No Cost Care

Published in the Fall 2009 issue of SSA Magazine

Free clinics fill the gap in health care for the uninsured

AROUND IN ONE FORM OR ANOTHER for almost a century, free clinics have served many functions over the years, from dispensing medicine to the poor to providing substance abuse treatment in the 1960s. But few realize that free clinics' current role is primarily to help those not caught by public health safety nets.

New research by Julie Darnell for her doctoral dissertation at SSA provides the first comprehensive understanding of today's free clinics. She found a diverse set of 1,007 facilities in the U.S., most operated primarily by volunteer staff who are motivated by a desire to focus on patient care but have little or no government funding. Unlike community health centers, whose fees are based on patients' household income, free clinics do not charge for their services.

Today, substance abuse treatment is usually provided by specialized clinics, and Federally Qualified Health Centers (FQHCs) typically provide primary health care services, mostly to those with insurance, primarily Medicaid. And when the uninsured need acute care, they generally head to emergency rooms.

But about half of poor patients are not eligible for Medicaid. "If you're a single male or female with no children, part of a two-parent household, a legal or illegal immigrant, or not mentally or physically disabled, you're generally not eligible for Medicaid, no matter how low your income," says Darnell, now an assistant professor at the University of Illinois at Chicago. "And if you're unemployed, have a job with no insurance coverage, and do not qualify for Medicaid, your only options are self-pay or go without care."

And so free clinics, the majority of which provide some acute care, have stepped in as important providers of basic primary care, chronic disease management and prescriptions for uninsured, non-elderly adults. Surprisingly, Darnell found that it is not necessarily the poorest communities that have the most free clinics. Rather, free clinics are more prevalent where there a few alternatives for affordable primary care and an ample supply of physicians. Darnell found that free clinics serve about 10 percent of the working-age uninsured adults who seek care, about 1.8 million adults per year.

Darnell also found that free clinics are a diverse lot. "If you've seen one free clinic...well, you've seen one free clinic," says Laura Michalski, associate executive director of CommunityHealth, a free clinic in Chicago. She says the vast majority of patients seen at CommunityHealth are between 25 and 65, mostly in for chronic conditions such as diabetes and hypertension, depression, thyroid issues and asthma. Darnell found that free clinics can be tiny operations only open on evenings and weekends (important for the working poor), or serve more than 8,000 patients a year, as does CommunityHealth.

Michalski says that Darnell's study, which won awards for outstanding dissertation research from the Association for Research on Nonprofit Organizations and Voluntary Action and the Society for Social Work and Research, should help foster best practices in delivering efficient, quality health services. "Julie's research has given us a framework," Michalski says. "She's really started conversations between clinics to help us get perspective on what we're doing, and new ideas for what can work."

— Danielle L. Schultz