Starting in 2014, almost all Americans will have access to health insurance through Obamacare. Private insurance, state or federal health exchange programs, and an expanded Medicaid system will cover most people. But others will fall through the cracks, remaining uninsured and living without access to health services.
The “coverage gap” will include those who make too much money to qualify for Medicaid but too little to gain federal subsidies to buy private insurance. This includes 6.4 million people who live in states that chose not to expand Medicaid coverage. Add to this group the people who will inevitably feel that monthly insurance premiums are too expensive and will decide to pay an increasing annual fee instead.
So where do the low-income, uninsured go for the health services they need? One organization based in suburban Illinois feels it has the solution.
Is Charity Care the Answer?
Access DuPage, located in DuPage County just outside of Chicago, Ill., provides medical care to low-income, uninsured county residents. The organization has been successful in caring for local residents and believes its system can be duplicated in other parts of the country.
Unlike community clinics, which charge patients on a sliding, income-based scale, Access DuPage partnered with area hospital volunteers, community clinics, and free clinics to not only provide an array of cheap services but also to give enrolled patients a “medical home” for ongoing primary care.
Access DuPage executive director Kara Murphy told Healthline, “We differ from free clinics because of our comprehensiveness.” The group charges minimal co-pays for care and medications and works with local specialists to provide advanced care. “We will almost always be able to get patients everything that they absolutely need,” Murphy said.
According to an Access DuPage community report, the average direct cost of its program was about $450 per member per year in 2012. The key to the organization’s success is charity care. “Every single hospital donates finances and services,” Murphy said. “It’s the magic elixir for our service.”
Access DuPage provides some services directly, but acts more as “the glue” that links federally qualified health centers (FQHCs), free clinics, and private doctors. In its system, private physicians control how many patients they see. The 13-year-old program also utilizes free clinic volunteers, some of whom have been with the program since the beginning.
But can the program work on a larger scale? Murphy offers a qualified yes. “I hope that every community can do something like we do, but assets and challenges of that community will dictate their attention,” Murphy said. “It wouldn’t look the same everywhere.”
Murphy also noted that DuPage County is unique. The community lacked services for its low-income population, but was rich in health care assets. It is a relatively affluent, politically conservative community. “Being private in funding and volunteerism makes the program attractive to the community,” Murphy said.
Doing 'Our Fair Share'
When Access DuPage began, the organization asked local providers, “What if we all did our fair share?” The message resonated with both private and public partners.
Yet health services for low-income and uninsured people are not new. In Oakland, Calif., an organization called La Clínica has served its community since 1971. Since then, the organization has grown to include 32 sites across three counties.
Patients at La Clínica—which include the under- and uninsured, undocumented workers, and others—pay for health services on a sliding scale. Unlike Access DuPage, it does not rely on volunteerism but rather on federal programs, state funds, grants, and a small amount from patients.
When asked if the Access DuPage model is feasible on a national scale, La Clínica doctor Kristen Miranda, M.D., told Healthline, “I think the fact that there is such a shortage of primary care providers across the nation would make it hard to get enough volunteers to cover the need.”
She also noted that community health clinics, which are located throughout the country in underserved areas, provide services similar to Access DuPage, in addition to family planning, prenatal, dental, and preventative care.
Murphy admits that Access DuPage has its limits. “We don’t ever have enough access to what we need when it comes to specialties. But our places of scarcity mirror provider shortages in general.” And as a part of her “qualified yes,” Murphy said, “We recognize the system’s strengths and limitations. Access DuPage evolved over time.”
“We have to be pragmatic in the reality of being a program driven by volunteers. There are definitely gaps in what we’ve been able to offer,” explains Murphy. But she also notes many services they don’t offer, like dental care and contraception, are available elsewhere in the community.
But do the factors that make Access DuPage unique also make it difficult to duplicate? “For any community, if they’re interested in creating an access model similar to Access DuPage, their best success will stem from their community assets,” says Murphy.
Perhaps DuPage County’s most valuable asset is the community itself – clinic and physician volunteers who answered the organization’s call.
For others, and for now, community health centers will have to fill the health services gap.