Holes in the Health Care Safety Net: Voices of the Underserved

Abstract

Background and Purpose. Physical therapy programs seek community-based learning experiences for students. The purpose of this ethnographic study is to develop an understanding of the experiences of individuals seeking health care at community-based free medical clinics. Subjects. The free clinic in this study is located in a suburban neighborhood community center in the Midwest. Three women and 3 men were purposively selected for participation based on recommendations from the clinic manager. Methods. Participants were involved in 2 in-depth interviews and follow-up meetings over a 6-month period. Extensive observations supplemented interview data. Feminist methodologies were used to analyze the data and develop the themes. Results. The patients/clients value the caring behaviors and respect shown to them by clinic volunteers. They reported seeking health care at free medical clinics because they are unable to meet out-of-pocket costs associated with physician-office visits and over-the-counter (OTC) medications, as well as lack of coverage for preventive services. Patients/clients with limited financial resources state they are more likely to feel stigmatized in traditional health care settings than at free medical clinics. Discussion and Conclusion. Patients/clients seeking services at free medical clinics need to be viewed by health care practitioners and volunteers beyond demographics and medical conditions. Patients/clients are immersed in complex life circumstances that create the context for health care interventions. Patient-centered care means creating space for dialogue beyond the chief complaint, even though all needed services cannot be provided in the free clinic setting. Key Words: Federally qualified community health center, Free clinics, Underinsured, Uninsured, Ethnography. INTRODUCTION AND BACKGROUND Other than hospital emergency rooms, 2 forms of ambulatory health care settings exist to provide health care services for the underserved. Community-based medical clinics typically take the form of either federally qualified community health centers (FQHC)' operated through grant funding, or a free medical clinic that springs up through the efforts of local civic or religious groups.2 FQHCs must be established in medically underserved areas (MUA) or serve a medically underserved population (MUP), meet extensive administrative reporting requirements, and provide specified primary care services in order to receive federal funding.1 In addition, they must also provide supportive services like transportation, interpretive services, social services, and patient/client education. There is great variation in the look and feel of free clinics around the country, in part because of their inception in the community through volunteer initiatives. Free clinics are typically supported through donations, volunteer professionals and staff, in-kind gifts, and rent-free locations in churches and community centers. The focus and mission of most free clinics is to provide urgent and preventive care services. Few free clinics are adequately staffed or set up for specialty care, mental health services, or dental care. Free clinics supplement services provided by FQHCs and emergency rooms. However, FQHCs cannot meet the need for health care that exists in the poorest counties in the US. Without free clinics, the outlook for the underserved would be even direr. Whether faith-based or secular, the free medical clinics have often been referred to as the last resort for individuals and families in poverty struggling with financial and social stresses that required urgent health care. However, public perception may not be keeping up with the changing profile of patients/clients actually receiving health care in free clinics. With rising health insurance premiums and larger proportions of out-ofpocket expenses passed on to employees, more and more working families and individuals are seeking health care in free clinics rather than physician and practitioner offices, even when they have insurance. …