"Access" is a noun that figures prominently in any discussion of so-called free clinics. It is also an important word in the arena of so-called health care reform. And it takes on new significance when trying to understand the impacts of the Patient Protection and Affordable Care Act (PPACA), also known as federal health care reform.

This act does not directly provide any assurance of access to health care. Instead, it provides a way of insuring a larger percentage of the population than are currently insured. In other words, by 2014 we may see better access to health insurance. But, despite this, the Congressional Budget Office estimates that by 2019 there will still be 23 million uninsured people.

Free clinics were developed to fill a gap in our health care system and that gap was the provision of care to the uninsured and underinsured. Lacking insurance, this population could not, in the case of many individuals, afford to obtain routine care. When health issues grew dire enough, many of them sought care in the Emergency Department at the nearest hospital.

Most free clinics supply basic urgent care to their patients. Some, like ours, also supply chronic disease care, which involves education and medical management. Many also address dental care in some way, as do we.

There are thought to be 1,188 free clinics in this country, of which 34 are in Washington state. What is their future? I present here some speculations informed by Mark Cruise of Free Clinic Solutions, but shaped by my own thoughts.

First, Congress has passed a bill that doesn't expand coverage until 2014. In the meantime there is no question about the need for free clinics. But what happens in 2014? At that time many who qualify for insurance may not be able to enroll nor choose to enroll, let alone find access to actual care. Even if everyone who qualified did enroll, which is highly unlikely, access to care is not guaranteed. Hence the continued need for free clinics, even after 2014.

The Dungeness Valley Health & Wellness Clinic has carried out its mission on the strength of broad community support. We are likely to seek this continued support in order to plug a huge gap in health care access for years to come.



Free clinics in need

So, what is the future of free clinics? The need for them is unlikely to be reduced in the foreseeable future. Some will continue serving the uninsured, as they are now, although the uninsured population that they serve may be different. Others may morph into something else by specializing (e.g., dental only clinics), moving into billing, converting to something else entirely, or ceasing to operate. Our plan is to continue to do what we are doing, including building the prevention and chronic health care components which address clear needs in our community. This is only possible with the continued support of our dedicated volunteers and the strong and broad support of our community.

The current state of the health care safety net is that free clinics in the USA serve an estimated 2 to 2.5 million uninsured or underinsured. In addition Federally Qualified Health Centers serve an estimated 7.5 million uninsured. This, combined, is not enough capacity to close the gap even if there is no growth in the populations requiring service.

Our clinic has been very actively moving into an emphasis on wellness and prevention. The PPACA does not deal with this at all. At a recent Washington Free Clinic Association conference, Mary Selecky, our state's Secretary of Health, stated: "While health care reform will greatly reduce the number of persons without health insurance, health will improve most from preventing chronic diseases in the first place, rather than treating them after they have occurred. This will require a public health system that assists individuals in adopting healthy behaviors, assists organizations and communities in encouraging these lifestyles, and assists policy makers in implementing science-based policies changing the conditions in which we all live."

I would add, that we must recognize the need for enough primary care providers, especially in rural areas, to offer access to care to the whole population. This cadre of providers coupled with an effective public health system could become a key component in reducing the cost of health care, by developing a healthier population.

Another issue that is essential to cost reduction is end of life care, but that's outside the scope of this report.

Finally, I would like to note that Mary Griffith, RN, when she founded the Dungeness Valley Health & Wellness Clinic in 2001, made a point of highlighting wellness. As a health care provider she knew the importance of prevention. So her dream lives on, both in terms of treatment and prevention. The world has changed, but human needs remain pretty much the same. And we must do a better job of addressing those needs, especially as they address access, most likely at the local level.



John Beitzel is a commissioner of Public Hospital District #2 (Olympic Medical Center), a member of the Clallam County Board of Health, and executive director of the Dungeness Valley Health & Wellness Clinic.