By Jaymie Baxley
For nearly 20 years, uninsured people in the Sandhills have turned to Moore Free and Charitable Clinic for medical services.
Operating in a converted warehouse at the end of an unassuming road near Pinehurst in Moore County, the clinic provides free or low-cost care to patients with diabetes, hypertension and other chronic illnesses. Construction is underway to add a dental treatment area to the facility.
Moore Free and Charitable serves hundreds of patients, some of whom may soon become eligible for Medicaid under the expansion signed into law in March by Gov. Roy Cooper. But Tony Price, CEO of Moore Free and Charitable, said his clinic does not plan on participating in Medicaid — at least not for the time being.
“Medicaid is a complex process,” he said. “There’s a whole lot of compliance issues that we don’t have to deal with today that you do when you take Medicaid.”
One issue is billing. Unlike traditional providers, the clinic does not have a billing system in place to streamline the claims process for Medicaid. Price said Moore Free and Charitable tracks the estimated value of every service it provides, but those records are for “internal use only.”
Even if it had a billing system, the clinic would need to hire staff to prepare claims and submit them to the state. This work is time-consuming and requires a fastidious eye, according to Price. A claim could get kicked back or rejected if the person filing it accidentally enters the wrong code. (Codes signify what a patient’s diagnosis is and what care they received.)
Price chairs the North Carolina Association of Free and Charitable Clinics, an organization made up of more than 70 clinics that cater to the uninsured. The association’s members saw a combined 82,480 patients in 2021, the most recent year for which data is available.
Price’s misgivings about accepting Medicaid are shared by other members of the association, many of which lack the money and manpower needed to overhaul their clinic operations to accommodate Medicaid patients. All of the state’s free clinics rely primarily on donations and grants to stay afloat, and the facilities themselves are staffed mostly by volunteer physicians, nurses and other medical staff.
“The infrastructure will have to change in the clinics, and that’s an expensive proposition,” Price said.
April Cook, CEO of the North Carolina Association of Free and Charitable Clinics, said only eight of the organization’s members accept Medicaid.
They mainly do so, she said, to deal with the “churn” of patients who receive Medicaid for a few months before being dropped from the program. Medicaid enrollees make up only 5 percent of the total number of patients served by the association’s member clinics.
Cook said the handful of free clinics that do take Medicaid are reimbursed at a lower rate than at community health clinics, officially known as Federally Qualified Health Centers. They also have far fewer employees.
“Typically, an FQHC has two to three times the number of staff members as free and charitable clinics, and the biggest reason is Medicaid and Medicare,” Cook said. “It takes so many more individuals to dot all the i’s and cross the t’s when you’re dealing with these federal programs.”
While the centers and clinics both focus on underserved populations, they are not always in the same communities. Price’s county, for example, is home to FirstHealth Moore Regional Hospital but does not have a federally qualified health center listed with the N.C. Department of Health and Human Services.
“Here’s the bottom line: there’s not enough FQHCs to address all of the folks that have Medicaid,” Cook said. “So if you’re in a rural area where there’s already not an FQHC or there’s a primary care shortage, there’s not a whole lot of options for patients.
“Medicaid doesn’t necessarily mean access, which is unfortunate.”
Over 600,000 people are expected to benefit from Medicaid expansion in North Carolina, but only if they are U.S. citizens or lawfully present non-citizens who have “qualified” immigration status.
Undocumented immigrants will remain ineligible for coverage, forcing an untold number of individuals to seek care through other channels. Free clinics are among the few available options for undocumented patients who have little or no income.
Cook said that while the association does not “want to condone people coming in illegally,” she believes it is “to everybody’s benefit to treat … where you can.”
“There are people that are on both sides of the fence here, but it’s about understanding the implications of not serving someone that is undocumented,” she said, adding that undocumented individuals with easily treatable issues may turn to emergency rooms for service if they cannot be seen elsewhere. “I think part of free and charitable clinics’ mission is to help drive down health care costs and take care of people preventively before they reach a condition that requires them to be hospitalized.”
Medicaid will not be officially expanded in North Carolina until a state budget is approved. Before that happens, many North Carolinians are expected to lose their existing coverage through the unwinding of a federal provision that prevented states from removing enrollees from the program during the COVID-19 pandemic.
This process, known as redetermination, will likely create a new coverage gap for free clinics to help fill.
“There’s been some talk that if [the General Assembly] can get the budget passed in June then they would try to expand Medicaid by October, which would be very fast, because of the unwinding,” Cook said. “They don’t want people that have been treated to feel like they’re out in the cold. I’m here to say they won’t be out in the cold because we have 70 free and charitable clinics in North Carolina that are there ready to help lead the way.”
Still, Cook acknowledged that funding is a persistent challenge for free clinics. The association, she said, has asked lawmakers to earmark $15 million in the state’s budget for recurring appropriations that will allow the clinics to hire additional staff and provide more services to patients. The budget passed by the House of Representatives last month contains only $5.5 million in annual funding for the free clinics, and the amount in the final budget passed by the legislature is likely to be less than what the association has asked for.
“We will not benefit financially from Medicaid expansion,” Cook said. “We are hoping that the General Assembly won’t forget about us and it realizes the critical part that we play as a safety-net provider.”
Cook stressed that the free clinics represented by the association are “fully in support” of Medicaid expansion.
“We’re very happy for our patients that will be eligible,” she said. “However, that being said, [expansion is] going to extend coverage to 500,000 to 600,000 uninsured in North Carolina, with a remaining 700,000 that will not qualify for Medicaid and will remain uninsured. We are primarily focused on those individuals.”
While none of the association’s members have immediate plans to begin accepting Medicaid, the prospect is not entirely off the table. Cook said there is a possibility that some free clinics may adjust their operations to serve enrollees who continue to lack access to traditional providers.
“If two years down the road we’re hearing over and over that patients that we had are suffering because they can’t find primary care for their Medicaid, then we may have to pivot,” she said.
Price, the association chair and clinic CEO in Moore County, said it is too early to tell what the future might hold for Medicaid in free clinics.
“How many patients are we apt to lose? How many might we get back from [redetermination]? How many undocumented patients do we have out there that weren’t counted in the first place?” he asked. “We’re gonna try to pull together data to better help us make a decision about how to proceed.”
Correction: A previous version of this article stated that only U.S. citizens will benefit from Medicaid expansion in North Carolina. Non-citizens who have “qualified” immigration status will also be eligible for coverage.