North Carolina has one of the largest networks of free clinics in the United States. But what becomes of a “free” clinic when most people are supposed to get some form of insurance under the Affordable Care Act? Clinic leaders say they’ll still be needed – with some changes.

By Rose Hoban

Mornings at Urban Ministries of Wake County find the place crowded, the way that agencies providing food, social services and health care often are. But the waiting room for the clinic is calm, soothing and orderly, and the patients there have appointments.

“We don’t look busy, or chaotic,” said Peter Morris, Urban Ministries’ executive director. “The best clinics don’t if they’re run right. People have their appointments, they come to see their professionals and then leave.”

With more than 6,500 patient encounters last year and more than 1,500 regular patients, Urban Ministries is one of the busiest free clinics in the state. It’s also facing some big changes as implementation of the Affordable Care Act starts to pick up speed.

For many in North Carolina who lack health insurance, free clinics have been a lifeline to help them get the health care they need. But now leaders of free clinics around the state say they’re not sure if they will sink or swim in the new environment created by health reform.

That’s because even if every proposal of President Barack Obama’s signature health reform law, the Affordable Care Act, were put into place, there would still be some people in North Carolina who lack health insurance and need free care.

Other long-time free clinic patients will finally have access to some form of insurance, be it Medicaid or subsidized coverage via the state-based health insurance exchange that will be established by late next year. Suddenly, formerly uninsured patients who haven’t had choices about providers will be able to choose their doctor. Free clinics that will finally be able to bill for some of their services want to make sure those existing patients keep coming back once they have choices.

Along with all those changes, free clinics have to continue to make the case to donors to continue supporting them.

“The perception [among donors] is, ‘Nice the legislation was passed… all will be well with the world, great, everyone is insured, it’ll all be hunky dory.’ Even some funders said that at the beginning,” said Jason Baisden, head of the N.C. Association of Free Clinics. ” The hardest thing we’ve had to deal with since passage of Affordable Care Act is a perception issue.

“So we had to go back and say to them, ‘OK, the Congressional Budget Office is saying that at the national level 23 million people will still be uninsured.’”

Real good for free

With more than 80 clinics in at least 55 counties, North Carolina has one of the country’s most extensive networks of free clinics. Most organizations have only a handful of paid staff people, but may have dozens, even hundreds of volunteer doctors, nurses, nurse practitioners, physician assistants and a host of other health-care workers who donate a couple of hours every week or month.

According to Baisden, free clinics in the state saw about 100,000 patients last year, out of North Carolina’s 1.6 million uninsured.

“It’s a decent ripple, not massive,” Baisden said. “That doesn’t really count the private doctors who do free care that we don’t really have numbers on.”

Baisden said he’s talked to many clinic leaders around the state who wonder how many patients will be out there once the health reform law is fully implemented.

“To get into a free clinic may be not as hard because of less demand,” Baisden said.

The N.C. Institute of Medicine estimates that up to 500,000 people will remain uninsured after the law is in place. As time goes by, that number is estimated to decrease, but there will still be people without insurance.

“Many of those will be undocumented,” said Gary Greenberg, medical director of Urban Ministries of Wake County’s Open Door Clinic.

Others who will still need care will be those who would rather pay the penalty than sign up for subsidized insurance, and some people won’t be able to afford that insurance. Others will still need low-cost or free care even if they have insurance.

“On paper, some people should be able to afford insurance with the subsidy, but will still be unable to. There will be those that are exempt from the tax… because coverage will be more than 8 percent of their income and if they cannot get on Medicaid, they’ll be left out,” Baisden said. “We’re already seeing those kind of folks.”

Underinsured

“At first, we were like, we can go out of business now,” said Beverly Kegley, head of the Volunteers in Medicine Free Clinic in Louisburg. “But then there was a dawning realization that we’d still be needed. And now we’re realizing that in the beginning [of implementation of the ACA], we’re really going to be needed.”

There will still be the self-employed, farmers and people who’ve never had health insurance, Kegley said, and also the underserved. “Some may end up purchasing catastrophic insurance coverage only, but the deductible could be $6,000.”

“Someone with diabetes, you can maintain them for less than $6,000 a year, and so they’ll never reach their deductible. But they still can’t afford that ongoing care.”

So Kegley and her board decided to get creative. In the past few years, they formed partnerships with the local health department to use their facilities to provide care and stay open longer. Those partnerships will serve her well as Volunteers in Medicine moves forward.

“These collaboratives have been out of necessity, but they’re possible because people are willing to come to the table,” she said.

Kegley has started talking to a large employer in Franklin County who has said he might drop his employees’ health insurance and have them instead buy insurance from the health benefits exchange that is part of the new law. She’s working on a deal to become the company’s primary provider. She’s also talking to a local private medical practice to collaborate with her organization.

“That’ll bring in the doctor for more hours and greater supervision,” Kegley said. “It could put us on the road to being a family-centered medical home. That’s our goal.”

Baisden said free clinics will have to think more like Kegley in order to survive and find ways to bring in revenue that comes from reimbursement as well as donations.

“It’s not a great business model to do only chronic care for Medicare and Medicaid recipients,” said the Urban Ministries’ Morris. “So I think Urban Ministries is on the edge of what the 21st century says a not-for-profit should be. … You need to be a social innovator and an entrepreneurial organization.”

Both Kegley and Morris said they’ll have to work smarter to make their organizations places where people want to come to for ongoing care, not places where they go because they have no other choice.

Logistics

“We have 450 volunteers who come in regularly,” said Greenberg, who sees patients all day, four days a week.

He said one of the ways the Open Door Clinic has prepared for the future has been by installing an electronic medical record, something that’s taken up a tremendous amount of his time, even though the product was donated.

“Unlike a clinical practice where the three partners are there every day, many of our volunteers are once a month, many of them are retired,” Greenberg said. “I’m still staying late two nights a week to chaperone the computer with the providers who are volunteers, because they only see the system once a month for three hours or so.”

And he said Urban Ministries will have to add paid staff to make it all work.

“It’s almost a cataclysmic change from what we are,” Greenberg said. “We’ll have to bill, hire people who bill, move to an electronic health record, look at quality-assurance mechanisms. We’ll have to get each of our volunteer providers to see if we can bill on their behalf.”

Other clinics will have to do the same as the health reform law is implemented.

“We’re looking for all kinds of ways to collaborate,” said Beverly Kegley. “We just arranged a three-year collaboration with the local health department. That’ll allow us to bring in a private physician for more supervision and more hours. That could put us on the road to being a family-centered medical home.”

Jason Baisden said his organization is considering a name change – something that will reflect that clinics may be supported by donations but won’t necessarily always be free, billing Medicaid for some patients, charging a sliding scale for others.

He also said free clinics provide a place to volunteer for professionals who are retired or working in administrative positions but want to maintain their clinical skills. He said that won’t change once health reform gets implemented.

“Free clinics will really need to engage their communities,” Baisden said. “There will be a lot of local discussions in 2013 – hospitals, health departments, the religious community, local providers. We have to ask ourselves what do we want to see to help those in need in our community and collectively come up with a strategy.”

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