Let’s Care for Those in Need—Today: Collaborating to Solve the Uninsured Crisis in America



 

Lee Jacobs, MD1

Perm J 2020;24:19.154 [Full Citation]

https://doi.org/10.7812/TPP/19.154
E-pub: 03/13/2020

Editor’s note: Please also see: Addressing the Health Needs of the Uninsured: One Community’s Solution, by Lynne M Hutchison, DNP, FNP-BC, and Raymond L Cox, MD, MBA (page 102); and Fostering Partnerships with the Safety Net: An Evaluation of Kaiser Permanente’s Community Ambassador Program in the Mid-Atlantic States, by Lorella Palazzo, PhD; Juno Matthys; Craig Sewald, MPA; et al (page 35).

ABSTRACT

This editorial is a call to action for medical communities across the country to address the uninsured crisis in their communities. Thirty million Americans without insurance need access to affordable, high-quality care. An insurance solution may be years away, so we must start today.

INTRODUCTION

What can be done to provide high-quality, affordable, and accessible care to those without health care insurance? There has been a lot of talk, scores of strongly held diverse opinions, posturing, and campaign slogans, but none of this helps the people in need of medical care today. What can be done now?

In this issue of The Permanente Journal, there are 2 articles that detail strategies for providing care to those in need (page 35 and page 102).1,2 Given a choice of standing on the sidelines and listening and watching, these people chose to act. They chose to deal with today’s realities—and to care for the uninsured population. They are the heroes, and there are many others across the country also taking action, as I will mention here.

This is a crisis that must be addressed now. We need a countrywide safety-net movement driven by the crisis, led by the health care community, and fueled by collaboration and compassion.

PEOPLE—NOT STATISTICS

After working for many years in a homeless clinic and for the last several years as medical director for a safety-net clinic, I have experienced firsthand the plight of those with no capability to pay for badly needed health care. I know them as people, not as a statistic. I know them as people with basic health needs but with limited options. I know them as very frustrated people asking for help and as people with a major sense of relief and appreciation when a caring person steps forward to help them.

I am not an expert on public health policy. I am not an economist. However, as a physician who deals daily with the medical needs of individuals without insurance, I have to ask: Why can’t the approach illustrated in the real-life examples of the articles in this issue be reproduced countrywide?

DEFINING THE PROBLEM: IT’S ABOUT THE “UNCARED FOR”

We all know what the problem is. More than 30 million Americans are without health insurance, limiting their access to affordable, high-quality care.3 However, the number of uninsured persons will not answer the most relevant question: What percentage of uninsured Americans need care today in each of our respective communities?

The problem with filling headlines with large national estimates is that it discourages interventions that could be undertaken today, thereby reinforcing the cop-out that “it is just too much for us to deal with.” So rather than be overwhelmed and discouraged by the numbers, it is helpful to remember: The objective is to fast-track care initiatives that will help the uninsured members of our communities who need care. Although providing health insurance is the essential long-term solution, the essence of a community solution today is not about insurance, but rather it is about how medical practitioners can provide the much needed clinical care.

A PROVEN CARE MODEL: THE SAFETY-NET CLINIC

There are heroes today in safety-net health care organizations throughout the country providing a variety of services to individuals in need of medical care. The National Association of Free and Charitable Clinics (NAFC) Web site4 provides the location and other information for these clinics, as well as a primer on how to start a clinic if there is not one in your area. According to the NAFC, in 2018 there were 1400 free and charitable clinics in the US, caring for 2 million patients and 6.3 million patient visits, and staffed by 203,000 volunteers, including 111,000 medical volunteers.4 Impressive numbers, and yet when the Affordable Care Act5 was being developed, the NAFC leaders were excluded from the dialogue,6 when the conversation shifted away from care solutions to insurance reform. As expected, there continues to be a major role for these clinics since the Affordable Care Act was signed into law,7 not surprising because this model has been shown to be effective in addressing the primary care needs of patients with low income.8

Recognition of the value of the safety-net clinic as a quickly implementable model to care for the uninsured population dates to 1991 when Kelleher9 wrote “Free Clinics: A Solution That Can Work … Now!” Since Kelleher’s article was published, the number of safety-net clinics has grown from 200 in 1991 to the present estimate of 1400. Good growth reflects the commitment of many individuals to serve in their communities, but there still are insufficient numbers to meet the demands. I wonder how different the health care landscape might be today if Kelleher’s 1991 solution had been implemented more extensively in more communities across the country.

Although there are several variations to the safety-net clinic model, most have in common that they are primary care focused and are staffed by a predominantly volunteer staff, and all exist to care for a patient population with limited options for care. Depending on the amount of time that practitioners volunteer, some clinics are able to function like any other primary care office, where patients see the same practitioner on follow-up visits. Many are free clinics, whereas others operate on a sliding scale with charges depending on the ability to pay. The article on page 102 of this issue describes a free clinic in South Carolina that offers a broad array of specialty and ancillary support without using government money.1 Heroes. Can you imagine the impact of this model if it were implemented around the country?

A CRITICAL SUCCESS FACTOR: COMMUNITY COLLABORATION

My intent with this editorial is not to add to the debate; I’ll leave that to the debaters. Rather, my intent is to encourage action for us—the medical community—to take a leadership role and develop local solutions so that care for those in need can be provided for now. I hope that we have not become so insulated in our practices, and protective of our cost structures, that we don’t believe we can solve this crisis. As a medical community, do we really believe that the government will provide the solution any time soon as to how we should care for patients without insurance? I do not believe that helping those individuals in need of care today through a safety-net model would in any way derail or delay a national insurance solution. The objective of the medical community is to provide care now and not wait!

Physician Volunteers

Collaboration starts with you. Please consider how you might be part of the solution to this crisis. Here are a few self-assessment questions:

•  Do you believe that this is, in fact, a health care crisis?

•  How responsible do you feel for helping the uninsured patients in your community in need of medical care today?

•  If you have cared for those in need previously—the poor, the uninsured, the homeless individuals—did you feel it was a meaningful experience?

•  Rather than planning to watch from the sidelines hoping there might eventually be a solution, do you want to help provide care now?

If you answered yes to any of these questions, here are some specific steps you can consider:

•  Visiting a clinic. Learn about their ministry; especially hear their passion. Hear about the experiences of volunteers, especially their patient stories.

•  Volunteering, even just 2 or 3 hours a month. I can guarantee you that most of the safety-net clinics need volunteers and administrative support, and all need financial support. Retired clinicians and their spouses can use their skills and experience to make major contributions.

•  Starting a safety-net clinic in your location, if there is not one already.

•  Advocating for the uninsured and medically underserved persons in your community. Discuss the need with your colleagues and friends.

This volunteerism may well be a remedy for physician burnout. In recent years much has been written on the topic of physician burnout,10 with estimates from surveys of more than 40%.11 I have found over the years that volunteerism has given me an overwhelming sense of appreciation for what I have, and it rejuvenates me professionally. I have found that helping people in need provides a perspective for me that is therapeutic. It has been well documented in the literature that volunteerism is an effective remedy for the situations that contribute to physician burnout.12-14

Other Key Collaborators

Obviously, fast-tracking any solution will take extensive community collaboration. I believe these collaborative efforts will primarily be driven by our compassion and not solely by our concern for our business future. However, the solution cannot rely on the compassion of a few heroes; we must mobilize and encourage several sectors in our communities to be involved, including medical groups, hospitals, community leaders, churches and synagogues, retailers, public communications, and many others. If strong, collaborative networks can be developed, I believe communities will have the resources to solve this crisis.

Hospitals

Obviously, hospitals are essential community collaborators and most already provide large amounts of uncompensated care. Hospitals have a major financial incentive to encourage care for uninsured patients in settings other than their Emergency Departments. By having access to primary care clinics, there will be fewer uninsured people using the Emergency Department for ambulatory care,15 and hospitals will have options for discharge appointments to decrease readmissions. It is imperative for hospitals to be strong partners in the community solution because, more than other sectors, they face major financial infrastructure changes if a government solution is initiated in the future.16

Pharmaceutical Companies

Other key collaborators to finding a solution for the uninsured patients are the pharmaceutical companies. Because these companies are such an important component of an affordable solution, I would like to clarify what I believe is a misconception that is prevalent in the chatter among nonmedical “authorities” as drug companies are labeled with derogatory terms such as Big Pharma.

Why do the pharmaceutical companies have such a poor public image? I believe physicians contribute to this image by prescribing new brand medications that generally do not offer any major advantages over older, time-proven medications. Sure, pharmaceutical companies aggressively market new expensive medications, but it is still the physician who writes the prescription! This problem is illustrated in the list of the top 10 Medicare medications prescribed in 2016, which made up $145 billion (17%) of Part D expenses.17 A primary care physician could practice for a long time and rarely prescribe any medication on this list. This problem is underscored by a major study in which researchers determined that the expensive newer insulins offered no advantage over older insulins in the treatment of type 2 diabetes.18

Clinician volunteers in safety-net clinics can attest to the fact that generic medicines for chronic conditions are generally available at affordable prices in the community. Although expensive medicines are not commonly prescribed in our safety-net clinic, when needed, these medications can be requested at no cost from pharmaceutical companies through patient assistance programs. For these reasons, I have not found medication availability for patients in financial need to be a major barrier, and certainly at no time do we compromise quality because of medication cost. We do need pharmaceutical companies to be part of the collaborative solution and would most certainly welcome any additional assistance, such as free, generic medication for those patients who qualify.

Specialty Support

Although the patients’ primary care needs are generally basic and not expensive, a limited number of patients in safety-net clinics need specialty care. In my experience, one of the greatest challenges for a safety-net clinic is obtaining subspecialty support, including mental health and dental care. Specialists are an integral part of the solution!

To obtain subspecialty consultations, there are several interventions that could be considered for communities. For example, it would be incredibly helpful if each subspecialist in a community would commit to accept a limited number of uninsured patient referrals per month. Committing to just 1 or 2 referrals would make a major difference to the clinics, while reassuring the consultant that by accepting a patient the floodgates of referrals would not open. Additionally, it would be supportive if specialists would agree to participate in videoconferencing, which is a high-quality, cost-effective approach for obtaining specialty opinions.19,20 An additional solution is linked to hospital privileges. If a specialist consults on a patient in the inpatient setting or sees a patient in the Emergency Department, s/he would commit to seeing the patient on follow-up in his/her office after discharge, regardless of insurance coverage or ability to pay. I believe that not to provide such follow-up care in these settings would actually be an ethical, not an insurance, issue.

Effective Collaboration Takes Mutual Commitment and Trust

Two recently published articles stressed the importance of a high level of trust among community collaborators, including a strong mutual commitment to the objective of caring for the uninsured population and, as in any successful partnership, clarity of roles.20,21 An additional important point is made; the level of the motivation of various sectors to be involved may be related to how well they can maintain their financial health while they collaborate to provide care.

Community collaboration is a critical success factor in caring for uninsured community members. So, convene your community collaborators to study, to implement, and then to celebrate!

HIGH-QUALITY, AFFORDABLE, AND ACCESSIBLE CARE, NOT SECOND-CLASS CARE

Implementation of a safety-net clinic strategy will help communities make major strides in addressing health disparities. However, to be a viable option for the care of uninsured patients, community safety-net clinics must provide high-quality, affordable, and accessible care.

Quality

First and foremost, the safety-net strategy must provide high-quality care. Volunteer physicians and associate practitioners need to feel that their time and skills are being used to provide high-quality and meaningful care. I have learned in my years as a clinician and as an administrative leader that high-quality care does not have to be expensive care. More magnetic resonance imaging and more brand medications do not necessarily equate to better care.

An excellent framework for establishing and tracking quality metrics is found at the HealthConnection Clinic, a Canadian primary care center that serves vulnerable patients.23

This center demonstrates what is possible when a highly engaged leadership shares a common vision and purpose, along with the importance of sustained and meaningful community engagement—an important aspiration for all safety-net clinics.

Affordability

There are various financial structures for safety-net clinics ranging from free clinics to clinics with sliding fee scales based on ability to pay. However, what they all have in common is they limit their overhead by having a predominately volunteer staff and solid financial support from partners in their communities. They all also have in common that, regardless of their financial model, no patient is turned away for lack of money.

Accessibility

In many communities, transportation is a major challenge for an uninsured person with limited financial resources, especially if there is no public transportation in the area. I have had patients walk several miles to see us in the office. Clinic location, the hours of operation, and tolerance of late patients are important access considerations for safety-net clinics.

THE TIME TO ACT IS NOW!

There is a crisis today in each of our communities. A large number of people have important medical problems that must be addressed. There has been a lot of talking and political posturing, but what we need now is action—action by those who are best able to organize and to provide the needed care. That’s us!

I am not arguing that safety-net clinics may be the long-term solution, but I do not believe that there is a more viable solution to provide care to the uninsured and underserved patients who are badly in need of health care today.

I told my daughter when she graduated from medical school, “You have earned a special gift—use it freely [to serve others].”24 Yes, all of us have special gifts, and most certainly we have an opportunity to serve others today. If we can rally now to address this crisis, community by community across the US, medical experts can continue to manage health care, and uninsured persons would have high-quality care options while the national dialogue continues in the future.

What we cannot do is go on with business as usual.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

1 The Permanente Journal, Portland, OR

Corresponding Author

Lee Jacobs, MD ()

How to Cite this Article

Jacobs L. Let’s care for those in need—today: Collaborating to solve the uninsured crisis in America. Perm J 2020;24:19.154. DOI: https://doi.org/10.7812/TPP/19.154

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Keywords: ACA, accessible care, Affordable Care Act, community, homelessness, safety-net clinics

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