Third World Medicine in a First World Town

by Carol A. Westbrook

On Wednesday evenings, I volunteer at a free clinic. For a few hours I become a primary care doc in an urban setting, instead of a high-priced oncologist in a modern medical center.

Our clinic, The Care and Concern Clinic, in Pittston, PA, opens weekly at 5:30 pm, and closes when we have finished seeing our 30 to 40 walk-ins. We make no appointments, and we ask for no payments, insurance or Medicare. We can do this because our overhead costs are low, as our space is donated by a church, and all of our staff are unpaid volunteers, from docs to nurses to clerks and social workers. We use our funds to purchase medications, and to pay for lab tests and X-rays, and provide them without charge to our patients as needed, though we have to be sparing in their use, because we have to make sure there is enough to go around. We are a nonprofit supported by charitable donations, and we have a tight budget.

Practicing medicine at C&C is a breath of fresh air for me. I see a sick patient, figure out what's wrong, treat it, make sure the patient gets follow-up, and spend as much time as needed for questions and reassurance. I try to keep the patient's prescription costs as low as possible. I rely on my clinical judgment rather than X-rays or blood tests whenever possible. I don't have to order every possible test to make sure I don't get sued. I write my chart notes and prescriptions by hand, because we don't have electronic records. I don't have to bill, or code my level of service, or fill out innumerable forms. I don't have to turn a patient away for the wrong insurance. I don't have quotas to fill. For one evening a week, I can practice medicine the old fashioned way–by spending my time with the patient instead of with the paperwork.

For the patient, however, the experience is not so great. The wait is long, and the resources are scarce. They need to go offsite for X-rays or blood tests, and won't get results until the next clinic (though there will be a call back if it is urgent). If we don't have their prescription medicine in our stock, they have to get it filled elsewhere, and use their own money. We can't provide emergency care, but we can tell when it's needed, and make sure they get to a hospital emergency room. We can't do surgery, set bones, give blood transfusions, give IV antibiotics, deliver babies, prescribe narcotic painkillers, treat motor vehicle accidents, extract or fill teeth, do biopsies, refer to a specialist, or admit to a hospital.

What we can provide, however, is a great deal of routine care for people who otherwise just can't afford it. We help them avoid the emergency room. Our social workers assist those who might qualify for aid, food stamps, or other programs. We treat many common ailments such as infections, asthma, and thyroid; we manage complex conditions like high blood pressure, diabetes, and congestive heart failure. Our cost per patient must be very low compared to insurance-based health care. In fact, our practice has more resemblance to medical care in a third world country than it does to the high-tech, modern medical practice that most of us are used to, where you cannot get past the door without health insurance.

Our patients do not have insurance. They are the “in betweeners” who make too little to afford their health insurance, but earn too much to qualify for state medical aid (yearly income below $10,830). They are in their 50's or 60's, no longer able to work in their trades, but too young for Medicare (age 65). They are not “lucky” enough to be on Social security disability, yet cannot get jobs because they are not healthy enough for full-time work. They are people with insurance denials due to pre-existing conditions. They are seniors with Medicare who can't afford the supplement that pays for their medications. They have lost their jobs, or have been cut back to part time status and lost their benefits. They do intermittent work in construction, trucking, eldercare, or house cleaning, and their agencies do not provide insurance. They are undocumented immigrants. They are stay-at-home moms whose husbands have lost their jobs and their insurance. They are the 20-somethings, fresh out of college, looking for their dream job, who can't be on their parents' policy because the folks are uninsured. They are the working poor and out-of-work poor.

I wonder what will happen to the Care and Concern Clinic after January 2014, when The Affordable Care Act, “Obamacare,” kicks in. At that time, all uninsured Americans will have to obtain insurance through health-care exchanges or their employer, or else face a tax penalty. Will our clinic shut its doors for lack of patients? I doubt it.

I believe that most of the people who have been coming to our clinic in 2013 will still be uninsured, and will still be coming in 2014. They will continue to be “in betweeners” who don't make enough to pay for medical insurance, and will take their chances on paying the tax penalty. The tax penalty in 2014 is $95 per adult, and $47.50 per child, up to a maximum of $285—or 1% of household income, whichever is greater. The penalty increases yearly to 2016, to a max of $695 or 2.5%. The Affordable Care Act will provide subsidies for insurance purchase to those whose income is less than 400% of the Federal poverty level ($89,000 for a family of four), but many people are unaware of that fact, or don't know how to apply. At least our Care and Concern social workers will be able to assist people in applying for this aid.

But of course, you have to be working and paying taxes to owe the penalty. And for those with low-paying or part-time jobs, the penalty may be a lot lower than the cost of health insurance–and we don't yet know what the new insurance will cost. Realistically I am concerned that C&C Clinic business will increase in 2014, because our area residents could lose their jobs or be cut back to part-time status without benefits, as their employers try to save on health insurance costs. Although many people will benefit from the Affordable Care Act, health care costs are likely to go up for the segment of the population that is served by our clinic. So I expect the Care and Concern Clinic will continue to be full on Wednesday evenings at 5:30 pm. And I will be there until we close for the night.

The opinions expressed here are my own, and do not reflect those of my employer, Geisinger Health Systems.