Sandy Hoffler of Kills Devil Hills, N.C. started coming to the clinic in 2008. Without it, she wouldn't be able to manage her blood pressure.
Sandy Hoffler of Kills Devil Hills, N.C. started coming to the clinic in 2008. Without it, she wouldn't be able to manage her blood pressure. Photo credit: Jasmin Singh

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By Jasmin Singh

Bobbie Cutrell came back to her home state of North Carolina in 2009 from Massachusetts to have a fresh start, but she didn’t realize that getting that start was going to be a challenge.

RuralRx: N,C, Health News coverage of rural health issues. This week: Dare County

“I cannot afford health insurance,” Cutrell said. “I went around to doctors to try to pay for an office visit, but they wanted cash, or I went to the emergency room where you could have a big bill.”

But when the house cleaner moved to Manteo and discovered the Community Care Clinic of Dare in Nags Head, she said everything was looking up.

“If it wasn’t for them, I don’t know what I would do,” she said.

A medical home

Rick Gray, executive director of the free clinic, said the clinic serves as a one-stop shop for a patient without insurance.

“Our mission is to provide basic health care, medication assistance and wellness education for the uninsured and financially challenged people living in or working in Dare County,” Gray said. “We’re the medical home for our patients.”

Gray said a community health assessment of Dare County in 2002 showed that there were a large number of residents without insurance. In response, the clinic was opened in 2005 to fill in that health care hole.

“Our industries here don’t lend themselves to health coverage,” he said. “Most of it is boat building, construction, restaurant work and a lot of seasonal workers.”

Sandy Hoffler of Kills Devil Hills started coming to the clinic in 2008. Without it, she said she wouldn’t be able to manage her blood pressure. Photo credit: Jasmin Singh

One patient, Kill Devil Hills resident Sandy Hoffler, said she was at first hesitant to go into the clinic because of her pride.

“When you go in, they treat you with respect and it wasn’t like they were doing me a favor, so I felt better and I felt very comfortable,” Hoffler said. “They never, ever made me feel like I was less just because I don’t have insurance, so that was important.”

“If you ask any of the people on our books who their doctor is, they’ll say the Community Care Clinic of Dare,” Gray said. “We’re like a private physician office, only we just see people with no insurance or with financial challenges.”

Gray said the clinic is dependent on community fundraising and grant-writing efforts.

“I personally like standing in front of Rotary Clubs and saying that we are a free clinic,” Gray said. “We do $800,000 worth of medical visits each year at no charge to our customers.”

Hoffler said the clinic is her only option for stable health care because it comes at no cost to her, or any person without insurance.

“I don’t know what I would do without them because I can’t afford to run to the doctor’s or the hospital,” she said. “If this clinic wasn’t here, I would probably be dead.”

The Medicaid gap

The problem for Hoffler and Cutrell is that neither is poor enough to qualify for Medicaid, the state and federal program that covers health care for low-income children and some of their parents, pregnant women and the elderly. In North Carolina, the income limit for Medicaid is 49 percent of the federal poverty level ($5,767 per year for one person).

Executive Director Rick Gray and staff nurse Tami Montiel work to make sure the clinic can continue to offer its services to the county for free. Photo credit: Jasmin Singh

And under the Affordable Care Act, neither qualifies for subsidies to pay for insurance either.

Pam Silberman, a professor in the department of health policy and management at the UNC Gillings School of Global Public Health and investigator with the N.C. Rural Health Research Program, said this gap is not unique to rural areas.

“It’s an issue that is a result of a quirk in the Affordable Care Act,” Silberman said.

When the federal health care law, commonly called Obamacare, was passed in 2010, it required states to expand Medicaid to up to 138 percent of the federal poverty guidelines. People without insurance would be able to qualify for insurance subsidies if their income was between 100 and 400 percent of the federal poverty guidelines and if they did not have access to affordable employer-based coverage and were ineligible for public-based programs.

“The reason they limited the subsidies for people who were between 100 and 400 percent was because Congress thought that anyone below 100 percent of the poverty guidelines would get Medicaid,” Silberman said. “So you couldn’t get the subsidies if you were eligible for Medicaid.”

But the Supreme Court overturned the Medicaid expansion requirement in 2012 and a new problem arose.

“In those states that have chosen not to expand Medicaid, individuals may not qualify for Medicaid because their incomes are too high to qualify for Medicaid or because they don’t meet one of the other Medicaid criteria,” Silberman said.

The Community Care Clinic of Dare has been providing free and sliding scale-fee care for residents for more than a decade. Photo credit: Jasmin Singh

North Carolina, along with 22 other states, has chosen not to expand Medicaid.

And because of that gap, Hoffler said, “Obamacare means nothing” to her.

“I’m in that situation where they would charge $675 for me to have insurance,” she said. “There is no way. You don’t make that much down here. The copay, even if it were $75, my budget’s so tight I don’t have a little window for $75.”

Gray said around half of the clinic’s patients are at 100 percent of the federal poverty line or lower.

“When the writers of the Affordable Care Act wrote this legislation, I don’t think they ever could imagine that anyone would question the Medicaid expansion,” he said. “They didn’t have the foresight when they wrote the bill that someone at the 100 percent line of the federal poverty level or less [would] get none of the credits. We’re the last straw for them.”

A rural anomaly

Silberman said rural areas tend to have fewer people who are eligible to buy health insurance coverage in the marketplace or enrolled than urban areas.

“There was a higher enrollment rate during the first enrollment period in urban areas than in rural areas,” she said.

But Silberman said despite being in a rural region of the state, Dare County is doing a better job at getting people insured and providing care. The Outer Banks Hospital, the Dare County Department of Public Health and the clinic provide visitors with information and directions on how to apply for insurance and how to navigate the insurance marketplace, key steps in boosting the county’s enrollment numbers.

The clinic is hoping to expand it’s reach through telemedicine. Photo credit: Jasmin Singh

Cutrell said the clinic’s staff is dedicated to providing their patients with the best care they can.

“These are people that you can call up, you can ask questions, and maybe they can’t answer it right then and there but they will call you back,” she said.

Gray said the clinic is trying to expand its reach by using modern technology and through partnerships with the health department and hospital.

“I preach about how poor we are and how we are always looking for money, but we are a free clinic with a helipad and we are working on doing telemedicine,” he said.

The clinic also works with the Outer Banks Hospital’s emergency department to provide follow-up care to those who are uninsured.

“We can get a hospital referral and we will see them one time and if they decide that they want to stay with us, they have to show us all of the proper documentation to qualify within 30 days,” Gray said.

Cutrell said the clinic isn’t just a medical practice, but a family.

“With the Community Care Clinic, you know that if something is going on with you, they would do the best they could,” she said. “And that’s all you can ask for.”

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Jasmin Singh

Jasmin Singh, was our intern in 2014. She was an editor at the Daily Tar Heel during the 2014-15 school year and graduated in 2015. Jasmin said her experience with NC Health News left her more likely to...