By Mary Ellen Howard, RSM, Executive Director of the Cabrini Clinic, Detroit, MI. This clinic is the oldest free clinic in the U.S.
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (ACA), landmark legislation designed to provide coverage for more than half of the nation’s 52 million uninsured citizens, and to address abuses in the insurance industry. The law is being implemented gradually. The uninsured poor have to wait until January 1, 2014 before Medicaid will be expanded. Until then, they will continue to defer care, or to seek it at free clinics and hospital ERs.
Since 1995, I have served as Director of the oldest free medical clinic in the nation, St Frances Cabrini Clinic of Most Holy Trinity Church. Free Clinics are nonprofit organizations that use volunteer health professionals to provide free or low cost care to uninsured individuals. Cabrini Clinic was founded in 1950 to provide for the primary medical care needs of Detroit’s uninsured poor families. We have a full-time staff of five, and over 100 volunteers. I came to the clinic following a 20-year career in hospital administration, including as CEO of two Mercy Hospitals.
It didn’t take me long, after coming to Cabrini, to figure out that free clinics were not the answer to the problem of the millions without access to healthcare in the USA, including the 200,000 uninsured persons in Detroit. This led me to get involved in local advocacy for access, and national advocacy for changes in health policy.
In 2009, I supported President Obama’s efforts for health reform, although the resulting ACA falls far short of the single payer expansion of Medicare that I had hoped for. ACA maintains a market-based insurance system, and does not effectively address the escalating cost of health care in this country. Still, it promises to cover 32 million of the 52 million uninsured which deserves our support.
On January 1, 2014, Medicaid eligibility will be expanded nationally to 138% of the Federal Poverty Level (FPL) which in 2012 is $15,418 for an individual and $31,809 for a family of four. In contrast, eligibility in Michigan is at only 35% of FPL or $3,910 for an individual and $8,068 for a family of four. If your annual income is above that, you are too rich for Medicaid in Michigan. ACA will also cover childless adults who formerly have been ineligible for Medicaid, regardless of poverty or severity of illness.
This year, I was awarded a fellowship from the McGregor Fund to study the effect of health reform on free clinics and their patients, and to help them through the transition. Free clinics are in a key position to help their uninsured patients apply for the Medicaid expansion and find a new Patient-Centered Medical Home. Given the demand for service and limited resources of many free clinics, long-range planning tends not to be a strong suit. Through the fellowship, I hope to keep free clinics aware of developments, provide tools to assist them, and encourage them to chart their destiny in this time of change.
There are many unanswered questions about ACA. With the Supreme Court challenge to the mandate, and with presidential candidates vowing to repeal the law, will it be fully enacted? And if it is, where will the newly insured find care? Will there be sufficient primary care providers who will accept Medicaid patients and Medicaid reimbursement rates? Who will remain uninsured, and where will they find care? Will there be a future role for free clinics in the health care safety net?
Three states have received a federal waiver to expand Medicaid coverage for their citizens in advance of ACA: Wisconsin, Vermont, and Massachusetts. I contacted free clinic leaders in these states to learn their experience and what can we expect when Medicaid is expanded in the rest of the nation. They reported that no free clinics closed as a result of the expanded coverage. In fact, volume of patients seeking care at the free clinics continued to grow. Free clinics helped enroll their patients in these new programs, and helped them find a new Primary Care Provider (PCP). The latter proved a challenge, due to a critical shortage of PCPs and their refusal to accept Medicaid. As a result, several free clinics are now accepting Medicaid patients, but not billing Medicaid. Because the population served has unstable income, they frequently go off and on Medicaid, and require navigation assistance. Dental care and prescription assistance remain huge gaps in service which some free clinics are attempting to fill.
Who will remain uninsured under ACA? It is estimated that only 40% of the uninsured will be eligible for the expanded coverage. The other 60% are undocumented immigrants and naturalized citizens in this country less than five years. Some persons, otherwise eligible for Medicaid, will not be able to pull together the required documentation, e.g., a birth certificate. Others are exempt from the mandate and will choose to remain uninsured. And some will choose to pay a penalty rather than acquire insurance. All of them will need care.
The future of ACA is uncertain, but one thing seems certain. The need for free clinics will not soon disappear. Communities will continue to need free clinics, and free clinics will continue to need the support of their communities.
Health reform is a work-in-progress. Health care advocates must continue to work for a national healthcare system which has as its goal improved population health rather than profit. The Affordable Care Act is a step in that direction, and we must ensure its continued implementation, while at the same time working towards “Health Care for All.”
*Cover photo attribution to LaDawna Howard, Creative Commons licensed content.
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