JAMA, by Rita Rubin, August 15, 2017
Growing up in Bakersfield, California, in the 1950s, the grandson of Oklahoma farmworkers, David Smith, MD, had never envisioned himself as an activist. But in 1967, when Smith lived in San Francisco’s Haight-Ashbury neighborhood and worked as a clinical toxicology postdoc, the growing counter-culture revolution of sex, drugs, and rock ‘n’ roll “hit right where I lived.”
Jakub Mosur/AP Images
He recognized that the flower children flocking to San Francisco during the Summer of Love needed health care that was free not only of cost but also of harsh judgment directed toward their lifestyle, whether it was their drug use or their funky clothes. Although most people are familiar with the saying “health care is a right, not a privilege,” relatively few know that Smith coined it back in 1967.
So despite opposition from city officials, Smith founded the Haight-Ashbury Free Clinic 50 years ago. It’s thought to be the country’s first nonsectarian free clinic, leading the National Association of Free & Charitable Clinics (NAFC) to dub Smith “the father of the free clinic movement.”
Need Hasn’t Diminished
The NAFC now counts more than 1200 member clinics, which in 2016 served 1.8 million patients, both uninsured and underinsured, for a total of 6 million visits. The clinics provide a range of services, including primary and specialty medical care, dental care, mental health services, and medication access, and rarely receive public funding. Some are open 1 day a week, some nearly every day. More than 8 out of every 10 of their patients come from a household in which at least 1 person works. Some actually have health insurance but can’t afford the co-payments and deductibles.
But even though the number of uninsured Americans shrunk by more than 20 million from 2010—the year President Obama signed the Affordable Care Act (ACA)—to 2016, according to the recently published results of a survey by the National Center for Health Statistics, US free clinics are as busy as ever.
“I don’t think you’d find a free clinic director who wouldn’t say, ‘we’d be happy to close our doors if everybody had insurance,’” said Karen Gottlieb, RN, MBA, the executive director of Americare’s Free Clinics in Connecticut since 1996 . “I don’t see that happening in the near future.”
Because of the common misconception that the ACA eliminated the need for free care, NAFC member clinics saw a 40% decline in donations over the last 2 years, NAFC Chief Executive Officer (CEO) Nicole Lamoureux said. And yet, Lamoureux noted, the clinics saw 100 000 more patients in 2016 than in 2015.
The NAFC continues to get calls every day from Rotary Clubs, churches, and other organizations interested in establishing a free clinic in their community, she said. “Just today, I’ve had 5 people call and tell me that they’d like to start a clinic. ”
How a repeal of the ACA would affect demand for free health care isn’t clear, Lamoureux said. One of the legislative proposals that stalled in Congress would have cut Medicaid spending by hundreds of billions, potentially adding an estimated 22 million people to the ranks of the uninsured by 2026, according to the CBO. If the ACA is repealed, Lamoureux asked, “[A]re states going to continue the (Medicaid) expansion efforts, or are they going to scale back?”
In the Beginning
Smith, orphaned by the time he was 19, used his inheritance to buy his home, an apartment building on the outskirts of Haight-Ashbury. He then earned his medical degree in 1964 from the University of California, San Francisco (UCSF), and during a postdoc in clinical toxicology, began directing the Alcohol and Drug Abuse Screening Unit at San Francisco General Hospital. Many of the unit’s patients were young people, the flower children who had heeded Timothy O’Leary’s rallying cry to “Turn on, tune in, drop out.”
The Haight, which escaped the fires that destroyed most of San Francisco after the 1906 earthquake, was a working-class neighborhood of Victorian homes with reasonable rents that in the 1960s attracted the likes of the Grateful Dead, the Jefferson Airplane, and Janis Joplin.
“The music, it was like a pied piper,” Smith recalled.
But city officials rebuffed his request that they open a clinic to serve the flower children. “We don’t want to set up a clinic for these people, because we want them to leave,” Smith said they told him.
“That’s when I started getting radicalized,” he said. He located a former dentist’s office at 558 Clayton Street, where the rent was only $300 a month. He called the clinic “Dr David Smith MD and Associates” so as not to attract the city’s attention and risk being shut down. His future first wife donated her kitchen table to use as an examining table. Pharmaceutical company sales reps and UCSF pharmacists helped stock the clinic pharmacy with free samples.
The first day, June 7, 1967, the clinic saw 250 patients, many of whom had lined up outside before it opened its doors. University of California, San Francisco students, nurses, and medical faculty volunteered to help. Concert producer Bill Graham held 2 benefit concerts that raised $10 000 for the clinic, and producer Lou Adler donated $25 000 from the Monterey International Pop Festival. A plaque honoring Smith on the clinic’s exterior notes, “We built this clinic on rock and roll.”
“That Summer of Love was wild,” said Smith, who left the clinic about a decade ago and now practices addiction medicine in neighboring Marin County. The Haight-Ashbury Free Clinic continues to care for patients at 558 Clayton Street, but it is now one of 5 HealthRight 360 clinics that provide free care. HealthRight 360 is a family of integrated health programs in 13 California counties whose motto is “Get better. Do better. Be better.”
Today, the flower children who gathered in San Francisco during the Summer of Love are well over 30 years old, the age they said they would never trust, and free clinics, including the one Smith founded, are more likely to care for aging seniors with chronic conditions than barefoot hippies on a bad acid trip.
Thousands of Miles From the Haight
In the early 1990s, after watching a television news report about the number of uninsured or underinsured Connecticut residents, Robert Macauley, the late founder of Americares, an international health-focused relief and development nonprofit organization, decided to start a free clinic in his home state.
A free clinic helped fulfill Macauley’s mission to fix whatever was wrong with the world, Gottlieb said. The first of 4 Americares clinics in Connecticut opened in 1994 in Norwalk, which was followed by clinics in Danbury in 1997, Bridgeport in 2003, and Stamford in 2014. The Stamford clinic began as a mobile unit, a converted school bus with 2 examining rooms, but in January of this year, it moved to a permanent site with 5 examining rooms. None of the clinics receive public funds.
To qualify for care, patients must earn less than 250% of the federal poverty level—$29 700 annually for a single person; $60 750 for a family of 4—have no insurance, including Medicaid or Medicare, and live in the areas served by the clinics. Some qualify for insurance but can’t afford the deductibles, Gottlieb said.
Just more than 300 patients—or about 10%—at the Americares clinics qualified for insurance under the Affordable Care Act, she said. “We lost them, which is good news.”
But the small reduction in patients was only temporary. Since 2014, 4000 new patients have sought care at Americares clinics, due in part to the opening of the Stamford mobile unit, Gottlieb said. “In two of our clinics right now, we’re not taking new patients. We have to do that once in a while when we get overwhelmed. Most of our patients come in with chronic problems. When we take a new patient, we make a commitment.”
All 240 physicians who see patients at the Americares clinics are volunteers, many of them retired physicians who work every week, she said. “Newly retired doctors are often not ready to retire,” Gottlieb said. “Free clinics are the perfect place for them. The adherence and the motivation of our patients exceeds any private practice.” Most of the nurses also are volunteers, and Quest Diagnostics has provided free laboratory tests for clinic patients since 1995.
The Americares clinics work closely with local hospitals, Gottlieb said. “There’s no way a free clinic can deliver quality care in a vacuum.” The hospitals, which provide access to diagnostic tools such as computed tomographic scans and x-rays, recognize that the free clinics help minimize inappropriate use of emergency departments for nonurgent care, she said. “We appreciate what they do for us, and they appreciate what we do for the community.”
Many of the nation’s free clinics have established relationships with nearby medical schools whose students and faculty regularly volunteer, and, Gottlieb said, she hopes to link up with a Connecticut school that already has a faculty member volunteering at an Americares clinic.
“One of the things that I think has really grown, particularly in the last decade, is the role free and charitable clinics play in teaching,” said Larry Robins, MSW, board chair of the NAFC and CEO of PediPlace, whose 3 North Texas clinics are unusual in that they provide care only for children and adolescents. “We are training the next generation of health care professionals.”
Real-world Education
A 2014 survey published in JAMA showed that the number of Association of American Medical Colleges (AAMC) member institutions with a student-run free clinic had more than doubled since the last national survey 9 years earlier. The authors identified student-run free clinics at 106 of 141 AAMC member institutions. Medical schools with free clinics reported that more than half of their students volunteered at them, and the most common diseases treated at the clinics were diabetes and hypertension.
Free clinic patients aren’t the only ones who benefit from medical students’ volunteering their time, a recent study suggested. Researchers twice administered the Jefferson Scale of Empathy, used to measure empathy in physicians and other health professionals, to 188 members of the class of 2015 at Sidney Kimmel Medical College in Philadelphia. The students completed the scale at the beginning of their first year and at the end of their third year. During that period, about 45% of the students volunteered at least once at JeffHOPE, a multisite free clinic run by Kimmel medical students. While their classmates who never volunteered demonstrated a significant decline on the empathy scale during medical school, those who worked at the clinic did not.
Students fill the volunteer slots at the Indiana University Student Outreach Clinic within minutes after they’re posted, said Javier Sevilla-Martir, MD, an Indiana University (IU) family physician who directs the clinic, open 10 am to 3 pm Saturdays at the Neighborhood Fellowship Church on Indianapolis’s east side. Butler University’s pharmacy program and the University of Indianapolis’s physical therapy school are also involved with the clinic.
Most patients are uninsured or unable to afford deductibles, but his clinic “graduates” many patients to Medicaid, Sevilla-Martir said. “We try not to be their primary care providers. We try to connect them to the system.”
Saturday hours are convenient for the clinic patients, most of whom work weekdays, Sevilla-Martir said. “We have felt the need to expand the clinic hours, but the building is maxed out.”
However, he said, plans are under way for the clinic to expand into space owned by the church in a nearby office building. The new space will serve as a meeting place for members of the community, whether or not they need health care. Besides office hours on Wednesdays and Saturdays, the clinic expansion will include a coffeehouse and an art center.
Although most of the care is provided by medical students, a recent study suggests it compares favorably with national data. Sevilla-Martir and his coauthors conducted a retrospective review of 64 patients with hypertension whose cases had been managed at the IU clinic over a 15-month period. The researchers found that the clinic’s blood pressure control rate did not differ significantly from the National Health and Nutrition Examination Survey (NHANES) average but was significantly greater than the NHANES group with no usual source of care.
“We don’t go there to play doctor or just give a good education experience to our students,” Sevilla-Martir said of the clinic. “We really want to impact the well-being of our community in an integral way.”
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