The Dispensary of Hope Blog

I just returned from a 3-day conference in Cleveland with 200+ clinics that are considered “free clinics” under the banner of the NAFC (National Association of Free Clinics).  What a great conference!  It was enriching to spend time with so many compassionate health care leaders. As we engaged in the topic of health reform, we confronted the fact that the uninsured population is projected to decrease from 17% to 6%. If these projections become reality, in 2014, 16 million newly eligible low income people may be covered by Medicaid with an additional 24 million people (including small business employees) who will finally be able to afford coverage through the exchanges.  There’s no doubt that the “access” these clinics provide will be needed, but their unique model is in question. Some attendees felt that health reform threatened their mission. Some focused on the fact that there will still be 23 million uninsured and prefer to remain “gap-fillers”. Others looked at the broad themes in the reform law, set aside the fancy terms and codified mandates, and realized that the ideas of access, patient-centered care, affordability, community wide collaboration, and using best practices were their ideas long before the law existed – and it was about time the government joined the movement.  These various perspectives speak to the potential identity crisis that many safety net providers are having. The various clinics that have been filling the gap trying to serve the 40-50 million uninsured people identify themselves in different ways (community clinics, federally qualified health centers, faith-based clinics, free clinics, etc.) The latter group was born out of a belief that patients in their community should NOT be denied care simply because they could not afford it. These 1200 clinics embraced the reality that the only care some sick people could afford is in fact “free” care.  These “free” clinics have a unique model and a galvanized shard identity. It seems that many are uncomfortable with why some of their peers are suddenly considering changing their model to become an FQHC.  If you change models, are you changing your mission?

Free Clinics and FQHCs present two different sustainability models, but they often serve similar patient populations. (In fact, many FQHCs used to be free, faith-based, or community clinics.) If you walked into each of their waiting rooms, you’d be hard pressed to see a difference. You would see a difference in what and how patients are charged. Free Clinics typically provide services at no or low cost. They are defined as “volunteer-based, safety-net health care organizations that provide a range of medical, dental, pharmacy, and/or behavioral health services to economically disadvantaged individuals who are predominately uninsured. Free clinics are 501(c)(3) tax-exempt organizations, or operate as a program component or affiliate of a 501(c)(3) organization. Entities that otherwise meet the above definition, but charge a nominal fee to patients, may still be considered free clinics provided essential services are delivered regardless of the patient’s ability to pay.” FQHCs have a sliding scale so patients contribute based on their income and what they can afford.  Free Clinics cover their operating costs through donations (staff who donate their time, hospitals who donate in-kind equipment and services, and foundations and individuals who donate money).  FQHCs bill for care provided to insured patients to generate enough revenue to cross-subsidize uninsured patients and cover operating costs.

The advent of health reform and the projected decrease in the uninsured population is accelerating the need for free clinics to decide what part they want to play and how they’ll stay sustainable. They have to consider if their mission is defined by the people they serve or the funding model of “free”. They have to decide whether they are most committed to the patients they currently serve (and are willing to evolve their models to take care of them if they become insured), or they are most committed to strictly uninsured patients (even if they are fewer in number or concentrated in fewer states where immigrants reside).  The conference set up the discussion, facilitated the competing arguments, and challenged everyone to take action.  Avoiding the future won’t stop it from coming. I’m optimistic to see how free clinics respond to the opportunities at hand.