Free clinic

A free clinic or walk in clinic is a health care facility in the United States offering services to economically disadvantaged individuals for free or at a nominal cost. The need for such a clinic arises in societies where there is no universal healthcare, and therefore a social safety net has arisen in its place. Core staff members may hold full-time paid positions, however, most of the staff a patient will encounter are volunteers drawn from the local medical community.

Free clinics are non-profit facilities, funded by government or private donors, that provide primary, preventive, and additional health services to the medically underserved. Many free clinics are made possible through the service of volunteers, the donation of goods, and community support, because many free clinics receive little government funding.

Regardless of insurance coverage, all individuals can receive health services from free clinics. However, said services are intended for persons with limited incomes, no health insurance, and/or who do not qualify for Medicaid and Medicare. Also included are underinsured individuals; meaning those who have only limited medical coverage (such as catastrophic care coverage, but not regular coverage), or who have insurance, but their policies include high medical deductibles that they are unable to afford. To offset costs, some clinics charge a nominal fee to those whose income is deemed sufficient to pay a fee. Clinics often use the term "underinsured" to describe the working poor.

Most free clinics provide treatment for routine illness or injuries; and long-term chronic conditions such as high blood pressure, diabetes, asthma and high cholesterol. Many also provide a limited range of medical testing, prescription drug assistance, women's health care, and dental care. Free clinics do not function as emergency care providers, and most do not handle employment related injuries. Few, if any, free clinics offer care for chronic pain as that would require them to dispense narcotics. For a free clinic such care is almost always cost-prohibitive. Handling narcotics requires a high level of physical security for the staff and building along with more paperwork and government regulation compared to what other prescription medications require.

History

At the turn of the century, healthcare in the United States became privatized despite many efforts by President Roosevelt and others to establish national health insurance, causing the healthcare system to neglect the lower classes. Starting in the 1950s, there have been incremental reforms to offset healthcare market failures and to better deliver healthcare services to low-income and underserved populations, including Medicaid and Medicare. Since then, there have still been increasing inequality and issues in coverage, access, cost, and quality of healthcare in America. In the United States, free clinics are a way to address this inequality and lack of universal healthcare, and as part of a health safety net.

The modern concept of a free clinic originated in San Francisco when Dr. David Smith founded the Haight Ashbury Free Clinic in 1967. From there free clinics spread to other California cities and then across the United States. Many free clinics were originally started in the 1960s and 1970s to provide drug treatments. Each one offered a unique set of services, reflecting the particular needs and resources of the local community. Some were established to provide medical services in the inner cities, while others opened in the suburbs and many student-run free clinics have emerged that serve the underserved as well as provide a medical training site for students in the health professions. From 1968 through the 1970s, the Black Panther Party established several Peoples’ Free Medical Clinics as part of their efforts to counter systemic discrimination against Black people in hospitals and private medical practices.

In 2001 the National Association of Free and Charitable Clinics (NAFC) was founded in Washington, D.C. to advocate for the issues and concerns of free and charitable clinics. Free clinics are defined by the NAFC as "safety-net health care organizations that utilize a volunteer/staff model to provide a range of medical, dental, pharmacy, vision and/or behavioral health services to economically disadvantaged individuals. Such clinics are 501(c)3 tax-exempt organizations, or operate as a program component or affiliate of a 501(c)(3) organization." In time various state and regional organizations where formed including the Free Clinics of the Great Lakes Region, Texas Association of Charitable Clinic (TXACC), North Carolina Association of Free Clinics, Ohio Association of Free Clinics and the Virginia Association of Free and Charitable Clinics (est. 1993). In 2005 Empowering Community Healthcare Outreach (ECHO) was established to assist churches and other community organizations start and run free and charitable clinics.

In 2010, the Patient Protection and Affordable Care Act (ACA) was passed as a reform that aimed to make healthcare insurance more accessible to low and middle-class families. Specifically, it subsidized low-income populations’ purchase of individual coverage. It also incentivized employers to provide coverage to low-income employees, and made it mandatory for states to expand Medicaid to include non-disabled and young people with incomes that were below 138% of the federal poverty line. Studies show the ACA has been successful in redressing inequality in the access to healthcare. In 2015, there was a “4.2 percentage point increase in full-year insurance for the poor and 5.3 point increase for the near-poor”.

However, the implementation of the ACA proved to be more challenging as some states chose not to enforce it. Additionally, the ACA does not support undocumented immigrants, which means that health care outside of the free clinic to those who are undocumented remain relatively inaccessible. The ACA also does not reach homeless populations. Barriers include this population's low healthcare literacy, the requirements of residency verification, their difficulty accessing/applying for social services, their access to transportation, and the fact that many healthcare facilities do not accept Medicaid. It is not yet clear if and how the Trump administration will influence healthcare reform, specifically the access to healthcare for the most vulnerable. Trump often speaks out against the ACA; some scholars worry that President Trump's 2017 executive order, which eliminated cost-sharing reductions in the ACA, will result in an overall decrease in the number of people who can access affordable healthcare, thus emphasizing the need for free clinics.

Patient demographics

Of the 41 million uninsured people in the United States, the 355 officially registered free clinics in the country are only able to provide services to about 650,000 of them. On average, free clinics have annual budgets of $458,028 and have 5,989 annual patient visits. In another survey of three free clinics, 82% of patients reported that they began using a free clinics because they have are uninsured, and 59% were referred by friends/family. A similar study found that 65% were unemployed with students making up 17%. There also seems to be little correlation between education or employment status and insurance coverage in free clinic patients.

Free clinic patients are mainly low-income, uninsured, female, immigrants, or minorities. About 75% of free clinic patients are between the ages of 18 and 64 years old. According to another study, 70% of all patients 20 years and older make less than US$10,000 a year.

In a 1992-1997 survey of the Charlottesville Free Clinic, the patient body consists largely of a low income working class that reflects the demographics of the Charlottesville area. Most of the patients reported that without the free clinic, they would either seek the emergency room or do nothing at all if they got sick. There has been a shift over the years from patients seeking urgent care to patients seeking treatment for chronic illnesses. Combined, these factors suggest that free clinics will require additional resources in order to meet the rising demands of their patient population.

In a study of the Miami Rescue Mission Clinic in Florida, the most common conditions were mental health, circulatory system, and musculoskeletal system disorder. The most common of the mental health disorders were depressive disorders and anxiety disorders. Throughout multiple studies about patient demographics in metropolitan settings, there was a higher than national average prevalence of mental health disorder, obesity, diabetes, and smoking in free clinic patients.

Operation and services

Some free clinics specialize in providing primary care (acute care), while others focus on long-term chronic health issues, and many do both. Most free clinics start out seeing patients only one or two days per week, and then expand as they find additional volunteers. Because they rely on volunteers, most are only open a few hours per day; primarily in the late afternoon and early evening. Some free clinics are faith-based, meaning they are sponsored by and affiliated with a specific church or religious denomination, or they are interfaith and draw support from several different denominations or religions.

Free clinics rely on donations for financial support. The amount of money they take in through donations to a large degree determines how many patients they are able to see. Because they are unlikely to have the resources to see everyone who might need their help, they usually limit who they are willing to see to just those from their own community and the surrounding areas, and especially in chronic care will only see patients from within a limited set of medical conditions.

Free clinics function as health care safety nets for patients who cannot afford or access other forms of healthcare. They provide essential services regardless of the patient's ability to pay. Hospital emergency rooms are required by federal law to treat everyone regardless of their ability to pay, so people who lack the means to pay for care often seek treatment in emergency rooms for minor ailments. These hospitals function as safety net hospitals. Treating people in the ER is expensive, though, and it ties up resources designed for emergencies. When a community has a free clinic, hospitals can steer patients with simple concerns to the free clinic instead of the emergency room. Free clinics can save hospital emergency rooms thousands of dollars. A $1 investment in a free clinic can save $36 in healthcare costs at another center. For this reason, most hospitals are supportive of free clinics. Hospitals are a primary source for equipment and supplies for free clinics. When they upgrade equipment, they will often donate the older equipment to the local free clinic. In addition some hospitals supply most or all of a local clinics day-to-day medical supplies, and some do lab work free of cost as well.

Medical malpractice liability

Free clinics can be granted medical malpractice coverage through the Federal Tort Claims Act (FTCA). FTCA coverage includes health care professionals who are acting as volunteers. In addition it covers officers, board members, clinic employees, and individual contractors. Medical malpractice coverage does not occur automatically, each organization must be "deemed" eligible by the US Department of Health and Human Services. To be eligible the clinic must be an IRS recognized nonprofit, that does not accept payments from insurance companies, the government, or other organizations for the services it performs. It also must not charge patients for services. It may receive donations from anyone and any organization; the stipulation is that it may not receive financial reimbursement for service rendered, which by definition a free clinic does not.

The Volunteer Protection Act of 1997 provides immunity from tort claims such as negligence, bodily injury, pain and suffering that might be filed against the volunteers of nonprofit organizations. Thus, volunteers working on behalf of a nonprofit free clinic are covered under the Volunteer Protection Act from most liability claims.

Individual states may offer additional legal protections to free clinics, usually under the states Good Samaritan law

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