Every Saturday morning, nurse practitioner Amy Beane can be found at the Ebbs Chapel Community Center in Mars Hill. The building is home to the Outland Family Clinic, which opened June 5; it’s where Beane volunteers weekly to provide free health care to anyone in need.
“I had someone come in who has not seen a primary care provider in 10 years,” Beane recalls of a recent Saturday. This patient did not have health insurance, had limited transportation and was employed irregularly, she explains. Through his appointment at Outland, the patient learned he had diabetes, hypertension and high cholesterol.
The following patient that morning, Beane says, was a 20-something who had recently gotten off a parent’s health insurance and was concerned that his fever was a symptom of COVID-19.
“It’s all over the place, what comes in the door,” says Beane. She has seen approximately 50 patients since the clinic opened; their only commonality is how finances have driven them to seek free health care.
Outland Family Clinic is one of several resources in Western North Carolina where people who are uninsured or underinsured can access free health care. According to Kaiser Family Foundation data, 10.9% of Americans under age 65 were uninsured in 2019, but in WNC, that percentage skews even higher: 14.6% for Buncombe County adults under age 65, according to 2018 Small Area Health Insurance Estimates data from the U.S. Census Bureau.
Many of the health clinics that serve the uninsured are federally qualified community health centers, which are funded by the federal Health Resources and Services Administration Health Center Program. In WNC, those centers include Western North Carolina Community Health Services, also known as the Minnie Jones Clinic, Appalachian Mountain Community Health Centers, Blue Ridge Health, Hot Springs Health Program and others. They provide primary care on a sliding scale based on yearly income and household size.
“The problem is that sometimes the sliding scale fee is more than what people can do,” says Beane.
A free clinic — whether subsidized by the government or funded through private donations, like the Outland Family Clinic — can be a last resort. Otherwise, says Erica Palmer Smith, director of Care4Carolina, a Raleigh-based nonprofit seeking to increase health insurance access across the state, the uninsured “go to the emergency room if something gets bad enough.”
Working without cover
Employment does not guarantee health insurance coverage, notes the Rev. Scott Rogers, executive director of Asheville Buncombe Community Christian Ministry. Seven out of 10 patients at ABCCM’s medical ministry are employed, he says.
ABCCM’s program serves only uninsured people with an income below 200% the federal poverty level ($25,760 for a single person and $34,840 for a family of two). This population may work while being injured or sick because taking time off work means forgoing a paycheck for their family, Rogers says. He notes that many of the ministry’s patients work in professions that service the tourism industry.
Outland Family Clinic does not collect data about employment, Beane says. But as a privately funded operation, the clinic accepts patients who have health insurance, and she says many are employed.
“These people are working hard, and this is where they’re finding themselves,” says Beane. “Every single person who shows up at my door has been a college student, somebody who has a job or someone who has kids in school that they’re trying to pay their tuition.”
Beane estimates that 80%-90% of Outland Family Clinic’s patients are uninsured; the remaining patients have private health insurance or Medicaid. However, those insured patients often have high deductibles that they can’t afford to meet.
Financial constraints can inhibit Medicaid beneficiaries, too. Beane says Outland Family Clinic has served patients who do not have reliable transportation, cannot afford gas to travel to specialists in larger cities or lack home internet access for telemedicine.
Ounce of prevention
One crucial role of free clinics is providing preventive care, such as wellness checks and cancer screenings.
“One of the biggest tragedies is that folks aren’t able to get preventative care,” says Smith of Care4Carolina. “Because someone wasn’t able to get a colonoscopy at the right stage, instead of finding out they have colon cancer at stage 1, or being able to catch it as a polyp before it even develops into cancer, they catch it when they’re symptomatic going into the emergency room at stage 4.”
ABBCM can provide cancer screenings for patients through Project Access, a volunteer program of the Western Carolina Medical Society, says Rogers. To qualify for Project Access, a patient must be uninsured, at or below 138% of the federal poverty level ($17,774 for a single person and $23,517 for a family of two) and a resident of Buncombe or Madison county for the past 12 months.
Other preventive care services include monitoring patients’ blood sugar, disbursing diabetes glucose strips and insulin, and offering access to medication, Rogers says. According to the nonprofit’s data, the ABCCM medical ministry saw 6,540 patients during 2020.
WNCCHS in Asheville also provides primary care, as well as dental and behavioral health services, says Scott Parker, the clinic’s director of development. According to federal data, about one-third of its nearly 14,000 patients in 2020 had hypertension, 14% had diabetes, 6% had HIV and 4% had asthma; 61% of all WNCCHS patients were uninsured.
The coverage gap
While free or low-cost clinics serve many needs, they are limited in their offering of speciality care. For example, a free clinic may be able to treat a stomachache, but persistent abdominal pain may require the expertise of a gastroenterologist. Other specialist care, such as chemotherapy, is so intensive that clinics are unable to provide it for free.
Additionally, clinics are subject to budgetary restraints, whether publicly or privately funded. “They can only go so far, because their dollars can only go so far,” says Smith.
To address the lack of affordable health care for many free clinic patients, Smith advocates for closing “the coverage gap”: the lack of financial assistance for people who earn too much income to qualify for Medicaid but do not earn enough to qualify for an Affordable Care Act subsidy in the private health insurance marketplace. To meet that need, organizations like Care4Carolina advocate for the expansion of Medicaid to cover people within the gap.
If the coverage gap were closed, 16,877 people in Buncombe County would gain access to affordable health insurance coverage, according to Care4Carolina data. And according to the Kaiser Family Foundation, Medicaid expansion would make 372,400 uninsured adults across the state eligible for coverage.
North Carolina is one of 12 states that has not expanded Medicaid coverage. Although Gov. Roy Cooper, a Democrat, included $1.3 billion from the federal American Rescue Plan Act to support Medicaid expansion in his proposed budget for fiscal years 2021-23 budget, the budget currently under consideration in the majority Republican General Assembly as Senate Bill 105 does not include that funding.
Until health insurance is more accessible, free and low-cost clinics will provide a stopgap for the uninsured and underinsured. And the health care providers who work and volunteer there are ready.
“I don’t really care why you’re here. I’m just glad for you to come,” says Beane.