lucky enough to be able to afford health insurance or live in a country that ensures that all its residents have access to essential health services.
• Julie S Darnell, PhD, MHSA, AM is Associate Professor of Public Health Sciences, Parkinson School of Health Sciences and Public Health at Loyola University Chicago. Her scholarship is focused on strengthening the capacity of the primary care safety net to provide high quality care.
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