Why are free clinics necessary and what role do they play in the provision of health care in the US. The answer is presented in the book’s foreward:
In 2011, 46.3 million people were uninsured in the United States, about 15% of the population) This figure was expected to rise by the end of 2012. For minorities, the figures are worse, with nearly 30% of Hispanics and nearly 20% of African Americans being uninsured) Free clinics receive nearly 4 million patient visits a year. Without these clinics, the nation’s emergency departments and public health clinics (including federally qualified community health centers) would have to absorb all these patients and the costs associated with their care.
Simply put, free clinics provide an enormous amount of care. Even after the full implementation of the Affordable Care Act it is estimated that 20 million plus people will be without health insurance in the US. Many millions more will be under-insured meaning that the cost of actually using their insurance will be prohibitive. Thus, “free clinics” stand as a reminder of the failure of our society to guarantee health care as a human right. They also demonstrate the enormous commitment of many health care professionals to caring for people even when not paid.
Since the chapters come from an academic journal there is focus on critical thinking and data-driven evaluation. This is not a coffee table book idealizing the people who provide free care. There is, for instance, discussion of the “stop-gap” and “band-aid” nature of free clinics. Half of the book is devoted to general experiences with free clinics and the other half is devoted to papers on student-run free clinics. The book will be particularly valuable for those involved with (or thinking of setting up) free clinics.
Free clinics should not really be needed. Yet for those of us working in primary care the problems of un-insurance or under-insurance (particularly in working-class immigrant communities) is a daily reality. We work at and we refer to free clinics because we must. But all the while we remember that in the great towers of Wall Street – the banks, the insurance companies, the brokers – there is the money to set this problem right.
Junot Diaz returns to Columbia University in A Night with Junot Diaz: Una Lectura y Conversacion on Saturday, November 6, 8:00 – 10:00 pm. The event will take place at Alumni Auditorium and doors open at 7:30 pm.
CoSMO is the free-clinic run by Columbia Medical Students, one of a number of such clinics run by medical students in New York City (see our series on free and low-cost health care). Two years ago, the clinic was fortunate enough to have Junot Diaz, the Pulitzer Prize-winning author of “The Brief Wondrous Life of Oscar Wao” read from his works in a benefit performance. The show was a sold-out and the auditorium packed. Now Junot Diaz returns to read and discuss the immigrant experience in the US and minority treatment in the US health care system. The reading will be followed by a question and answer session.
Last Tuesday’s Social Medicine Rounds (9/8/2009) was prompted by the brutal murder of family physician George Tiller on Sunday May 31st 2009. While serving as an usher at the Reformation Lutheran Church in Wichita, Dr. Tiller was shot in the head and killed. We convened this Rounds to consider how we might respond to his death. Two issues dominated the discussion. The first was the failure of the American Academy of Family Physicians (AAFP) to condemn the murder. The second was an examination of the ongoing barriers to abortion care that exist even in a relatively progressive state such as New York. These problems were illustrated through 3 case vignettes.
In July of 1970, I planned to start a dermatology residency. On August 21, 1970, my father, mother, sister and brother-in-law were killed in an aircraft accident. My sister had a 12-month-old boy, Maurice. They had written out a will in longhand the evening before the airplane crash, that I was to raise Maurice. So we took charge of my sister’s boy and we moved back to Wichita. My game plan was to spend six months here, close out my father’s huge family medicine practice.
After I had been there for a little while, patients in the practice began to ask me if I was going to do abortions like my father did. I was outraged. Why would these nice people say that he was a scumbag kind of a physician?
I began to ask some of these women. And I found out that in 1945, ’46, or ’47, a young woman for whom Dad had already delivered two babies came to him pregnant again right away, and she said something to the effect that, “I can’t take it, can you help me?” That is apparently the way you asked for an abortion from your regular doctor before abortion was legal. Dad said, “No. Big families are in vogue, by the time the baby gets here, everything will be all right.” She had a non-healthcare provider abortion and came back and died.
I can understand how upset my father was. I do not know whether he did 100 abortions or 200 abortions or 300 abortions. I think it may have been something like 200 over a period of about 20 years, but I don’t know for sure. The women in my father’s practice for whom he did abortions educated me and taught me that abortion is about women’s hopes, dreams, potential, the rest of their lives. Abortion is a matter of survival for women.
When it became legal and my patients began to ask for it, I’d say, “Sure. It’s a legal process.” I was a service provider. I was a physician. The patients needed abortions, and I did them. It is my fundamental philosophy that patients are emotionally, mentally, morally, spiritually and physically competent to struggle with complex health issues and come to decisions that are appropriate for them.
We’ve been picketed since 1975. My office has been blown up. In 1993, I survived an assassination attempt. My kids were harassed in high school. I had to write letters of complaint to the City Council and the Board of Education. We had people who actually camped across the street from our house. I restrict where I go to eat, where I travel. You see a car following you, you think, “Ah-ha, let’s watch that.” You’re always on alert. You’re always looking around.
I was leaving the office. It was 7:00 in the evening. As I’m driving out, I have to slow down and I have to stop. Bang, bang, bang, bang, bang, bang, and I thought to myself, “That lady is shooting me with rubber bullets. I’m not afraid of rubber bullets.” Then I looked down and all this blood is all over the place. I thought, “She shot me. She can’t do that! I’ll get her.” I saw her running through some front yards. So I zipped down the street, turned in front of her to block her escape. She stops and reaches into this little fanny pack that she’s wearing in the front, and I thought, “She’s going for her gun again. She shot you once, George. She’ll shoot you again. You are in the wrong place at the wrong time.”
So then I drove off. Ended up back at the office, and I don’t remember anything for about 20 minutes. I remember trying to get into my car and drive myself to the hospital. I said, “Let’s not make this a big media event.” Well, I had lost 20 minutes and the TV trucks were there. I thought, “How’d they’d get here so soon?”
There was never any question in my mind that I was going back to work the next day. I belonged there and they were not going to separate me from my job and they were not going to separate me from my community. So I did go to work the next day, and we got everything done. People got taken care of, it took a long time. Arms hurt, bled a little bit, but so what? I am not going to be run over and I’m not going to run out. It’s just that simple.
I am a member of this community. Our DNA has been here since 1880. I belong here. The folks that come in from out of town, they are the intruders. Forty percent of all the people who were arrested here during the Operation Rescue in 1991 came from out of state. I intend to stay here. I am part of the fabric of Kansas and Kansas is part of the fabric of me.
I have more to be grateful for than I have to be resentful about. We have much more support in Wichita than we have rejection and castigation. If Wichita and our community did not want us to be here, I wouldn’t be here. But the vast majority of people in Wichita support, on a quiet level, what we do, which is help women and families.
Extensive coverage of the murder can be seen in this June 1, 2009 broadcast of Democracy Now. This program includes an excerpt from a 2008 speech Dr. Tiller gave to the Feminist Majority Foundation in which he explained his social vision: “We’ve given war, pestilence, hate, greed, judgment, ego, self-sufficiency a good try, and it failed. We need a new paradigm that consists of kindness, courtesy, justice, love and respect in all our relationships.”
Non-Response of the American Academy of Family Physicians
Tiller’s death was clearly not a random act of violence. As noted by Colorado physician Dr. Warren Hern:
I think it’s the inevitable consequence of more than 35 years of constant anti-abortion terrorism, harassment and violence. George is the fifth American doctor to be assassinated. I get messages from these people saying, ‘Don’t bother wearing a bulletproof vest, we’re going for a head shot.’
The American College of Obstetricians and Gynecologists (ACOG) finds the murder of George Tiller, MD, deplorable and tragic. There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it. It is especially chilling and deeply disturbing that this violence has occurred at a time when the leaders of this country are committed to finding a common ground in the abortion debate.
ACOG extends its sympathy to the family of this dedicated physician who treated his patients with dignity and compassion.
As ACOG expressed in response to the 1998 murder of Dr. Barnett A. Slepian, “With each new incident of anti-abortion violence, the previously unthinkable becomes commonplace—that vandalism could turn to murder, that slayings could move from the clinic to inside the home.” The murder of Dr. George Tiller is even more horrific in that he was killed in a house of worship as he and his family attended church services.
There is no common ground when it comes to violence of this nature. All groups in the abortion debate, whatever their personal opinion on abortion, must condemn such brutality in the strongest possible terms. Failure to make such condemnation is acquiescence to violence and intimidation. Only by standing together can we ensure that acts of brutality end.
The fundamental tenet of the pro-life movement is that human life has intrinsic value and is deserving of protection from the moment the seed and egg unite, until natural death. To take a life without due process devalues all life.
We at Operation Rescue were shocked to hear of the killing of late-term abortionist George Tiller and were among the first groups to denounce the cowardly act that took Tiller’s life. It was not justice, but vigilantism, which must be abhorred by a society that embraces the rule of law over anarchy.
With even the anti-abortion movement condemning the murder, how odd it seems that the American Academy of Family Physicians (Working for Family Medicine, Working for You), of which Tiller was a member, refused to issue a statement. A strongly critical commentary by Dr. Joshua Freeman (The Murder of George Tiller – Where is Family Medicine’s Response) in this month’s Family Medicine explored the reasons cited by the Academy for this refusal. The AAFP pointed to a policy that it “does not comment publicly on a member’s death (regardless of how it occurred) but expresses condolences privately to the family.” Of course George Tiller did not merely die. He was murdered. He was not simply murdered. He was assassinatedfor carrying out his duties as a physician. One cannot help but remember the comments of ACOG:
All groups in the abortion debate, whatever their personal opinion on abortion, must condemn such brutality in the strongest possible terms. Failure to make such condemnation is acquiescence to violence and intimidation.
Barriers to Abortion Access in New York: 3 case studies
We then considered three case scenarios illustrating the barriers to abortion access in New York State. Each case came with a series of discussion points. One point, considered in each of the cases, was the role of abortion in current health care reform proposals. (All identifying information has been removed or altered in these cases).
Case 1: Teresa is a 22 year old woman, G1P1, who comes to your office for a refill of her Nuva-Ring. She reports that she had actually run out 4 weeks ago, but couldn’t afford the time off from work at the Post Office to get in any sooner. She had unprotected sex 2 weeks ago. Her pregnancy test is now positive. Teresa is sure she cannot afford to have another baby right now. She decides with you to have an abortion. You give her the number to call Planned Parenthood to schedule it, and she calls you back later to tell you her insurance does not cover the procedure because she is a federal employee.
The Hyde Amendment bans the use of federal funds for abortions except in cases of life endangerment, rape or incest.
In addition, 32 states and the District of Columbia have prohibited the use of their state Medicaid funds for abortions except in limited cases allowed under the Amendment.
What is your role as her primary care doctor in facilitating her timely access to abortion care?
What are the implications for a universal federal health plan?
Case 2: Angela is a 31 year old woman G6P4, who works as a babysitter “off the books,” and comes to your office because she is pregnant and wants an abortion. You know that she has Medicaid so you refer her to the local abortion clinic for care. She calls you the next day to tell you she was denied care because her insurance does not cover abortion. You are confused because in New York Medicaid does cover abortion, so you call the clinic. They tell you that your patient has Fidelis (a Catholic HMO) and Fidelis does not cover abortion care.
What is your role as her primary care doctor in facilitating her timely access to abortion care?
What happens with Medicaid HMO’s that are “owned” by the Catholic Church?
What does this mean about how our tax dollars are being spent?
Can Angela use her Medicaid to pay for her abortion?
Would she be covered by a federal health plan?
Case 3: Monica is a 16 year old woman, G0P0, currently attending Roosevelt High School. She was sent to you by her school-based health center because she had a positive pregnancy test. Monica’s parents have insurance, but she does not want them to know that she is pregnant. After talking to you, she decides she would like an abortion. But she stresses the importance of not letting her parents find out. She tells you that last year her 18 year old sister got pregnant and they kicked her out of the house.
What are the rules in New York State regarding confidentiality for teens around pregnancy care?
Can she get other insurance to pay for her abortion?
What are the systems issues around eligibility for Medicaid?
What is your role as her primary care doctor in facilitating her access to abortion care?
As a follow-up to our post last month on the Justice is Healing Campaign we were asked by community organizer Minh Ha Nguyen to post this information about free legal services available to Cambodian and Vietnamese immigrants living in the Bronx.
CAAAV and NMCIR-Bronx Project have partnered to provide FREE
US Citizenship Application
Low-cost Adjustment of Status
Low-cost Family-based Petitions
Where: CAAAV Office, 2473 Valentine Ave.
(Fordham Rd. at 188th St.), Bronx, NY 10458
(Available by the BX 12 bus)
When: Last Wednesday of every Month
(July: Wed 28th, August: Wed 26th, Sep Wed 30th)
Time: 10 am- 2pm
Phone: (718) 220-7391 ext.16,
For Vietnamese: Minh-Hà, For Khmer: Chhaya
Please note that if you are at least 50 years old and have lived in the US as a legal permanent resident for 20 years or if you are at least 55 years old and have lived in the US as a legal permanent resident for 15 years you are eligible to take the Citizenship Exam in your native language and the exam is oral – not written
CAAAV kết hợp NMCIR-Bronx Project
cung cấp dịch vụ
FREE- miễn phí
Tư vấn Luật Di trú
Hồ sơ xin Nhập Tịch
Hồ sơ xin Thẻ Xanh (lệ phí thấp)
Hồ sơ xin Bảo Lãnh Thân Nhân (lệ phí thấp)
Địa điểm: Văn phòng CAAAV
2473 Valentine Ave.
(Fordham Rd. và 188th St.), bus Bx12
Bronx, NY 10458
Thời gian: Thứ Tư cuối cùng mỗi tháng
(Tháng 7: ngày 29, Tháng 8: ngày 26, Tháng 9: ngày 30)
10:00 sáng – 2:00 chiều
Phone: (718) 220-7391 ext.16
Tiếng Việt: Minh-Hà Tiếng Khmer: Chhaya
This website has a very extensive list of resources. For example, it lists 170 dental providers and 687 clinics. Each listing provides detailed information about the provider, including address, phone, services provided and even links to provider web pages. It is also possible to search for providers by zip code and distance you are willing to travel. The site also has a help phone number: (866) 370-HITE.
Here is a description of the site taken from their FAQ page:
The Health Information Tool for Empowerment (HITE) is the first online directory of health and social services specifically for uninsured and under-insured New Yorkers. With the click of a mouse, HITE allows professionals to link their underserved clients with a broad array of health and support services.
HITE has two components:
Resource Directory. A comprehensive directory containing thousands of national, state, and local organizations and programs available to low-income, under-insured, and uninsured people, as well as links to dozens of Web sites that provide information on everything from how to apply for public health insurance to where you can get free or low-cost medications.
Eligibility Calculator. Eligibility screening tool for public health insurance, private health insurance, and other public benefits programs. HITE links to two screening tools. The NYC Human Resources Administration pre-screening tool helps determine whether their clients meet the basic eligibility requirements for one of New York’s publicly funded health insurance programs: Medicaid, Child Health Plus (CHP), and Family Health Plus (FHP); or for a low-cost private insurance program. ACCESS NYC, sponsored by the City of New York Mayor’s Office screens for eligibility for public health insurance and other public benefits/government entitlements.
As part of our series on free and low cost health care in New York I wanted to share a few resources on free and low cost medicines.
Dr. Brian Alper (a family physician who foundedDYNAMED) has put together a very useful set of clinical links for physicians at: www.myhq.com/public/a/l/alper. Among the many categories in this list are six links to “indigent drug programs.” To test these sites out, I decided to look up Herceptin, an anti-cancer agent made by Genentech. [I was recently asked to find this drug for a medically indigent patient.]
Needy Meds: is a not-for profit “with the mission of helping people who cannot afford medicine or health care costs.” The information at NeedyMeds is available anonymously and free of charge. The most useful part of this website is the listing of drugs – both generics and brand – that are available from patient assistance programs (PAP’s). If you find a drug and a PAP, many of the applications can be downloaded from the website. Most of the links seem to be from 2008. The site also has a link to free clinics. I easily found Herceptin on the Needy Meds site with links to application form in English and Spanish as well as the Genentech website.
Rx Assist is managed by Astra Zeneca and claims to be the “Web’s most current and comprehensive directory of Patient Assistance Programs.” The Rx Assist site has a searchable database so you don’t have to scroll down lists. Herceptin was also easy to find on RxAssist, but the site linked only to the English application and the Genentech site.
Benefits CheckUp is run by the National Council on Aging and is a very different type of site. It provides information on a wide variety of benefits – housing, food, medication, medical care, utilities, “and more.” It works a little bit like an online social worker. To find information on Herceptin (for a fictious patient), I needed to input zip code, age, information about work, income, and assets; this process generally takes 10-15 minutes according to the website. I could easily imagine that it would take much longer if you had to find all the documentation. When this was through, Benefits CheckUp suggested I apply for New York State’s EPIC program (which helps elderly people with prescription costs), New York State Medicaid and also offered the Genentech program. There were links to the Genentech site, application forms, and even a list of documents I would need. Very complete, but a bit daunting in terms of the information I needed to supply.
All three of the above sites linked to a variety of health care resources, not just medications.
Partnership for Prescription Assistance also links to PAP programs. This site required me to enter information (age, location, income, insurance coverage, etc) before leading me to the Genentech site. It did not link directly to the Herceptin application. Unlike the sites listed above PPARx did not provide links to other types of social programs (such as free clinics).
Finally, Dr. Alper’s site links to an August 2004 article in the American Family Physician “Curbside Consultation: When Patients Cannot Afford Their Medications” This is a very thorough review of the topic with – in typical AFP style – lots of useful information. According to the AFP article 5.5 million people were enrolled in PAP programs in 2002.
I would note that – based on my personal experience – the typical patient who needs the PAP’s often times does not have access to the internet nor facility with completing forms. So having someone to be their advocate is crucial. This is a weakness of these websites.
A couple of additional suggestions:
Patients should always check to see if they are overpaying. Do this by looking up the prices of medicines on Drugstore.com. Oftentimes pharmacies charge unreasonable prices (people go, after all, to the local store) and lots of money can be saved by shopping around.
A recent blog from Suite 101.com entitled “How to Find Free, Cheap Drugs” offered (among other information) a list of retailers offering low cost or free medications. These include WalMart, Target, K-Mart, and various food chains. For example, “Publix supermarkets offer free antibiotics if you have a valid prescription, regardless of whether you have health insurance. A 14-day supply is offered.”
Some sites I have seen offer to help patients find low-cost drugs from a small fee. Clearly this is not reasonable since this information is available for free.
As I have noted in previous blogs these various efforts do not solve the root cause of the problem: lack of universal access to healthcare (including medications) in the United States. But for patients in need these resources can be helpful.
A 2003 article in the Village Voice entitled Free and Low Cost Health Care describes various options available in the City. One of the key issues for many people is dental care and the Voice article suggests the NYU College of Dentistry Clinic. Similar clinics exist at other dental schools and generally charge less than private practice. The New York City Department of Health also has dental clinics for people up to age 21.
There are several additional free medical student clinics which we did not mention in our prior posting. The following list (hopefully complete) is taken from the Cornell site:
Finally, New Yorkers may want to look at the website of the Mayor’s Office of Citywide Health Insurance Access to learn if they might be qualify for either public or private insurance.
Free and low cost services are vitally important to the many people who are denied coverage by the current US healthcare system. But it is equally important that our society provide care to all who need it, obviating the need for free clinics.
For addtional posts about this topic, click here. We would be happy to post additional resources.
As a follow up to our October 8, 2008 posting on free and low-cost health care in New York City, our friends at Columbia Medical School sent us an announcement about Columbia Student Medical Outreach (CoSMO), a free clinic in operation since 2004. Their website is http://www.cosmoprimarycare.org.
The clinic operates on Saturday mornings in the UrgiCare Center, located on the corner of 166th Street and Audubon Ave in the northern tip of Manhattan. Patients who are interested in more information can obtain details on their website.
Junot Diaz, the Pulitzer Prize-winning author of The Brief Wondrous Life of Oscar Wao, will be joining CoSMO for a book reading and conversation on Friday, November 7th at 7:30pm. All proceeds from the reading will go toward prescription medications for CoSMO’s uninsured patients.
The night will also include free appetizers provided by Mamajuana restaurant, old school hip-hop sounds by DJ Strike (former tour DJ of De La Soul), and visual arts by the Sound of Art collective.
The fine print:
Junot Diaz: A Reading, A Conversation
Friday, November 7th at 7:30pm
William Black Research Building
650 W. 168th Street
New York, NY 10032
Tickets sold online: https://www.ovationtix.com/trs/pe/769922
$15 general, $10 with student ID
Some of The Brief Wondrous Life of Oscar Wao was originally published as a short story in the New Yorker Magazine. You can also hear Junot Diaz read excerpts from the book online.
[Correction: The day of action on 11/7/1008 has been canceled. See the comment section for another upcoming Rock Dove event.]
The Rock Dove Collective, a “radical community health exchange” is organizing a day of action on 11/7/2008 to find free and low cost health clinics in New York City. The development of a comprehensive list of such clinics – available on the web – would be a great resource.
The NYC Department of Health has free clinics available for STD screening and treatment, dental care, as well as for the treatment of tuberculosis. [In our opinion the City's chest clinics provide the best TB care in New York.] Unfortunately the link to the list of all DOH clinics is down. Calling 311 might be a good place to start to see if a clinic is available for a specific problem.
There are at least three student run free clinics in the city. The Institute for Urban Family Health runs two. The ECHO clinic in the Bronx was the first medical student free clinic, set up by students at AECOM. The New York City Free Clinic in Manhattan is a project of NYU medical students In addtition, students at SUNY/Downstate have organized the Brooklyn Free Clinic.
New York City also has an extensive network of Community Health Centers which provide low cost care to people without insurance.
Free clinics are not the solution to our healthcare problems, indeed they are a symptom of the problem. And yet they also point to what might be the ethos of a national health system devoted not to profit, but to health. I would be happy for interested readers to post additional resources.
What follows is the Rock Dove announcement:
Rock Dove Day of Action!!
Health Clinics for Community Healing
Friday November 7th
10:30am – 4:00pm
Your friendly neighborhood Rock Dove Collective is calling our second Day of Action! On Friday, November 7th, volunteers will fan out across the city, visiting free and low cost health clinics and gathering information about their services from both the staff and the clients who are there receiving services. Our goal is to use this information to create comprehensive profiles of health clinics in NYC, as part of our ongoing effort to make free and low cost health services accessible to those in need.
We will meet up in downtown Manhattan at 10:30am, at a location TBA. Over breakfast and icebreakers, volunteers will receive their travel plans for the day as well as a quick training on how to gather information when visiting a clinic. Volunteers will go out in pairs and hit up 1-2 clinics before we all meet up at 4pm to decompress, share information, eat, drink, and be merry!
How to Contribute:
-Volunteer! Bring your friends! Join us as we hoof it through NYC in search of comprehensive information about free and low cost health services. If you plan on volunteering, RSVP to Freya at firstname.lastname@example.org.
-Donate! If you can’t join us the day of, please donate food and/or cash so that we can feed our volunteers breakfast and snacks, and help them