Is There A (Volunteer) Doctor in the House? The Role of Free Clinics and Volunteer Referral Networks in Serving the Uninsured Stephen Isaacs, J.D., and Paul Jellinek, Ph.D. Isaacs/Jellinek December 2007

The Need to Provide Medical Care to the Uninsured and the Poor has Risen Dramatically Between 2000 and 2005, more than 17 million Americans lost their health insurance or signed up for Medicaid Between 2000 and 2005, more than 17 million Americans lost their health insurance or signed up for Medicaid More than one in four Americans—88 million people— is now either uninsured or covered by Medicaid More than one in four Americans—88 million people— is now either uninsured or covered by Medicaid

Private Physicians are the Principal Source of Primary Care for Uninsured and Medicaid Patients

Even as the Need is Growing, the Proportion of U.S. Physicians Providing Charity Care Has Been Declining

Two Options that Can Make it Easier For Doctors To Volunteer Free clinics Free clinics Volunteer referral networks Volunteer referral networks

Free Clinics Started in 1960’s Started in 1960’s More than 1,700 currently operating More than 1,700 currently operating Serve more than 2.5 million people Serve more than 2.5 million people Doctors go to the clinic to provide services Doctors go to the clinic to provide services

Volunteer Referral Networks Started in 1990s Started in 1990s More than 50 currently in operation More than 50 currently in operation Doctors provide services in their offices Doctors provide services in their offices

How These Programs Make It Easier For Doctors to Volunteer Screen for eligibility Screen for eligibility Distribute the burden of care equitably Distribute the burden of care equitably Work with PAPs and other sources to assure access to prescription meds Work with PAPs and other sources to assure access to prescription meds Coordinate access to labs, specialty care, hospitalization Coordinate access to labs, specialty care, hospitalization Minimize no-shows Minimize no-shows

Kellogg Project on Volunteer Health Care (Completed in 2006) Literature review Literature review Expert interviews Expert interviews Meetings with national, regional, and state associations Meetings with national, regional, and state associations Site visits to 21 free clinics and volunteer referral networks Site visits to 21 free clinics and volunteer referral networks

Volunteer Programs Visited 1. Asheville, NC 2. Chicago, IL 3. Charleston, WV 4. Cleveland, OH 5. Coldwater, MI 6. Cotati, CA 7. Exeter, NH 8. Grand Rapids, MI 9. Hilton Head, SC 10. Kalamazoo, MI 11. Knoxville, TN 12. Maryville, TN 13. Miami, FL 14. Omaha, NE 15. Racine, WI 16. Red Bank, NJ 17. San Francisco, CA 18. Sevierville, TN 19. Venice, CA 20. Wichita, KS

We found great variation in: Size of program Size of program Staffing Staffing Services Services Sources of support Sources of support

Although Each Program is Unique, They Have Many Features in Common Local roots Local roots High patient volume High patient volume Primarily serve uninsured patients Primarily serve uninsured patients High proportion of immigrant patients High proportion of immigrant patients Constant financial challenges Constant financial challenges

External Challenges Growing demand Growing demand Increasing burden of chronic care Increasing burden of chronic care Increasing economic strain on providers Increasing economic strain on providers Changing patient mix Changing patient mix

Service-Related Challenges Access to specialty care Access to specialty care Access to medications Access to medications Malpractice coverage Malpractice coverage

Organizational Challenges Hand-to-mouth existence Hand-to-mouth existence Lack of contact with similar programs in other communities Lack of contact with similar programs in other communities Burnout Burnout

The Bottom Line Since private physicians provide four-fifths of the care to uninsured and poor people, the recent decline in the number of physicians willing to do this, combined with the growing number of uninsured, poses a threat to the nation’s safety-net services. Since private physicians provide four-fifths of the care to uninsured and poor people, the recent decline in the number of physicians willing to do this, combined with the growing number of uninsured, poses a threat to the nation’s safety-net services. Free clinics and referral networks can make it easier for doctors to volunteer. Their experience to date illustrates the potential of volunteerism and also its limitations. Free clinics and referral networks can make it easier for doctors to volunteer. Their experience to date illustrates the potential of volunteerism and also its limitations. Given the sheer numbers of uninsured and poor people—25% of the U.S. population is either uninsured or receives Medicaid—the reach of volunteer programs (and, indeed, the reach of all institutions providing safety-net services) is limited, requiring a national solution. Given the sheer numbers of uninsured and poor people—25% of the U.S. population is either uninsured or receives Medicaid—the reach of volunteer programs (and, indeed, the reach of all institutions providing safety-net services) is limited, requiring a national solution.