The New Health Dialogue

Yesterday, the National Association of Free Clinics put on the seventh of a national series of massive free clinics, this time choosing D.C.’s Walter E. Washington convention center for the deployment of their hospital-in-a-box.  Being a burgeoning health-wonk, and wanting to put a face on the frequently abstract issue of the “uninsured,” I ventured out of the confines of the think tank and volunteered as a “patient-escort” at the clinic.

Over 1,000 volunteers (the people in the red shirts), and 1,200 pre-schedule patients turned the floor of the convention center into a make-shift hospital open to anyone without insurance -- and for those who can’t afford care through other avenues. Blue curtains were arranged into “pods,” each effectively a self-contained clinic.  Each pod had 14 exam rooms, staffed by volunteer doctors ranging from internists to pediatricians to surgeons.  Each exam room had matching a nursing station with a nurse triaging patients and ordering any of the 10 tests that were available in the “lab”-- another bank of tables in the center of each pod.

Though I expected a scene of general calamity, the day went far smoother than I could have imagined. Nicole Lamoureux -- the program’s director -- pointed out that many of the day’s patients “haven’t been to a doctor in five or ten years,” and that they are generally a fairly frightened set. Coupling a well-rehearsed strategy for managing patient flow and copious amounts of comfort and cheerfulness from volunteers, the clinic moved nearly 2,000 patients through their system. 

Most of the patients seen were uninsured due to employment that didn’t provide health insurance, breaking a common misconception that being uninsured is synonymous with being unemployed.  In an interview with McClatchy Newspapers, the program’s Medical Director Dr. Bobby Kapur noted:

More than three-quarters of those attending, don't have insurance because they are recently unemployed, work for small businesses, earn hourly wages, or must work multiple part-time jobs with no insurance... According to the National Association of Free Clinics, about 83 percent of the patients who go to free clinics are employed but don't have health insurance.

After waiting in the long entrance line (even for those with pre-scheduled appointments), patients were given a numbered folder, paired with a numbered wristband that served as their day’s medical record. Passed from a larger, central waiting area to one of the three “pods,” the patients were then cycled through triage, labs, a doctor’s exam, a pharmaceutical consultation, and discharge. 

My job as a patient escort was to shepherd both the patient -- and just as importantly their medical record -- through the various steps of the clinic. The medical record was key to the clinic’s strategy for facilitating the rapid-fire flow of thousands of patients. If you look at the form (here), it gives an insight into the entire process of the day.

Many doctors expressed pleasure at how the free clinic set-up allowed for “the practice of pure medicine” in a way that their regular, for-profit practices did not allow. No complicated paperwork. No insurance billing. No worrying about the cost of tests. Instead, doctors and nurses were free to do what they desire most basically: to care for patients. If they suspected a patient might have breast cancer, a screening could be done by the Howard University Cancer Center (in the “pod” next door), and a plan for free follow-up treatment established right then and there. No billing departments involved.

At the same time, the ease with which care was carried out in this context illustrates by juxtaposition some of the weaknesses of our health care system. Even the simple, preventative tests that made up of the majority of treatment rendered at the free clinic are generally too expensive for the majority of the uninsured to afford.

It is unacceptable that nearly 2,000 people (merely a fraction of D.C.’s 57,200 uninsured residents) had to come to a one-off clinic in a convention center to get the basic types of care that could save our health care system untold millions.

The deterrent effects of even small costs, as told to me by one of the patients, was enough to prevent many from seeking the cheap, easy, immediate care that can prevent later expensive, catastrophic care. The long-term outcomes of these chronic conditions, when left untreated, are a huge cost burden on our health care system. If a person in this vulnerable segment of our society has an extra $50, he or she is much more likely to spend that money on rent or groceries or a car payment than a cholesterol test. 

Additionally, many of the patients seen yesterday had been previously diagnosed with various conditions, and many brought bags of medications prescribed by other doctors. However, without accurate medical histories for a large portion of the patients, the doctors had to repeat tests and diagnoses that have probably been done by previous doctors. I was repeatedly struck throughout the day by how many of the problems both within the event and in its interaction with the wider system of health care could be mitigated by electronic medical records. I can only imagine the effects on the continuity of care for an individual if the clinic doctor could see all of a patient’s past test results and could pass along the treatment prescribed at the clinic to a patient’s future doctors -- a potentially huge step forward in effectively treating the chronic conditions that were the order of the day.

The majority of patients came for these long-overdue diagnoses or the maintenance of chronic conditions such as diabetes, high cholesterol, and arthritis. Recognizing the inability of a one-time, however comprehensive, free clinic to contribute to the long-term well being of such patients, the staff emphasized getting people into the city’s network of safety-net care. Volunteers were told not to think of the event as a single opportunity to provide care, but the front-line of a much broader network of available care. An entire segment of the floor was dedicated to education about the various free options available to the uninsured.

Congresswoman Donna Edwards (D-MD) spoke at the opening of the event, pointing out that events like this were temporary stop-gaps to cover the nation’s vulnerable uninsured until the opening of the exchanges in 2014, a sentiment echoed by organizers throughout the day.

Starting in 2014, many of the day’s patients will end up absorbed by the expanded Medicaid eligibility (133 percent of the federal poverty line), while the rest will be required to purchase (largely or fully subsidized) insurance on the exchanges. Coupled with regulations regarding essential benefit packages and cost-free preventative care, much of the work done by the clinic today should be thankfully unnecessary in the coming years.

There remains reason for skepticism. As we make the system-wide shift to a fully insured population, the visible need for large-scale events such as this one (aimed exclusively at the uninsured) will disappear. However, there are doubts as to our ability to successfully inform and enroll everyone who will be newly eligible (not even considering the potential calamity caused by repeal of the individual mandate), and then, subsequently, from whom the newly enrolled will receive medical care. The network of doctors that accept Medicaid is already stretched thin and a significant expansion of this workforce will be required to provide for the newly expanded pool of the publicly insured.

Hopefully, the provisions in the new health reform law aimed at workforce expansion will help ease the problem of access to care. Health reform implementation is a work in progress--and it will remain so for awhile--but it's important to remember the key word there: progress!