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Free Clinics and the Uninsured: The Increasing Demands of Chronic Illness
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Brief communication 165 FREE CLINICS AND THE UNINSURED: THE INCREASING DEMANDS OF CHRONIC ILLNESS Despite the economic prosperity of the 1990s, the number of uninsured individuals and families in the United States has continued to increase. In 1998, approximately 44 million Americans younger than 65 lacked health insurance.1 The traditional safety net providers for the uninsured have been community health centers, public hospitals, academic health centers, and private practitioners willing to treat patients for reduced or no fees. Volunteer free clinics emerged in the 1960s as an alternative health care delivery model for this population. Free clinics are private, nonprofit corporations with taxexempt status. They are designed to provide primary and specialty care, access to laboratory services and prescription medications. Services are provided at little or no charge and delivered primarily or exclusively by volunteer licensed health care professionals.2 In recent years, particularly after the 1994 failure of health care reform, free clinics have taken a prominent place on the list of safety net providers proposed as nongovernmental solutions to the problems of the uninsured. President Bush and others in the federal government have stressed policies that call for an even bigger role for nongovernmental, charitable organizations to fill gaps in medical care for the nation's uninsured.3 There are currently 345 free clinics registered in the United States.2 Despite their long history, there is surprisingly little published about them. In the past 10 years, several reports have addressed the challenges of starting free clinics.2,4"10 Some of these reports provide brief summaries of patient demographics and categories of clinical problems seen.5,11 To our knowledge, there are no publications providing detailed descriptions of demographic and clinical characteristics of free clinic patients. This information is vital for clinic management as well as broader public policy concerns. To begin to fill the gap, we describe in this paper the experience from the first 5 years of operation (1992-97) of the Charlottesville Free Clinic in Charlottesville , Virginia. The Charlottesville Free Clinic is a nonprofit organization staffed by volunteer health care providers that has been described previously.4 It is 1 of 32 clinics in Virginia. Since 1992, it has provided free primary care medical services, including x-ray and pharmacy services, to uninsured patients from the city of Charlottesville and the surrounding counties. The clinic is open three Received October 31, 2001; revised March 14,2002; accepted April 22,2002. Journal of Health Care for the Poor and Underserved · Vol. 14, No. 2 · 2003 DOL 10.1177/1049208903251517 166 Free Clinics and the Uninsured evenings a week and provides internal medicine, pediatric, basic gynecology, and limited psychiatric and dental services. Patients are eligible for care if they have no private insurance, are not covered under Medicaid or Medicare, and do not qualify for free care at the local university medical center. It has four full-time administrative staff members and a panel of approximately 200 volunteer health professionals, including physicians, nurses, nurse practitioners, physician assistants, dentists, and pharmacists. Since its inception in 1992, the Charlottesville Free Clinic has maintained a computerized database that includes patient demographic information along with clinical information about each encounter. In this report, we describe patient demographics, the most common primary diagnoses, trends in acute and chronic illness visits, and information on sources of care for patients served at the clinic during its first five years of operation. Method All patients provided demographic and survey data at the time of their first visit to the clinic. Patients were asked several questions about their usual source of care and emergency room usage and where they would have sought care if the free clinic did not exist. Primary visit diagnoses were coded by the treating physicians using ICD-9-CM criteria. These diagnoses were compared with National Ambulatory Medical Care Survey data, a national survey of diagnoses and demographics of patients presenting to physician offices and outpatient departments.12 Statistical analysis included use of the chi-square test for comparison of categorical variables and the Cochran-Armitage trend test to assess trends in categorical variables. Statistical analysis was performed using SAS Version 8.1 (SAS Institute, Cary, NC). Results From 1992 through...