Surveying the Safety Nets

The growing landscape of safety net medical providers, the impact of the Affordable Care Act, and the mission of the church

by John Mills

The church has a long history of being involved in the health of its members and the community it serves. Well into the nineteenth century, a local pastor was likely to be consulted on both spiritual issues and matters of health. In the early twentieth century, denominations became involved in funding, constructing and running modern hospitals. By and large these hospitals were meant to serve the poor and provide care to those without the means to call in a private physician.

In the last half-century, however, the manner in which hospitals are run has shifted along with the wider landscape of how health care is delivered and experienced. What has not changed is the reality that gaps exist in care, and many populations still benefit from “safety net” care.

The Safety Net Sector
The US medical safety net is a complex web of organizations providing a multitude of medical, dental, pharmacy, mental health and wellness services for the roughly 41 million uninsured and 60 million underinsured individuals in the US. For this article, we will define an uninsured individual as someone having no private (such as Blue Cross or Kaiser) or public (Medicaid or Medicare) health insurance coverage. An underinsured individual is defined as having some health insurance coverage but not enough, insured yet unable to afford the out-of-pocket responsibilities not covered by the insurer, or unable to find a medical provider willing to accept the payment offered by the insurance.
Safety net medical providers include free and charitable medical clinics, Federally Qualified Health Centers (FQHCs) and look-alike clinics, rural health clinics, public hospitals and similar nonprofit and public providers and systems. Understanding the parameters of the various participants in the safety net sector helps understand the role they play in the larger challenge of health care for uninsured and underinsured individuals.
A free medical clinic is a nonprofit organization that offers some combination of medical, dental, pharmacy, vision or behavioral health services at no cost to eligible recipients of its care or for a nominal donation. Many free clinics depend upon volunteer medical professionals to provide the care for their patients, but some may also employ administrative and medical staff. Free clinics typically serve low-income uninsured adults ages 18–64. In some parts of the country, undocumented individuals make up a large percentage of the patients that free clinics serve. Free clinics generally are started by founders who believe access to health care should not be contingent on the ability to pay for that care.

A charitable clinic charges a fee for service, but the fee may be a small fixed amount or a sliding fee based upon the user’s income. Like free clinics, charitable clinics often depend upon the support of volunteer medical providers but may also employ paid staff to deliver services. Organizers of charitable clinics often believe that everyone should contribute something financially for their health care. Both free and charitable clinics depend on the financial support of the community to operate, since revenue from patients does not cover cost of operation and they do not accept reimbursement from public or private insurance plans.

A hybrid clinic is a charitable clinic that also accepts public or private insurance plans, but it is not a Federally Qualified Health Center or a look-a-like clinic. Because hybrid clinics accept insurance reimbursement, they typically serve all age groups. The changing health care landscape after the passage of the Affordable Care Act led some free and charitable clinics to convert to the hybrid clinic model as they found their client base newly insured by Medicaid or private insurance.

Federally Qualified Health Centers (FQHCs) are public and private nonprofit health care providers located in medically underserved areas that treat anyone regardless of ability to pay using a sliding fee scale, and meet certain federal criteria under the Health Center Consolidation Act (Section 330 of the Public Health Service Act). FQHCs employ administrative and medical staff to provide primary medical, dental and mental health services for all age groups. They receive substantial financial support from the federal government and benefit from an enhanced reimbursement model for their Medicaid and Medicare patients. This support allows FQHCs to be open for longer hours and serve more patients than a typical free or charitable clinic.

Look-alike clinics are organizations that meet the eligibility requirements of an FQHC but do not receive federal grant funding. Look-alikes receive many of the same benefits as FQHCs, including enhanced Medicare and Medicaid reimbursement and eligibility to purchase prescription and non-prescription medications at a reduced rate.

Rural health clinics must be located in nonurban areas of high medical need. They can be either nonprofit or for-profit entities, but they must employ a non-physician provider (physician assistant or nurse practitioner) for at least 50 percent of the hours they are open. They generally focus on providing primary medical care services to both insured and uninsured of all ages with no requirement to offer dental or mental health services.

The ACA’s Impact on the Safety Net

When Congress passed the Patient Protection and Affordable Care Act (ACA) in 2010, most in the safety net sector were excited by the possibility that low-income individuals would finally have a way to receive affordable health insurance. The act was designed to drastically lower the number of uninsured by requiring all Americans to have health insurance and imposing a penalty for noncompliance. It also required the creation of health insurance exchanges and aimed for states to greatly expand their Medicaid eligibility for low-income folks to 133 percent of the federal poverty level (FPL) ($32,252 in 2015 for a family of four), covering approximately 17 million new Medicaid recipients by 2022. The federal government was to cover 100 percent of the new Medicaid costs for the states through 2016 and then gradually decrease until it covered 90 percent of new enrollees’ costs by 2020. The government would also offer health insurance subsidies up to 400 percent of the FPL ($95,400 in 2015 for a family of four) to encourage the purchase of private health insurance by those not eligible for Medicaid. Congress also increased funding to enable the expansion of the network of Federally Qualified Health Centers, which would be the new medical home for millions of new Medicaid enrollees. In spite of the fact that the ACA did not make any provision for covering the millions of undocumented residing in the country, many in the sector thought that the legislation would go a long way toward solving the issue of access to health care for America’s most vulnerable residents.

However, in June of 2012, the Supreme Court found the provision in the ACA requiring states to expand their Medicaid programs to be unconstitutional, while allowing the expansion to remain in effect for states that choose to enact it voluntarily. The mechanism for covering the health insurance needs of our country’s lowest-income individuals was thrust back to the states to determine participation, and to date 31 states have implemented it. In the 19 states that did not implement the expansion, low-income individuals continue to depend upon safety net clinics and their local emergency departments for routine medical care.

The Supreme Court decision had the unintended consequence of actually making it harder for those at the lowest income levels to access affordable health insurance. Most states have a very low income threshold for eligibility to their Medicaid program for healthy adults, several as low as 13 percent of the FPL. The federal subsidies for purchasing health insurance on a state or federal health insurance exchange begin at 100 percent of the FPL because the legislation anticipated covering the lowest income individuals via Medicaid expansion. A new gap emerged between the Medicaid-eligible income levels and the subsidy-eligible income levels; in this gap, no assistance is available even though income levels are low. The need for safety net clinics to provide health care access in these states remains as high as before the passage of the ACA.

In the states that did choose to expand Medicaid coverage to 133 percent of the FPL, the newly insured Medicaid recipients often face difficulty finding a medical clinic and provider that will accept the lower payments for services that Medicaid offers. Free and charitable clinics in those states saw an immediate decrease in their patient census as their low-income clients enrolled in Medicaid or the health insurance exchanges. However, many clinics report those same patients are returning to the clinic after struggling to find care using their new coverage. Some clinics have elected to begin accepting insurance reimbursements in order to continue to serve their long-time patients. Other clinics have amended their eligibility requirements to include serving these underinsured clients.

The Church and the Safety Net

Approximately 30 percent of the recognized free and charitable clinics identify themselves as faith-based organizations. Being rooted in faith often carries greater openness to whole-person care, which means not only treating the medical issue that motivated the patient to come to the clinic, but also inquiring about other aspects of the patient’s life that affect overall health and wellness. By asking about the patient’s relationships, housing and employment status, diet, spiritual life and family dynamics, the provider can discern if a referral is needed to address nonmedical determinants that may be impacting the patient’s health. The referral may be to a staff or volunteer social worker, nutritionist or counselor at the clinic or to one in the local community. Faith-based safety net clinics are particularly well suited for the whole-person approach to treatment because of their commitment to providing care with respect and dignity and their desire to build relationships with their patients.

In one example of whole-person care, an uninsured patient with asthma was referred to a faith-based free clinic because he was a frequent user of the local hospital emergency department. Joe had visited the ED eight times during the past six months as he struggled to manage his chronic asthma without a traditional medical home and a local private physician. The medical provider at the free clinic educated Joe on the correct use of his asthma medications, ensured that he had a sufficient supply, and then referred him to the clinic’s volunteer social worker, Cynthia. She interviewed Joe about his employment status, family and living situation, and nutrition. During the interview she learned that Joe was renting an unfurnished room and that he stored his clothing in an old box. As a result of not being stored properly, Joe’s clothes often were moldy, which exacerbated his asthma and led to his multiple visits to the hospital emergency department. Cynthia made a call to a local thrift store and for ten dollars procured a clothes dresser and made arrangements for it to be delivered to Joe’s rooming house. She also encouraged Joe to thoroughly wash and dry his clothes and to store them in his new dresser. Joe’s frequent asthma attacks were eliminated because the clinic’s treatment team took the time not only to treat his asthma medically but also to explore Joe’s life situation.

Dr. Beth Mulberry, medical director of the Mustard Seed Health Center in Greensboro, North Carolina, works with many new immigrants to the US and commented on this process. “The treatment team really needs to take the time to ask questions and listen to what is being said but also be aware of what is not being said. Relationships are very important in the cultures of our patients, and it takes time to build the trust needed for them to open up to us. But once we have built that trust, our patients often share intimate details about their family life, their faith and the struggles that are impacting their health status. That’s when we can really begin to make an impact on their lives.”

Reaching Out

Safety net clinics embrace a wide diversity of methods, models of care and funding structures. However, the core of their mission is often to provide health care access to the most vulnerable in our communities. Many churches support safety net clinics through donations, volunteering or promoting their services to members of their church and community. Yet even with the implementation of the Affordable Care Act, many safety net clinics continue to need support. Individuals, congregations and communities of faith are uniquely positioned to support safety net clinics—yet another way that the church can respond to Christ’s call to preach, to teach and to heal.

Individuals and congregations interested in more information about ECHO’S services may contact John Mills at millsj@churchhealthcenter.org or vision echoclinics.org.

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