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Arlington Connection: Arlington Free Clinic Faces Uncertain Future Print

Much depends on health-care reform’s effects.

BY Michael Lee Pope

Created:  Wednesday, May 4, 2011

Last month, 136 people showed up for a monthly lottery at the Arlington Free Clinic. Numbers were drawn out of a plastic bin, and 27 people were served. The vast majority of people left the clinic without making an appointment for medical services.

Since the global economic crisis hit, demand for services has skyrocketed. In 2008 alone, the clinic saw a 200 percent increase. Leaders at the clinic say they are concerned that a recent ruling from Virginia Attorney General Ken Cuccinelli in January that charities cannot be funded directly from the state might mean that the operation would take a hit of $70,000 a year from its $2.1 million budget.

Yet there are even more daunting problems on the horizon.

When the Patient Protection and Affordable Care Act goes into effect in 2014, free clinics across America will be facing an existential question: How will they respond? The Arlington Free Clinic has four options. It can continue to offer services to people without health insurance, a group that would consist mainly of undocumented residents and people who make too much money to qualify for Medicaid but not enough to buy into the health exchange. Or it could start taking Medicaid patients, which would ditch the free-clinic model and adopt a sliding scale for those without insurance. Another option would be to simply close the doors and cease operations.

"There are going to be some problems," predicted Arlington Free Clinic executive director Nancy Pallensen. "People think that all these people will have insurance so they can just go see a doctor, but it's not that easy."

UNDER THE REVISED rules for Medicaid under President Barack Obama's health-care reform, Virginia will get about 400,000 new Medicaid patients. That's because the threshold for qualifying will move from 80 percent of poverty to 133 percent of poverty, opening the door to hundreds of thousands of newly enrolled Medicaid patients. But the Virginia General Assembly keeps reducing the reimbursement rates for doctors who see Medicaid patients, which means that fewer and fewer doctors are seeing them.

"It's a big problem," said Del. Patrick Hope (D-47). "I think we are going to have to look at relaxing the laws in terms of who can treat patients."

Instead of requiring physicians see every patient, Hope said, perhaps nurses or physician assistants could be allowed to supervise some care. Getting more doctors to take Medicaid patients will require raising Virginia's reimbursement rates, although finding the money to do that will pose a challenge. Others have suggested that incentives need to be created to encourage people to go into the medical profession because the market for general practitioners is about to be flooded with new demand on an unprecedented scale.

"All of a sudden there will be all these new patients who have never had health insurance before," said Jody Kelly, director of clinical administration. "But what happens if there are no doctors to see them?"

That's a vexing question for the Arlington Free Clinic, one that its board of directors is set to take up later this month. One possible scenario would keep the clinic operating under the same rules — offering free medical services to people without health insurance and sending Medicaid patients somewhere else. Because the clinic estimates that about half its patients fall somewhere between 80 percent of poverty and 133 percent of poverty, that's a substantial amount of its business although it's difficult to determine how many of those people are undocumented and, therefore, ineligible for Medicaid.

"Are donors going to continue contributing if our clinic serves primarily undocumented patients?" asked Pallensen. "That's something we are going to have to think about."

Another scenario would drastically change the operation to start taking Medicaid patients. For legal reasons, the clinic would need to start charging for service for those without health insurance, although it's possible to create a sliding scale where people could receive service for as little as $10. A related option would be for the clinic to become a satellite of a federally qualified health care center. Both of these options would be a drastic change for the clinic, which currently has no billing operation.

"We would need to start applying for Medicaid reimbursements if we wanted to go that route," said Pallensen. "And that's an extremely complicated system that we would be taking on."

CLOSING THE DOORS to the Arlington Free Clinic is a less appealing option, especially because everybody acknowledges that the need for those without health insurance would continue. Undocumented residents would still arrive seeking service. Then there are those who fall through the cracks, making too much for Medicaid but not enough for the exchanges. Another group that would require service are those unwilling or unable to navigate the system, a population that the Arlington Free Clinic feels an obligation to serve.

"Whatever happens, we'll still have a huge number of people looking for services," said Kelly. "I don't see us ever going out of business because of a lack of demand."

Pallensen said the path of least resistance may be to continue with the current model and see what happens. If patients find themselves without service, the clinic might find some way to respond. For now, the uncertainty makes planning for the future a challenge.

"The bottom line is that we are going to need to commit more resources to health care," said Hope. "It's either that or start paying for the cost of emergency-room care, which will be far more expensive in the long run.