A night at the free clinic shows limits of health-care reform

By Marina Bolotnikova
The Toledo Blade, February 1, 2015

TOLEDO, Ohio -- Every Thursday night, CedarCreek Church in South Toledo becomes a bustling health clinic that serves the region’s uninsured population. Medical students in white coats take each patient’s vital signs, hear their complaints, and refer them to one of the clinic’s doctors.

Patients can get consultations, medications, and simple tests for free. Most have no access to regular, preventive care. Many attend the clinic regularly to manage their health.

A crowd of patients often lines up long before the clinic opens, said Chris Marino, a second-year medical student at the University of Toledo college of medicine and life sciences — formerly the Medical College of Ohio — and executive director of UT’s CommunityCare Clinics. Many of the patients need insulin, which is in short supply and sometimes runs out early.

Guadalupe Peña, 40, recently lost his job and health insurance, and comes to the clinic to manage his diabetes. “If it wasn’t for this place, I wouldn’t have my medication,” he said. Mr. Peña is waiting to hear about his application for Medicaid coverage.

He said he doesn’t mind the often hours-long wait to see a doctor. Other patients echoed his attitude: They may have to wait three hours to talk to a doctor, but they appreciate the volunteers’ dedication and quality of care.

And they don’t have much choice. Even as the number of insured Americans climbs to unprecedented levels thanks to Obamacare and Medicaid expansion, countless people like the clinic patients struggle with prohibitively difficult applications, long wait times, and appeals processes to get health care. Estimates vary, but patients like these likely number in the millions.

Dr. Johnathon Ross, an internist at Mercy St. Vincent Medical Center and a weekly clinic volunteer, invited me to shadow his patient consultations. One woman got a prescription to treat dangerously high blood pressure. Without health insurance, there was no guarantee she’d have a follow-up consultation.

The patients I saw with Dr. Ross did not know they were eligible for Medicaid based on their income. Others said they had tried and failed to get insurance, or were waiting to hear from state agencies.

Karen Burnsworth, 50, said she earns about $7,000 a year, well below the poverty line. But when she tried to apply for Medicaid last year, she was denied.

Out of the woodwork

Many of the clinic’s patients fall into Ohio’s “woodwork” population: people who are eligible for Medicaid based on their income or disability, but haven’t enrolled. The Ohio Department of Medicaid estimated that 231,000 eligible Ohioans would come out of the woodwork and enroll in the program last year, because Americans without health insurance now face tax penalties under the Affordable Care Act. But Sam Rossi, a department spokesman, said that the actual number of woodwork patients to enroll has been much lower.

Part of that is because of the perceived difficulty of applying. Ohio Medicaid has streamlined its processes and introduced an online application to make it easier to apply, Mr. Rossi said.

Even so, many uninsured patients like Ms. Burnsworth say they find the application process arduous, and don’t have the knowledge or time to appeal unfavorable decisions. Free, no-questions-asked clinics such as the one at CedarCreek offer an alternative to the psychological barrier of applying, waiting for approval, and being denied coverage.

Donald Stout, 52, comes to the clinic for treatment of his high blood pressure. He was approved for Medicaid, but he didn’t like the coverage because of its limited network of doctors.

“They’re too pushy — they pick what doctors you can go to,” he said. “I like these doctors [at the clinic]. They’re all good people.”

Network inadequacy has always been one of Medicaid’s biggest shortcomings. Because doctors are reimbursed at a fraction of their regular rates to treat Medicaid patients, few physicians are willing to see them at all. So patients struggle with a small selection of doctors and long wait times.

Medicaid expansion has expanded the pool of eligible Ohioans to include childless adults who earn as much as 138 percent of the federal poverty level — about $16,100 a year for an individual. That change has helped 450,000 more Ohioans get coverage, bringing the state’s Medicaid enrollment to 2.9 million people.

But the expansion also threatens to make network inadequacy worse. To accommodate the influx of Medicaid patients, the federal government mandated an increase in Medicaid reimbursement rates for primary-care physicians to the same rates it pays doctors who treat Medicare patients. In Ohio, that was a pay bump of about 69 percent.

But that parity expired at the end of last year. According to the Ohio State Medical Association, 40 percent of doctors who were treating Medicaid patients said they would see fewer or none of those patients once the higher reimbursement ended. A bill sponsored by Sen. Sherrod Brown (D., Ohio) that would extend the pay increase through 2016 hasn’t budged in Congress.

Long way to go

Through a combination of Medicaid expansion and insurance subsidies for low and middle-income households, the Affordable Care Act has reduced the percentage of uninsured Americans from 17.1 percent to 12.9 percent. That’s an impressive drop, but it leaves more than 30 million Americans, including 1.2 million Ohioans, still uninsured.

For Dr. Ross, a vocal advocate of health reform, the need for free clinics illustrates the injustices and inefficiencies of American health care.

“The complexity of trying to figure out who’s supposed to pay and how in the private system generates billions of dollars of waste,” he said. “Here, we try to cobble together care for patients who fall through the cracks.”

Dr. Ross, a former president of Physicians for a National Health Program, advocates a single-payer system funded by tax dollars. The government, not insurance companies, would pay for health-care. Every American would be covered from birth. No confusing applications, networks, or payment schedules.

The Congressional Budget Office has consistently found that a single-payer system could cover every American and still cost less than what we pay for health care now, because of the enormous administrative costs of managing private insurers.

It’s hard not to see the appeal of a single-payer system. Obamacare has extended coverage to millions of people, but it hasn’t eliminated the basic problems of our health-care system: the link between health care and employment and the chaos of competing insurers. It hasn’t spared poor Americans the indignities of being denied care, or waiting for hours to see a doctor at a free clinic.

For now, though, single-payer health care in the United States is a pipe dream. As health reform moves at a glacial pace, patients will continue to depend on the goodwill of groups such as CommunityCare.

If free health clinics remind us of the indignities of American health care, they also show us the generosity of providers who are willing to work long, unpaid hours to fill the gaps in a broken system. I was reminded of that when I asked Mr. Marino of UT how working with uninsured patients has affected him.

“The people who come here are really struggling,” he said. “They’re giving us a lot of trust by letting us play a role in their care, because we’re students and we’re still learning.

“Another volunteer put it really nicely: ‘We’re not just here to volunteer. This is a privilege.’ ”

Marina Bolotnikova is an editorial writer and columnist for The Blade.