Is Medicaid Expansion the Solution?

The Case for Free Medical Clinics

On September 22, 2023, the North Carolina General Assembly passed the state budget, and shortly after, Governor Cooper announced he was directing the North Carolina Department of Health and Human Services (NCDHHS) to begin the process for expanding Medicaid. North Carolina now joins 40 other states that have expanded Medicaid, which will provide coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,120 for an individual in 2023) as well as provide an enhanced federal matching rate (FMAP) for this expansion population. This also closes the coverage gap for many North Carolinians, as Medicaid pays for doctor visits, yearly check-ups, emergency care, mental health, medications and more — at little or no cost to participants.

While we celebrate this unprecedented legislation and historic announcement we must also understand and raise awareness that there will remain a realistic and factual need for free clinics which provide critical healthcare services. These needs are based on real world factors, data sets, past experiences, present conditions and future state.

History

The first free clinic in North Carolina, the Open Door Clinic, was established in 1974 in High Point. It was founded by a group of concerned citizens who realized the need for accessible healthcare for the uninsured and underserved populations. Since 1969 Asheville Buncombe Community Christian Ministry (ABCCM) has provided services addressing poverty, hunger, homelessness and access to health care for the under-served in Western North Carolina. Now one of North Carolinas key non-profit organizations, ABCCM works with over 300 local churches and leverages over 6,000 trained volunteers; and provides programs across NC. In 1991, ABCCM opened their free clinic in South Asheville and expanded their free pharmacy in 2016 in collaboration with a Local Management Entity (Vaya Health). Over the years, ABCCM along with many other free clinics in North Carolina have faced various challenges, including financial constraints, lack of sustainable funding and resources, increasing demand for services and even faced uncertainty on how the Affordable Care Act (ACA) would affect the vitality of these clinics during healthcare reform. One of the most common misconceptions during this time was when ACA was fully implemented that there would no longer be a need for Free Clinics. In fact, many are surprised to hear that even after full implementation of the ACA, there are as many as 27 million people who are still without access to health insurance. In 2001, the National Association of Free and Charitable Clinics was founded and incorporated in NC under the name of the National Association of Free Clinics. At present NC has 70 free clinics in membership that utilize volunteers and donations to provide health care to those who have no access to receiving services.

Different from Federally Qualified Health Centers (FQHC’s) which receive federal funding from the Health Resources and Services Administration (HRSA) to support operations, free clinics rely on a combination of donations, grants and volunteer healthcare professionals. However, free clinics are also not subject to specific regulation and standards, therefore can adapt and cater to the specific needs of their community, allowing for a more personalized approach and strengthening communities with a more focused and intentional strategy.

Economic Factors

At the ABCCM free medical clinic we know that approximately two-thirds of our patients are currently employed and, in many circumstances, work two jobs to support their families. Unfortunately, this demographic of ‘working poor’ are often not provided health insurance, yet make too much to qualify for Medicaid. Even with some of the upcoming flexibilities that NC may be instituting with this much needed expansion, many will remain ineligible for these expanded benefits. Free Medical Clinics offer healthcare to these individuals, which allow many to remain strong in a still recovering workforce post-COVID. Free clinics will remain necessary because they play a crucial role in providing healthcare services to individuals who may not have access to affordable healthcare otherwise. Keeping our workforce healthy benefits local businesses and the economy at scale which can often be affected by a simple preventative or urgent health visit to a free clinic.

Additionally, many free clinics are Volunteer-based initiatives which rely on the dedication of healthcare professionals and volunteers who generously donate their time and expertise to help those in need. In the last year alone, the ABCCM free clinic and pharmacy distributed about $3.3 million in prescriptions and about $2.5 million in medical care, an impact of $5.8 million in health care in Buncombe County. This community-driven approach fosters ‘Intentional Communities’ with a sense of solidarity and compassion, ensuring a health safety net.

Filling the Gaps

Free medical clinics often operate in areas where there are limited healthcare facilities or where healthcare services are not readily available. This is often the case in rural areas where both geography and healthcare resources provide challenges. This scarcity of medical professionals makes it difficult to access regular healthcare services, leading to unmet needs and preventable health issues. Free clinics often prioritize serving vulnerable populations such as low-income individuals, those experiencing homelessness, refugees and undocumented immigrants, many of whom will not benefit from Medicaid expansion. These free clinics will continue to play a vital role in filling the gaps in healthcare access, particularly in historically marginalized and underserved communities.

As stated earlier many of the uninsured will not be eligible for Medicaid services, yet cannot afford insurance; and filling the gap in preventative care proactively creates a stronger foundation of health. Free clinics encourage and emphasize the importance of vaccinations, health screenings and health education. Many of these free clinics offer pharmacies as well and can provide life-saving medications to include, antibiotics and diabetic medication. By focusing on these health elements clinics can support individuals manage their health and prevent chronic conditions from worsening or even occurring.

Building an Intentional Community

Since inception ABCCM has developed a well-rounded clinic, offering services such as cardiology, psychiatry, optometry, podiatry, pulmonology, endocrinology and will be re-opening the free dental clinic in the spring of 2024. Offering these extensive specialty services re-enforces that the community can and will be a safety net when needed most. Through strong and trusted partners that also provide food, clothing, housing, legal, and transportation to name a few SDOH’s encourages a more comprehensive delta of care within the community. Free clinics are imperative when thinking about building these intentional communities. Offering community health care through these clinics helps to support a sense of belonging and connection. In todays fast-paced and often isolating world, it can be challenging to find genuine connections with others much less when experiencing health issues. Free clinics are instrumental in creating a safe and inclusive environment where individuals can receive care without fear of judgment or discrimination. These partnerships leverage the ability for a community to be not only culturally competent but more importantly culturally inclusive. ABCCM offers robust services supported by language interpreters at all levels of the clinic, which addresses accessible communication challenges and promotes inclusivity.

Free Clinics also boost collaboration and cooperation out of both necessity and intentionality. Bringing people together who are intentionally seeking to live, work and play in a shared neighborhood encourages teamwork, shared responsibilities, and collective decision-making. The opportunity for retired nurses and physicians to continue to utilize their experience and skills on a volunteer basis increases the clinical work force capacity and generates healthcare community resiliency. This environment can lead to innovative solutions, increased creativity, and a sense of shared purpose for other community partners that provide other human service needs. This model of community care generates a strong foundation for positive social change through the safety net of care….and not just healthcare. These clinics often are the only place where patients are provided resources that include housing, legal, employment, and transportation to name a few. ABCCM’s Medical Clinic leverages NC’s NCCare360 network. This network utilizes the closed-loop Unite Us technology platform that improves both the efficiency and efficacy in the delivery of the social determinant needs that impact healthcare, thus promoting a stronger and collaborative of care. At an operational level a patient upon discharge is assessed by a Care Navigator on other social determinants of health prior to leaving the clinic, and connecting them to the appropriate community resource. This ecosystem of care includes over 7,000 NC community based organizations, tracking both resolved needs and more importantly unresolved needs that can directly affect a family’s health. A recent example includes a patient who presented in the clinic for an acute medical condition who was struggling with housing and transportation and was connected same day into a Veterans housing program attained housing of receiving care. The clinics’ ability to better coordinate social services as well as an enhanced level of tracking co-occurring needs, greatly improves our ability to train, educate and target resources at both the organizational and community levels.

Free clinics can serve as a catalyst for change by raising awareness, organizing campaigns, and actively engaging with the broader society and advocating for social justice, equality, and other important issues. It’s important to recognize the value of free clinics in promoting equitable healthcare access and supporting the well-being of underserved populations.

We must continue to support and leverage these clinics for our community neighbors in need of accessible and affordable healthcare moving forward in order to keep our communities healthy. (This article was originally published on Medium Daily Digest.) For more information on the Asheville Buncombe Community Christian Ministry and their services in North Carolina please visit: www.abccm.org.