As a home health aide, Karla Sacaza has spoon-fed patients with AIDS and tuberculosis, bathed a woman dying from the effects of obesity, and soothed adults who are mentally ill, or just plain ornery, all for $6.15 an hour.
After all of that, Sacaza had no one to take care of her health. For a while, she had relied on Medicaid. But after her second child was born, a caseworker told her that she would lose her health benefits. Neither her part-time job nor her husband's position at a paint store offer medical coverage, and their budget is so tight that Sacaza says even a $27 physical exam at a clinic is beyond their reach. “I've been working since I was 14 years old,” Sacaza says, still outraged. “Why shouldn't I get health insurance?”
It turns out the caseworker was wrong, and Sacaza can get her health insurance back. But she might never have known that if it weren't for an unusual experiment taking place in a small brick building in the Bronx.
At the corner of Walton Avenue and East 177th Street in Tremont, a team of doctors and medical students from the Albert Einstein College of Medicine volunteer every Saturday, seeing patients who come for anything from check-ups and immunizations to nagging pains or symptoms of potentially deadly diseases such as asthma and heart disease. They come because everything here–the physical exams, blood tests, prescriptions, and even expensive but essential services like CAT scans and radiology–is free of charge.
Sacaza learned of the Walton Free Clinic from an advisor at Bronx Community College, where she was taking a class. There, she was able to get a physical exam without breaking her budget. A volunteer social worker also helped her apply for the nutrition program WIC for the baby–and helped her reapply for Medicaid, hopefully making it unnecessary for her to return.
“Free clinics” like this once abounded in the city. Thirty-nine of them endure in one form or another, legacies of a wave of activism among doctors in the 1960s and 70s; some date back to the turn of the century. The notion that health care is a right, not a privilege, guided those civil-rights era clinics, and it is central to this one as well. But beyond providing needed care to patients, the Walton clinic reckons intimately with the health care crisis of the 2000s: the swelling ranks of the uninsured. Its volunteers don't just treat symptoms and promote prevention; they figure out how to coax uninsured patients into an ongoing relationship with health care.
Kathryn Haslanger, director of policy analysis at the United Hospital Fund, a nonprofit research group, sees the Walton Free Clinic as a significant effort at a time when the number of uninsured New Yorkers has reached a crisis point. “For those of us who are interested in patching up the holes in the safety net,” she says, “it's going to be fascinating to see what we can learn about who goes to the clinic and why they go and what brings them back.”
And go they do. Every Saturday, a dozen or two patients make it in by 11 a.m. before a student rolls down the metal gate over the clinic's front door and puts up a “closed” sign. They are signed in by first-year students, have their charts reviewed by second-years, get their blood pressure measured by third-years and go through initial physical exams given by fourth-year students, and are seen by a volunteer doctor.
The clinic is hosted by Dr. Neil Calman, who is all too aware that many New Yorkers are unable to pay for basic health care. He is founder and president of the nonprofit Institute for Urban Family Health, which operates 16 clinics in the Bronx and Manhattan. While those centers and dozens like them around the city receive federal subsidies to help them treat uninsured patients, those patients still have to chip in their own copayments, and the centers, too, must spend money they don't have–about $1 million last year. Even low fees deter many from coming in–until a crisis hits. The system, says Dr. Calman, is “designed to do as crappy a job taking care of poor people as it possibly can.”
Operating on a budget of more than $150,000, and a whole lot of volunteer labor, the Walton Free Clinic brings in those, like Sacaza, who do not have insurance and cannot afford to pay for treatment. It also helps them apply for Medicaid and other public benefits if they are eligible.
For the medical students who volunteer there, Calman hopes it will inspire them to practice in community-based clinics. “We changed her life,” fourth-year medical student Gautam Mirchandani says proudly of one 13-year-old girl, who found out that she has diabetes and is now on a treatment program.
But the project's greatest value may be as a precious model for a health care industry in upheaval. Every patient who comes in shows physicians and policy-makers what can happen when uninsured people have unrestricted access to medical care. Instead of coming in for emergencies, they are getting their health care the way doctors agree they should: with prevention first. “The most surprising thing,” says Dr. Calman, “is that the major reason people come to the clinic is for preventive care.”
One of those people is a security guard at Albert Einstein. Though he has worked at the medical school through a contracting firm for more than a decade, the guard does not receive health insurance. This winter, he stopped by the free clinic for the first complete physical of his life.
The number of uninsured New Yorkers has reached heights that haven't been seen since Medicaid's arrival in 1965. Welfare reform–and the city Human Resources Administration's persistent efforts to deter applicants from seeking Medicaid coverage–has forced Medicaid enrollment down by 13 percent since 1995. According to a survey by the Commonwealth Fund, 28 percent of working-age adults in New York City are now uninsured. At over a million, that's more than receive Medicaid benefits.
Of New York's children, 10 percent are uninsured; they are six times as likely as insured children to go without needed medical or dental care, five times as likely to go to the emergency room instead of a doctor's office or clinic and four times as likely to delay seeking needed medical treatment.
Dr. Calman and his colleagues first thought of opening a free clinic several years ago, when they noticed that more and more patients were losing Medicaid. While the uninsured poor can visit his clinics at low cost, they have no way of paying for expensive medicines or lab tests.
He didn't know it, but a dozen students at Albert Einstein had a similar idea. They were looking for a way to practice their clinical skills and provide free medical care to their neighbors in the Bronx, which boasts the state's highest rates of youth asthma and has dismal access to prenatal care. But the students couldn't find a site or licensed doctors to oversee their work. A professor at Einstein put the two groups in touch, and after nearly a year of planning, the free clinic opened in September.
The volunteers have collected antibiotics, asthma medication and other drugs from pharmaceutical companies, which donate some medicines through charity programs and many more through aggressive distribution of promotional samples to doctors. They have convinced Montefiore Medical Center to perform $10,000 worth of blood and urine tests for free, and wheedled a team of local radiologists into donating their services. If a patient needs a sophisticated test like a CAT scan or an MRI, a referral to the medical school's Jacobi Medical Center is available for $25, or without cost to those who cannot pay.
Should doctors and medical students be stitching the medical safety net together on their own? Freelance goodwill is ultimately no substitute for rational, accessible medicine. But in an increasingly market-driven system for bringing health care to poor people, the uninsured poor have zero buying power. As a provider, Calman is as vulnerable to that changing economy as they are: as Medicaid enrollment has gone down and Medicaid managed care brings lower payments for those patients who do remain, Calman's clinics have been forced to lay off their health outreach workers, reduce their nursing staff and cut back on counseling services. For Calman as much as his uninsured patients, going outside the marketplace is at least one response that promises progress.
Dr. Calman is now negotiating with a foundation to fund expansion of the clinic, opening it on Sundays or even bringing it to other sites. He knows he's got a big case on his hands. “I don't even think we're scratching at the surface of this problem,” he says. “We're not even coming close.”
Maura McDermott is a reporter for the Riverdale Press.