Paras Minhas*
*Stanford University School of Medicine, Palo Alto, CA 94305, USA
Correspondence: pminhas@stanford.edu
Synopsis
While the effect of the Affordable Care Act has yet to be fully measured, early results indicate legislation will not be felt on the ground, as certain populations still lack healthcare. In Miami-Dade and Dallas-Ft. Worth, for example, significant geographic and cultural barriers exist which prevent populations from accessing healthcare. This article examines the possible use of mobile clinics to offer temporary relief to these populations until more permanent measures may be constructed, such as Federally Qualified Health Centers.
“Spacial and Temporal Changes in Mercury” by Erin Dvorak
Sometimes we need more than just a bridge.
When people mention the City of Palo Alto, they rarely speak about healthcare. Instead, you’ll usually find a 20-something talking about his or her start-up or new endeavor with Facebook or Google. Yet less than 3 mi away, across the University Avenue bridge, exists a shocking juxtaposition. On the east side sits East Palo Alto, a town that struggles with crime, poverty, and the uninsured, while the west contains one of America’s most luxurious accommodations: the Four Seasons Hotel.
While nearly 40,000 cars cross the bridge every day, healthcare rarely traverses the gap.
Take Mr. Sanchez*, a patient at Arbor Free Clinic in East Palo Alto with pain in his mouth.
This 58-year-old male sought treatment for the pain in his upper right molars that started three weeks ago. What he did not voluntarily present was his backstory.
Upon physical examination, he was flushed, fatigued, and contained a dental abscess surrounding his upper right molars. Twenty-two of his thirty-two teeth were missing, and he had signs of recurrent infections in his gums. It quickly became apparent that the pain in his teeth was an acute sign of a much larger, chronic problem.
Have you seen a dentist Mr. Sanchez?
No.
How about a physician?
Yes.
When?
Six years ago. Mexico.
My heart sunk a little.
How about a physician here?
No.
You said the pain started three weeks ago?
Yes. Very bad.
May I ask why you have not seen a physician sooner?
No time. I need to watch my kids, see my parents.
Is there someone else who can help with your parents and children?
No.
Upon eliciting a further social history, I found that Mr. Sanchez was a Spanish-speaking 58-year-old single parent working two construction jobs to support his three children and parents, both of whom were diagnosed with terminal cancer.
We gave him acetaminophen and a prescription for penicillin for the dental abscess. He refused to take a referral for a primary care physician or for a dentist. He did not have the time. In fact, he needed to go back to work later that afternoon, having traveled to Arbor Free Clinic by riding with two friends, and coming from nearly 30 mi away. Without further treatment, he would likely lose his right molars too.
Unfortunately Mr. Sanchez’s case is not an isolated occurrence. Those who are underinsured or uninsured are often overworked, overstressed, and overdue for healthcare—and the problem seems to be getting worse.
Five of the nine counties in the bay area have more than 10% of their population uninsured: San Mateo (14.7%), Contra Costa (11.4%), Sonoma (11.2%), Alameda (10.3%), and Santa Clara (10.2%) (Figure 1). The town of East Palo Alto, where Arbor Free Clinic is based, has an uninsured rate of 25.9%, or over one in four individuals—the highest among any municipality in the bay area. In addition, the problem has been consistently increasing across the entire nine county bay area, with the number of uninsured increasing from 9.4% (577,000) to 10.9% (668,000) between 2007 and 2012 (CHIS, 2012).
Perhaps even more alarming is that the San Francisco bay area fares better than most of the United States. In fact, the city of San Francisco, thanks to its Healthy SF program, has an uninsured rate of less than 5%. This is in sharp contrast to other major US metropolises that have much higher uninsured rates: Miami-Dade (34%), Dallas-Fort Worth (31%), Los Angeles (25%), Houston (20%), New York (15.7%), and Chicago (11%) (Figure 2) (DeNavas-Walt et al., 2012). Only Boston has a lower uninsured rate, at less than 4%, due in part to the health care reform initiative of 2006 enacted by the state of Massachusetts.
While the effects of the Affordable Care Act (ACA) have yet to be seen, it is doubtful that federal legislation will be felt on the ground, as a recent study estimates that a large portion of the uninsured in the Bay Area (563,000/668,000; 84%) are undocumented immigrants who do not qualify for the state’s healthcare insurance, MediCal (CHIS, 2012). And while more community clinics are being built, the bay area has only approximately 15 truly free clinics—of which most have limited hours and services.
Additionally, many of the free clinics are limited in whom they can help due to geographic location or transportation barriers. A study conducted by the Washington State Department of Health found that individuals are willing to travel 8.6 mi to find routine care, on average. This, however, includes individuals who own cars and have the ability to travel in vehicles (Yen, 2013). If we examine individuals who must walk, a study conducted by the Minnesota Department of Health found that people are only willing to walk 1.5 mi (Iacono et al., 2008). This leaves extensive gaps in coverage not only across the San Francisco Bay Area but also across the entire country that free clinics simply cannot fill alone.
So what then can be done to help the uninsured who do not qualify or are ineligible for medical insurance under the ACA? An obvious answer would be to increase the number of free clinics. This, however, is an arduous process, requiring months if not years of resource gathering and labor. In addition, getting governmental approval through Clinical Laboratory Improvement Amendment waivers and county as well as state permits is an uphill battle, to say the least.
Mobile clinics may offer a solution to the dilemma. According to the Mobile Health Map, an estimated 2,000 mobile clinics receive approximately 6.5 million patient visits each year. These custom vehicles are spread throughout the United States and provide a wide range of services, including primary, secondary, and specialty care. One recent study conducted in Massachusetts on the Boston “Family Van” found that blood pressure was significantly reduced (systolic/diastolic differential: 10.7/6.2 mmHg) in those individuals who visited a free mobile health van between 2010 and 2012 (5,900 unique patients; 10,509 visits). In addition, according to patient surveys, a large number of emergency department visits were also avoided. The same study estimated the annual cost savings from this mobile clinic to be over $3.1 million through a reduction in emergency department visits and prevention of acute illnesses (Song et al., 2013).
Indeed, further studies within the United States must be done to confidently say that such an approach would help improve healthcare access and the situation of the uninsured. Although many major metropolises have large pockets of residents that lack health care access, each situation may be surprisingly unique. Miami-Dade and Houston, for example, with uninsured rates of 34% and 20%, respectively, may suffer from cultural and lingual barriers, as a large portion of the uninsured (37%) are Spanish-speaking Hispanics (Gee, 2014). In addition, many individuals simply do not wish to enroll or are ineligible for state Medicaid. A mobile clinic that provides free healthcare to these individuals can serve a combined role of enrolling individuals in free or sliding fee clinics, determining eligibility under the ACA, and providing much needed healthcare.
Other metro areas have fewer cultural and language obstacles but more geographic barriers to accessing healthcare. The South Central neighborhood of Los Angeles, for example, has an uninsured rate of 52%, one of the highest in the nation (CHIS, 2012; Steinhauer and Morris, 2007). Unfortunately this 50.1 mi2 region within Los Angeles also has a dearth of hospitals, with MLK Jr.-Harbor hospital closing in 2008 and the next hospital not scheduled to open until late 2015. A free mobile clinic could serve to improve geographic healthcare access to urbanized pockets such as South Central Los Angeles while also educating individuals about the benefits of Medicaid and the ACA (Steinhauer, 2008).
The Dallas Ft. Worth and Houston metropolitan areas, on the other hand, showcase what happens when states refuse to expand Medicaid coverage. After Texas decided against expanding its Medicaid coverage, many of the city’s residents fell into what is being called “the new doughnut hole,” (Berard, 2014). Under Texas Medicaid, for a family of four to be covered, the household cannot make more than $298 per month, or approximately $9.60 per day. The ACA envisioned expanding state Medicaid eligibility up to an annual household income of 133% of the federal poverty level (FPL), which is $11,170 for an individual or $23,550 for a family of four. The ACA also provides stipend assistance to those who fall between 400% ($88,020 for a family of four) and 133% ($29,326.50) of the FPL. With state refusal to expand Medicaid coverage, many individuals make too little to qualify for stipend assistance but too much for state Medicaid. In the case of Houston and Dallas-Fort Worth, that means any family of four that makes more than $3,756 and less than $29,326.50 automatically does not qualify for any federal or state insurance and lacks healthcare access (Heberlain et al., 2013). In the Dallas-Fort Worth and Houston metros, an estimated 1 million individuals now fall into this category (Berard, 2014). Again, a coordinated set of free mobile clinics with a strong referrals system could help relieve the situation as well as educate local populations about free and sliding fee clinics that offer more extensive services. Such is being done at the Cardinal Free Clinics (CFCs) affiliated with Stanford University School of Medicine in the San Francisco Bay Area. The CFCs mobile health team (formally known as the CFC Screen Team) works in the community regularly with shelters, community centers, and food banks to offer healthcare and provide referrals for patients to surrounding clinics in an attempt to increase healthcare access. Since the initiative started last August, over 2,000 individuals have been visited by the mobile health team, and the number of patients at two stationary CFCs in East Palo Alto and San Jose has nearly doubled on a weekly basis.
While these results are encouraging, it should be noted that mobile free clinics are only a temporary relief for areas that lack healthcare access due to geographic, cultural, or insurance barriers. A more permanent solution would be to establish a freestanding federally qualified health center (FQHC). FQHCs receive expense reimbursement from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid services under the Public Health Service Act for admitting uninsured and low-income individuals. FQHCs have been a large success in medically underserved areas, both in rural and urban settings.
Unfortunately due to limited government funding, the United States only has a little over 1,200 FQHCs currently, and many more are needed to fill in healthcare gaps. Furthermore, the obstacles to becoming a FQHC are immense. First, clinics and health centers must acquire a sufficient number of physicians and healthcare workers to operate. Second, they must have an established history of serving an underserved community or demographic, a feat that is neither profitable nor sustainable without external assistance. Third, they must receive a section 330 grant from the Federal Government. There are large costs associated with starting a FQHC before an organization even becomes eligible for federal funding from a section 330 grant. In fact, on average, it takes between 5 and 7 years for a clinic to transition to FQHC status, if successful (HHS, 2011).
While this may seem like a taunting task, the ACA has recently helped make it easier for clinics to transition to FQHCs by increasing the amount of available funding for FQHCs by $11 billion. While free mobile health clinics are by no means the end all solution, they can offer temporary relief to neighborhoods in the time it does take to establish a FQHC, as they typically only take 3 to 6 months to become fully operational (Hill et al., 2014). Therefore, free mobile health clinics offer a viable solution to help address issues of healthcare access and uninsured within both urban and rural areas while more permanent measures are enacted, such as FQHCs. Such temporary measures are vital for neighborhoods such as South-Central Los Angeles and Miami-Dade county, where more than one in four individuals who lack insurance coverage also lack proper healthcare access (DeNavas-Walt et al., 2012).
*Mr. Sanchez is a fictitious name provided by the author in accordance with the rules and regulations of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
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