News & Issues April 2017
Volunteering for health
Free clinics try to fill the gaps in region’s medical system
By TRACY FRISCH
Dr. Richard Dundas, right, started the Bennington Free Clinic eight years ago after retiring from a 40-year medical career. Sue Andrews became the clinic’s executive director. The clinic is one of several in the region at which doctors volunteer their services, treating uninsured patients at no charge. George Bouret photo
Soon after the Bennington Free Clinic opened in 2009, a woman in her 40s came in looking very ill.
Despite severe back pain over a period of months, she hadn’t sought medical care because she was poor and had no health insurance.
The physician who saw her, clinic founder and medical director Richard Dundas, observed that she moved with difficulty and could barely get up onto the exam table. His examination revealed a large breast lump. Her disease was very advanced.
“It was obvious that her cancer had metastasized to her spine,” the retired internist recalled.
The clinic became her advocate and point of entry to the health care system. The staff arranged for her to see a surgeon pro bono the next day for a biopsy. A navigator at the clinic got her enrolled in insurance, and she received treatment through the cancer center at the local hospital until her death.
The case at once dramatized the hazards of unequal access to health care – and the need for clinics like Bennington’s, where volunteers provide care free of charge.
“All of the doctors, and I suspect all of the nurses, realize that our health-care system leaves many people in the lurch,” Dundas said.
Free clinics like Bennington’s are a community response to a need that persists even after the reforms of the Obama era.
Although the number of people without health insurance in Vermont and New York has declined sharply in the past few years as the federal Affordable Care Act has taken effect, there are still plenty of uninsured or under-insured patients who wind up seeking care at free clinics in Bennington, Rutland, Middlebury and seven other sites around Vermont.
“We thought we were going to be out of business with Obamacare,” recalled Fred Loy, a retired surgeon who volunteers at the Bennington clinic. “But there were so many people who didn’t fit into it.”
In Massachusetts, a free clinic in Great Barrington has grown up over the past 15 years to become the largest and busiest such operation in the region -- even though Massachusetts now boasts nearly universal health insurance coverage under reforms enacted more than a decade ago under then-Gov. Mitt Romney. (The Massachusetts system became a model for the national Affordable Care Act that President Obama signed into law in 2010.)
‘Falling through the cracks’
The staffs and volunteer medical providers at the region’s free clinics say there are a variety of reasons why patients still lack access to the conventional health-care system.
“There are so many ways that people are falling through the cracks,” said Jeff Bliss, the development director at the Great Barrington clinic. The clinic, known as VIM Berkshires (VIM stands for Volunteers in Medicine), serves patients from western Massachusetts as well as many from across the state lines in New York and Connecticut.
Some patients who show up at free clinics are eligible for Medicaid coverage but have been unable to navigate the process for obtaining it. Some have bought subsidized insurance plans but found they were unable to keep up with the premiums or out-of-pocket costs for care.
For others, changing life circumstances leave them without insurance. A patient may have recently lost a job that provided coverage -- or separated from a spouse who had an employer-provided plan. Or they’ve moved across a state line.
And a significant number of patients at the region’s free clinics are immigrants or temporary foreign workers at area farms or in other labor-intensive sectors of the local economy. Many of these workers are undocumented, but their legal status is irrelevant: People who aren’t citizens, even if they have green cards, aren’t eligible for the benefits of Medicaid or subsidized Obamacare plans.
The region’s free clinics depend heavily on local charitable contributions, and they’re powered by the generosity of volunteers – especially the physicians, dentists, nurses and other clinical professionals who donate their time. The clinics typically serve adults from 18 to 65. (Medicare covers older adults, and Medicaid has more liberal eligibility guidelines for children and pregnant women.)
For those who go to free clinics, often the only other alternative for medical care is at a hospital emergency room -- the most costly point of access to the health-care system.
“Being low-income puts people in a situation where they delay care,” explained Tony Morgan, executive director of the Rutland Free Clinic. “The emergency room will cost a lot more than a donation to the free clinic.”
Some patients have so many challenges that they “don’t know where to start,” Morgan said. But unlike an emergency room or a conventional medical practice, free clinics are designed to help people with complicated life situations obtain access to the health care they need.
The Bennington Free Clinic is the youngest of the 10 free health clinics in Vermont. Five of these, including Bennington, provide actual medical care on site. The others function as referral clinics, with most being attached to a hospital system; these clinics provide intensive case management and other support to get low-income patients the care they need.
There is no mandate for free clinics, and many areas have none. In the greater Capital Region of New York, only Schenectady has a free clinic, and it limits eligibility to county residents.
Because most patients who show up at free clinics have no insurance, most of the clinics make it a priority to quickly get patients enrolled in insurance of some kind if possible and into a primary care medical practice – so that these patients won’t continue to rely on the free clinics’ limited services.
Celia Berks, the insurance navigator at the Bennington clinic, said that in Vermont, Medicaid coverage normally activates within 72 hours of a successful online application. If a patient needs immediate coverage, she can call to expedite it overnight. Signing up with private insurers takes longer.
But there are some, such as immigrants, for whom insurance isn’t an option.
A different kind of care
Often a patient’s first encounter with a free clinic involves an acute problem, such as pain or an infection. But in contrast to the protocol in urgent care and emergency rooms, once the immediate health issue has been dealt with, patients gets a physical exam and other medical tests and screenings.
Sometimes these clinics discover life-threatening conditions. The Great Barrington and Rutland clinics, for example, both reported finding undiagnosed aneurisms in patients who came in seeking dental care. The Rutland clinic sent its patient to Dartmouth-Hitchcock Medical Center in New Hampshire for surgery to repair a large abdominal aneurism. The Great Barrington patient ended up receiving open-heart surgery.
In Great Barrington, a patient who showed up at VIM Berkshires complaining of frequent nosebleeds ultimately was found to have an unrelated cyst growing on his pituitary gland. Volunteer driver Phillip Kellerman has taken the patient, an immigrant worker, on six trips to Massachusetts General Hospital in Boston, where he underwent successful surgery.
“I’m convinced that VIM has saved his life,” said Kellerman, a retired farmworker advocate who now lives in East Greenbush, N.Y.
The free clinics try to provide comprehensive services for their patients. Simply providing the name of a specialist makes little sense if the patient lacks insurance or a vehicle, for example. Patients often need help making appointments, finding transportation or filling out applications for charitable assistance. It can help to have someone official plead the patient’s case.
In Vermont, free clinics receive a core allocation from the state to coordinate care for each person. State funding also allows the clinics to screen patients for alcohol and substance abuse and depression and to participate in the Ladies First program, which provides breast, cervical and heart health screenings for women.
State funds also pay a stipend to navigators to enroll those needing insurance coverage. For many of the clinics’ clients, navigation is a complex and time-consuming process, the more so if the clients have multiple income streams and changing addresses or life circumstances.
Patients’ immediate non-medical needs, whether food, housing or a ride home, cannot be ignored. Dundas told of a patient with pancreatic cancer who walked across town to his clinic appointment. He had vomited four times along the way. One of the volunteers drove him home.
The Great Barrington clinic takes this a step further, with a part-time staff member dedicated to improving the social determinants of health. That person, along with trained volunteers, assesses every patient’s needs -- from home heating and domestic-violence services to substance-abuse counseling, high-school equivalency classes and higher education. The clinic uses an electronic database of more than 20 organizations and agencies to help patients find appropriate local resources.
Affordable Care Act debate
Although President Trump and congressional Republicans have long called for repealing the Affordable Care Act, their attempt to craft a replacement plan collapsed in late March, and the law remains in place for now. The Congressional Budget Office estimated that under the Republican proposal, which House leaders abandoned shortly before a scheduled vote, at least 24 million people nationally would have lost their health coverage by 2026.
In New York, 3.6 million people have obtained insurance through the New York State of Health exchange, which was created as a result of the federal law. The majority of those – nearly 2.5 million – gained coverage through an expansion of Medicaid, while nearly 250,000 signed up for private insurance. Of the latter group, more than 60 percent receive subsidized coverage.
Since the Affordable Care Act took effect, the percentage of Vermont’s population that lacks insurance has plummeted from 10 percent to less than 3 percent. Sue Andrews, the Bennington clinic’s executive director, said navigators at her clinic have enrolled more than 1,000 people into insurance through Vermont Connects, the state health exchange. Most of these people qualified for coverage through the expanded Medicaid program.
But Laura Hale, the executive director of the Vermont Coalition of Clinics for the Uninsured, said some people are still left out by the federal health care reform – even some who nominally have coverage.
“The ACA did a lot of great stuff, but it also created a perception that everyone has equal access,” Hale said. “If you have health insurance but you’re not able to use it, that’s not acceptable.”
Hale, who administers state grants for the 10 free clinics in Vermont, explained that many people remain underinsured if they buy only the cheapest plans available on the state health exchanges.
Berks, the insurance navigator at the Bennington clinic, offered an example: A single person with an income of $17,000 a year could enroll in a bronze-level plan at no cost, with the government subsidizing the insurance premium at the rate of $461 a month. But that person probably would avoid using the insurance except in an emergency, because the insurance plan would carry a $4,600 annual deductible and a $7,150 annual limit on out-of-pocket costs.
The same person could get a better, silver-level plan for $60 a month, with much smaller deductibles and co-pays and a cap of $700 on out-of-pocket expenses. But keeping up with the premiums might be too much of a struggle because of the person’s low income.
Retirement project takes off
The Bennington Free Clinic got its start when Dundas, who had recently retired from a four-decade medical career, happened upon a brochure for the Rutland Free Clinic in the waiting room of his wife’s orthopedist. He had been looking for a worthy retirement project.
A visit to that clinic and a little background research convinced him to try setting up a free clinic in Bennington. Rather than start a new nonprofit corporation, Dundas approached Greater Bennington Interfaith Community Services, and the clinic became a program of the nonprofit group. Without a board of its own, the Bennington clinic works closely with an active medical advisory committee.
When Dundas rented space in a church, he met Sue Andrews, who was managing the interfaith group’s Food and Fuel Fund a couple hours a week. She had a strong community health background and soon joined the project. She now serves as executive director.
“I remember telling Dr. Dundas about my Peace Corps experience teaching nursing in Kenya in the 1970s -- and joking that he could do Peace Corps work right here in Bennington,” Andrews recalled.
Later they brought on a part-time secretary-receptionist. The clinic also has a part-time insurance navigator on staff and recently hired a nurse, for eight hours a week, to follow up with patients. Another person screens new patients during clinics, and a state grant covers screenings and other benefits available through the state’s Ladies First program for women.
More people donate their services for each week’s Thursday evening clinic. A rotating roster of two doctors and two nurses see the patients. Community supporters bring a meal for patients to enjoy while they’re waiting. Other volunteers provide transportation or serve as interpreters for Spanish-speaking patients.
Dundas, 74, acknowledged that starting the clinic was “a bit of a risk.”
“I knew I couldn’t provide enough help by myself,” he explained.
Through his affiliation with the local hospital, he was able to recruit about 20 other doctors to help at the clinic. Most are generalists, such as family physicians, internists, hospitalists or emergency room doctors. Twenty-five nurses also signed up to volunteer.
A mission to serve
Great Barrington’s free clinic grew out of a conversation about health care on New Year’s Eve of 2002. Two older professional couples who had recently moved to the Berkshires full time were wondering aloud how people managed if they didn’t have health insurance. Soon they had assembled a dozen people, including a few physicians, to pursue the idea of a free clinic.
With a small planning grant, the group hired a Harvard public health graduate student to assess the local needs over the summer of 2003.
That fall, a friend asked Arthur Peisner, then the chief executive of Lionel Trains Inc., to lead a two-day planning meeting. The group developed a vision and mission statement and identified core values. A year later, VIM Berkshires started seeing patients in a space that had previously been an ophthalmologist’s office.
The clinic is allied with the Volunteers in Medicine Institute, a national organization that has helped to start 86 free clinics in 25 states. The clinics don’t have a corporate or financial connection, but they do share a common strategy of recruiting volunteer clinicians to serve low-income patients who lack insurance. The Great Barrington operation remains the only VIM clinic in Massachusetts.
Peisner, now the board chairman, said the organization has grown far more than they could have anticipated – and has enjoyed surprising continuity among its staff and some of its volunteers.
Family nurse practitioner Ilana Steinhauer has been VIM Berkshires’ director of medical services from the beginning. Given the vulnerable population the clinic serves, she said, it’s important to provide the most comprehensive medical care possible under one roof. Besides standard medical and dental care, the clinic holds a monthly optometry clinic and offers counseling services, consultations with a nutritionist, acupuncture and bodywork.
Susan Minnich, the human resources director at VIM Berkshires, coordinates the work of 120 volunteers. She said the Great Barrington clinic’s medical staff is “literally fed with gratitude.”
In a brief recruitment film made by the clinic, emergency physician Andy Plager describes it as a place “where medicine still has a heart and you still feel good about what you’re doing.” He volunteers a half-day shift every month and sees eight patients. The Great Barrington clinic welcomes patients with incomes up to 300 percent of the federal poverty level.
VIM Berkshires could easily be mistaken for a private medical practice, though its ambiance feels friendlier and less frenzied, and its layout is more compact. Space is allocated to different functions – medical exam rooms, a dental suite with two patient rooms, laboratories, a bodywork area with an optional room divider, private counseling rooms, as well as places for intake and consultation. There’s also a conference room and a lunchroom.
Staff members, several of whom are native Spanish speakers, leave their office doors open unless they’re with a patient or in a confidential meeting.
Patients seem to feel at ease. Speaking through an interpreter named Kenneth Mayer, who has volunteered 10 hours a week for about a decade, an immigrant worker who didn’t want to be named in print said he was “very happy” with his treatment at VIM Berkshires.
“Starting with the receptionists, I was received with a smile and attended to very well,” he said.
The patient said he lives 40 minutes to the west in the Hudson Valley. Apart from three years in which he had medical insurance through an employer, he said he had to pay for health care entirely out of pocket until he found the Great Barrington clinic.
Another Latin American patient who lives less than a mile away said he has been coming to the clinic for a decade. Before that, he went without any health care for two or three years.
“In my country, a lot of people die because they can’t afford a doctor,” he said in English. “Here, I feel safety about my health. Otherwise, I don’t know where I would go.”
Contrasts in style, scope
Although both communities have free clinics, Great Barrington and Bennington are at quite different positions on the spectrum of affluence. Bennington County is Vermont’s second poorest, and 15 percent of the town of Bennington’s 16,000 residents live below the poverty line.
Great Barrington, with half the population of Bennington, is significantly wealthier, with a per-capita income exceeding Bennington’s by 80 percent, according to 2010 census data.
The relative capacity of the two clinics reflects these demographic differences. VIM Berkshires holds clinics every weekday and meets its $850,000 annual budget without any government funding. Some call it “the Canyon Ranch of free clinics,” after the luxury resort in nearby Lenox. Last year, it cared for about 750 unique patients in 5,000 medical and dental visits.
“We have an incredibly generous, long-term committed group of donors,” said Bliss, who two years ago was hired as the clinic’s first fund-raiser. Before that, the board of directors managed to raise the annual budget without such staff support.
Last year, the clinic raised another $350,000 for an addition that increased floor space by 60 percent, he said. This was the clinic’s second physical expansion since it opened in 2004.
The Bennington Free Clinic carries out its work in much more modest quarters. Its annual budget is about $250,000 -- less than one-third the size of VIM’s.
Nearly half of the Bennington clinic’s funds come from state grants. And a significant share of its spending is for patients’ lab work, medical imaging and dental care that the clinic cannot provide in-house.
The Bennington clinic’s hours or service are limited to one evening per week plus one morning per week by appointment.
“Much of my work is figuring out how to raise the next thousand dollars and the next thousand after that,” explained Andrews, the clinic’s executive director.
Loy said that when compared with the Great Barrington clinic, “we’re at the other end of the food chain.”
“We scramble for resources,” he said. “We scramble for space.”
The clinic shares a wing of the Bennington First Baptist Church with two other projects of the Greater Bennington Interfaith Council -- the Kitchen Cupboard food pantry, founded in 2012, and the Food and Fuel Fund, now in its 44th year. The Center for Independent Living also has a small space in the building.
The clinic’s staff offices – for the executive director, receptionist, insurance navigator, and the new, very part-time nurse – are carved out of a single crowded room, broken up into a maze by banks of filing cabinets. A subdivided room contains three small examination rooms flanked by a small common area. The walls are cinderblock.
Last year, the Bennington clinic saw a total of 563 patients.
Reaching out to immigrants
At the Open Door Clinic in Middlebury, which opened in 1993 and later added a second site in Vergennes, 60 percent of the patients now are immigrant farmworkers. Of the estimated 1,000 to 1,200 Latin American workers statewide, about 500 are in Addison County, where the clinic is located, explained Heidi Sulis, the clinic’s executive director.
Most of these workers are employed year-round on large dairy farms. Since there is no visa program for dairy farms, they live in the shadows, without legal documentation. The nation’s only program allowing foreign agricultural laborers, known as the H-2A program, supplies seasonal workers to fruit and vegetable farms and some poultry operations, but these workers must return to their home countries for at least a couple months each year.
Last fall, the Middlebury clinic’s outreach nurse and a cadre of volunteers visited 35 dairy farms and eight orchards, reaching 270 foreign workers. As they developed relationships and built trust and rapport, the number of farm workers cared for by the clinic has steadily grown, Sulis said.
Transportation is a major barrier to migrant workers getting care. For a time, Open Door offered rides to the clinic and specialists through a network of volunteer drivers called Amistad, which means friendship in Spanish. In 2014, Amistad gave 667 rides to 165 patients, logging 23,000 miles. But administrative challenged doomed the Amistad service; instead, the clinic now refers farm workers who need rides to a peer migrant worker who has a Vermont driving privilege card.
Much of this population is young single men, but Sulis said that over time, the clinic’s staff and volunteers have seen people put down roots. Some now have families.
Given the Trump administration’s push to radically change policies on health care and immigration, Sulis said she’s worried about what the future will bring.
At the Bennington clinic, undocumented farm workers make up the biggest category of patients who can’t get insurance and, as a result, continue as regular patients at the clinic. Andrews said these laborers commonly work up to 90 hours a week. Many are Guatemalans with only a year or two of primary education.
Dundas said the clinic has made farm workers a focus of its efforts to reach people in need of medical care. It held its first clinic specifically for Spanish-speaking patients in 2012.
“We realized that there were a lot of Central American farm workers with no health care,” Dundas recalled. “We got the farmers’ permission and picked up farm workers. We brought them to the clinic, gave them a meal, immunizations, and physical exams.”
Most of these workers are at dairy farms just across the New York border in Washington and Rensselaer counties. Bennington County is believed to have only one dairy farm with foreign workers.
The clinic also cares for Jamaican apple pickers who are brought to orchards seasonally on H-2A visas. And a number of immigrants from India use the clinic.
“Most notably, they run small motels,” Dundas said. “They buy a motel and bring over family members.”
Chronic disease can take an enormous toll on immigrant workers.
One worker who lives in Columbia County and was receiving care at the Great Barrington clinic described how he had developed diabetes.
“I lost my job because I wasn’t well,” he said in Spanish.
Suffering from debilitating headaches and dizzy spells, he went to Albany Medical Center. There he was diagnosed and initially treated, but the cost of continuing care was beyond his reach. A year ago, the hospital referred him to VIM Berkshires.
The clinic gave him a handheld glucose meter and test strips at no cost and taught him about diet and how to control his disease. He now returns quarterly.
“Thank God, I’m a lot better,” he said, adding that he is back to working part time and is seeking more employment.