Karen Gottlieb says she shares a dream with everyone else who runs a free clinic.
“I would like nothing better than to close our doors,” said Gottlieb, executive director of AmeriCares Free Clinics, which serves uninsured adults in Bridgeport, Norwalk and Danbury.
But Gottlieb doesn’t expect to get her wish anytime soon, even with the impending rollout of federal health reform.
Instead, on the eve of what’s expected to be a massive expansion of health insurance in the state, Gottlieb’s organization is preparing to open another free clinic for the uninsured. Like its other three sites, AmeriCares’ new Stamford clinic will serve area residents 18 and older who earn up to twice the poverty level.
People who work in free clinics — “the safety net below the safety net,” Gottlieb calls them — take it as a given that many of their patients will still be without insurance after Jan. 1, when, as part of Obamacare, Medicaid eligibility will be expanded, coverage sold through a new private insurance marketplace will take effect, and nearly all Americans will be legally required to have health care coverage.
And those who work with the uninsured think it could become harder for them to get care anywhere else. More insured patients will be vying for appointments, while cuts in state funds to hospitals for caring for the uninsured were slashed in the current-year budget.
“Everybody in the state that does this sort of thing is actually expecting a vast increase [in demand],” said Peter Kelly, an attorney who co-founded Malta House of Care, a mobile medical clinic that provides free care in Hartford.
Barbara Bartucca, executive director of the Malta House of Care Foundation, said the organization has gotten requests from Paterson, N.J., Dallas, Illinois and Ohio on how to replicate their model. And there’s an effort to start a similar mobile program in New Haven.
An analysis published last month in the journal Health Affairs estimated that in Connecticut, 162,000 people would remain uninsured by 2016.
“The [Affordable Care Act] will leave tens of millions uncovered. It will do little to alter racial disparities in coverage,” Dr. Rachel Nardin and four colleagues from Harvard Medical School wrote in the article. “The ACA, whatever its merits, will fall well short of its stated goal of providing affordable care for all Americans.”
Expanded coverage, for some
That’s not to say Obamacare won’t make a big dent in the number of uninsured residents in the state, currently put at roughly 337,000.
Between 50,000 and 55,000 people are expected to become eligible for Medicaid as of Jan. 1, when eligibility increases for adults without minor children. Another 80,000 to 100,000 state residents are expected to buy private insurance through Access Health CT, the state’s health insurance exchange. Many are expected to qualify for discounted coverage, subsidized by the federal government.
AmeriCares is one of the many organizations signed up to tell people about their options under Obamacare and help those who qualify sign up.
From October through March, the open enrollment period for coverage through Access Health, the goal will be to evaluate as many patients as possible, Gottlieb said, pushing those who qualify for Medicaid into the program and telling those who qualify for private insurance about their options.
Based in Stamford, AmeriCares is better known for handling disaster relief and humanitarian aid. It delivers medications and supplies to health care facilities worldwide and helps people with chronic diseases in the U.S. get free prescription drugs.
But closer to its home base, in what is by some measures the highest-income state in the country, AmeriCares also operates free clinics, two in cities where close to one in five people are uninsured. Many of the 2,700 or so patients have chronic diseases like diabetes or hypertension, or lower back pain.
“This is the working poor, and they’re out there working,” Gottlieb said.
At the Bridgeport clinic, on the first floor of a former school, there’s a table with a basket on it bearing a sign: “Please take what you would like…for yourself or someone you know. Free” It was set up after volunteers noticed that patients were showing up in the winter without coats or sweatshirts.
The remaining uninsured
Some of those who will remain uninsured after Jan. 1 won’t be eligible for Medicaid or assistance paying for insurance because they’re not in the country legally.
But Gottlieb said it’s a common misconception that they’ll be the only ones without coverage.
“There will be people who truly can’t afford insurance,” she said.
The health law’s individual mandate doesn’t apply to people who earn too little income to file a tax return, or to people for whom insurance would be considered too expensive to buy.
For people with low incomes who aren’t poor enough to qualify for Medicaid, federal subsidies will help reduce the cost of buying insurance. Gottlieb said the premiums will be affordable.
“But it’s the out-of-pocket expenses that are high,” she said, particularly for people who are sick and need lots of medical care.
The exact copays the poorest insurance customers would face vary by income, but the highest earners at the AmeriCares clinics — people making the equivalent of up to $22,980 a year for an individual or $47,100 for a family of four — would have $10 copays to see primary care doctors and $30 to see a specialist.
Clinic on wheels
Gottlieb would like to see her organization raise its income limit slightly so it can serve more people who remain uninsured next year. Making the change requires working with the clinics’ partners — the local hospitals, which provide diagnostic testing for free, and Quest Diagnostics, which provides free lab work.
The clinics provide primary care and some specialty services. Patients get medications free — $1 million of it last year, much of it through patient assistance programs run by pharmaceutical companies.
In Stamford, where the newest clinic will be, about 20 percent of the population is uninsured. The clinic is expected to open in the fall aboard a specially outfitted 40-foot van with two examining rooms. The goal is to eventually have a permanent location, but Gottlieb said the mobile clinic is an important steppingstone: People will become familiar with AmeriCares from seeing the van in their neighborhoods.
The Bridgeport clinic started the same way, and Gottlieb thinks people who now travel across the city to the permanent site wouldn’t have done so if they hadn’t first gotten comfortable with it where they live.
‘Severely cut back’
Seven years after it started, Malta House of Care is still mobile, operating in a Winnebago parked outside one of four Hartford churches, depending on the day of the week. A separate Malta House of Care program now provides care in Waterbury two days a week.
The Hartford mobile clinic gets about 4,800 patient visits a year and has about 2,600 patients who use it as their “medical home,” a regular source of care.
Kelly, who leads the Malta House of Care Foundation’s board, noted that the coverage expansion taking place under Obamacare won’t likely happen all at once. And once it does, he predicted there will always be a certain number of people who remain outside the system, such as those who don’t speak English or new immigrants. Even in countries with socialized medical systems, he said, a certain percentage is never part of the system.
He also expects it to get harder for poor people to access care because of a roughly $500 million cut made in the current two-year state budget to funds for hospitals to help cover the cost of treating uninsured and Medicaid patients. Gov. Dannel P. Malloy’s administration argued that the hospitals would make up the money because more people will have insurance, meaning they’ll have less uncompensated care to deliver. But hospitals have disputed that analysis, saying they lose money treating Medicaid patients and so having more patients covered by the program won’t make up for the cut.
“The net result of that’s very simple: Huge numbers of structures that are there to deal with lower-income people are going to be either cut or severely cut back, and those patients are going to be people who go to emergency rooms,” Kelly said.
“The net result of that is actually going to, we think, very, very significantly raise the kind of need for this ultimate safety net,” he said.