Welcome Dr. Virginia Brennan (Meharry Medical College) (Journal of Health Care for the Poor and Underserved) and Host Dr. Matthew R. Anderson (Albert Einstein College of Medicine)

Free Clinics: Local Responses to Health Care Needs

Dr. Brennan is an Associate Professor at the Graduate School of Meharry Medical College, one of the historically black medical schools in the US. This book grows out of her work as editor of the Journal of Health Care for the Poor and Underserved; almost all of the articles were previously published in this journal.

Why do free clinics exist and why do we need a book about them? Isn’t the Affordable Care Act (ACA, Obamacare) going to provide health insurance to all Americans?

The ACA will dramatically reduce the number of uninsured Americans from the estimated 46 million in 2010 (when the bill was made law) to an estimated 23 million by 2019 (when it will be fully implemented). Seven of these 23 million will be undocumented workers. The refusal of many states to accept federal dollars for Medicaid – if continued – will mean that the number of uninsured will probably be significantly more than 23 million.

The creation of “free clinics” to provide services to those without access to health care has a long and rich history, some of which has made it into the popular imagination: the Gesundheit Institute, a free hospital associated with Patch Adams; the Common Ground clinic, created after Hurricane Katrina in New Orleans; and San Francisco’s Haight-Ashbury’s free clinics. What do free clinics accomplish? In 2001 it was estimated that “only about 650,000” of the 41 million uninsured Americans got care at free clinics. The author’s comment that “[m]uch literature posits that free clinics exist as a short-term solution to serve victims of a failing health care system, […] even the most successful clinics cannot provide a viable long-term solution to disparities in health care.” Yet free care to 650,000 people is an impressive accomplishment and a tribute to the survival of a service ethic in an increasingly corporatized medicine.

We know a fair amount about the functioning of free clinics from published articles and books, as well as from organizations such as the National Association of Free and Charitable Clinics and the Association of Clinicians for the Underserved. But this data is not systematically collected. Brennan’s book does a major service in its first chapter by providing a comprehensive review of what we do know based on a rigorous review of ninety articles. Free clinics see a population that is “disproportionately low-income, female, uninsured, immigrants, or minorities.” Diabetes and mental illness are common problems; in fact, mental illness – related to harsh social conditions – is nearly universal. Money to run the clinics is pieced together from a variety of sources: individual donations, institutional funds, corporate and charitable donors, and (minimal) state and federal dollars. Clients are often referred to other parts of the health care safety net. Services provided tend to focus on prevention, education and providing access to medications. This review closes with a long list of potential research projects regarding free care.

Free Clinics offers us a rich selection of papers fleshing out the details of this review. The primary audience will be health care providers and medical educators; nearly half the book is devoted to student-run clinics. The book’s chapters allows the reader to get a good sense of the practical problems of free clinics, the challenges faced by them, and their limitations. If you want to work in (or set up) a free clinic or a student rotation in poor/underserved medicine, this book has much information that will be useful to you.

But free clinics – by their very existence – raise a host of interesting social questions that will engage a broader audience.

Let us begin by considering the important place that free clinics play in medical education. We have no less than seven student-run free clinics in New York City, one of the cities with the most advanced health care infrastructure in the world. The chapters in Brennan’s book stress the need for institutional support and supervision for projects that are typically initiated by enthusiastic students. These clinics can be associated with community activism, such as the 2002 Candlelight Vigil for Uninsured Georgians organized by students from Emory and Morehouse. Students need support to assure that a stable setting is developed that provides high-quality care for the patients and an appropriate educational experience for students.

But what is the real place for such free clinics within academic medical centers, which are increasingly indistinguishable from large for-profit businesses? Is this simply an interesting pastime carried out by a few “progressive” students and their faculty mentors? An activity that makes the institution look good but is entirely peripheral to the real mission? What does it say when a homeless person is rejected in the outpatient clinic but seen by a student outreach team on a van or in a shelter?

The existence of free clinics highlights the inadequacies of the current system, most specifically the inability of our profit-based institutions to provide health care for all. The fact that such institutions are free also creates opportunities to “do things differently” and not simply to recreate the existing health care model. This is, for example, an explicit goal of the Gesundheit Institute: “a project in holistic medical care based on the belief that one cannot separate the health of the individual from the health of the family, the community, the world, and the health care system itself.” Brennan’s book concentrates on the role of free clinics “as a pillar of the health care safety net” and this is entirely appropriate. But there are potentially more emancipatory roles for free clinics. Many were created by social movements and thus embody particular political ideals. A recent book by Alondra Nelson – Body and Soul: The Black Panther Party and the Fight against Medical Discrimination – traces the fascinating history of free clinics within the Black Panther Party.

As the Greek health care system has imploded in the past few years, physicians in Thessaloniki, Greece’s second largest city, partnered with the local community to create the “Social Clinic of Solidarity”, a free clinic that was originally designed for refugees but now serves the entire community. This clinic involves over 200 doctors and provides general medical care (including pediatrics), dental services, physical therapy and a social (i.e. free) pharmacy.

So, it doesn’t seem like free clinics are going away anytime soon. We can thank Dr. Brennan for providing us with a road map as we move forward, as well as material that should foster a debate on where our health care system is going.

 

[As a courtesy to our guests, please keep comments to the book and be respectful of dissenting opinions.  Please take other conversations to a previous thread. - bev]

102 Responses to “FDL Book Salon Welcomes Virginia Brennan, Free Clinics: Local Responses to Health Care Needs”

BevW August 10th, 2013 at 1:49 pm

Virginia, Matt, Welcome to the Lake.

Matt, Thank you for Hosting today’s Book Salon.

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dakine01 August 10th, 2013 at 2:00 pm

Good afternoon Virginia and Matt and welcome to Firedoglake this afternoon.

Virginia, I have not had an opportunity to read your book so forgive me if this is addressed there but how do you respond to the folks who claim that having poor people “just go the Emergency Room” constitutes good quality health care?

I have been without any health insurance for over 9 years now and have been fairly lucky in that I had cash to cover a couple of doctor’s office visits as well as a trip to the ER for stitches after slicing my hand – but that trip to the ER wound up costing me over $1,500 in total to receive 4 stitches

Matt Anderson August 10th, 2013 at 2:01 pm

Good Afternoon all.

This is Matt Anderson, a family physician from the Bronx, New York and an Assistant Professor at the Department of Family and Social Medicine at Montefiore Medical Center.

I wanted to thank Firedoglake for offering me that chance to moderate this discussion of Dr. Virginia Brennan’s book Free Clinics: Local Responses to Health Care Needs.

I have written a brief review of the book which has been posted above and which suggests some of the questions raised by the existence of free clinics.

But, before we start our conversation with Dr. Brennan, I was interested to find out if any of the people who are here today have been a patient at a free clinic. If so, I’d be interested if you could write a sentence or two about your experience(s).

Matt Anderson August 10th, 2013 at 2:02 pm
In response to dakine01 @ 2

Dakine01, Dr. Brennan’s book is about free clinics, not about getting care at Emergency Rooms.

dakine01 August 10th, 2013 at 2:04 pm

I understand but there is a relationship as there are times the free clinics are not open and folks are forced to the ER – the whole medical industry is interrelated

Virginia Brennan August 10th, 2013 at 2:05 pm
In response to BevW @ 1

Hi everyone. I am delighted to be here today.

Matt Anderson August 10th, 2013 at 2:06 pm
In response to dakine01 @ 5

Dakine01, This is a valid point, but Dr. Brennan’s book is about free clinics. They exist because of the deficiencies in the larger health care system.

Virginia Brennan August 10th, 2013 at 2:07 pm
In response to dakine01 @ 2

This is response to #2: The problem with ER care is that — while very important for emergencies — it yields poor outcomes for people who use it for regular care. Their overall health and longevity are much lower than those of other fols who have what people call a medical home.

BevW August 10th, 2013 at 2:10 pm

Virginia, Matt, How many free / student-run clinics are there in the US. What is the length of time a doctor or student will participate in the care?

Matt Anderson August 10th, 2013 at 2:11 pm

Virginia, I will let you answer.

Virginia Brennan August 10th, 2013 at 2:12 pm

Yes, it is true that both free clinics and current use of ERs both are largely driven by the inadequacies and overall fractured nature of the USA health care system.

The special thing about free clinics is that they are (1) not government associated (this has plueses and minuses), and (b) they *can* serve as a medical home — something like a (federalloy qualified) community health center) and something like a private doctor’s office.

Matt Anderson August 10th, 2013 at 2:14 pm

Virginia, Could you explain the pluses and minuses of being associated with the government?

Virginia Brennan August 10th, 2013 at 2:15 pm

Some of the shortcomings of free clinics: hours are often hit-or-miss; care is often of a stop-gap nature — which presupposes that people have someplace else to go for their “real care”; there is little chance of getting anything like comprehensive care. Specialists, mental health practitioners, dentists, and others are often *not* on hand.

Matt Anderson August 10th, 2013 at 2:16 pm

Is there anything a free clinic might do better at than a regular clinic?

ben August 10th, 2013 at 2:19 pm

Hello, I am a big fan of Dr. Brennan’s and know that she has conducted research in places like Cuba. I wonder if Dr. Brennan might comment on what she learned from her trip there and whether there are aspects of the Cuban medical model that might be helpful here in the US.

Virginia Brennan August 10th, 2013 at 2:21 pm

GOOD question: Being associated with the government means

ON THE POSITIVE SIDE: guaranteed budget, the benefits of regulations regarding care given, the qualifications and licensing of practitioners, connections with other parts of the health care system (e.g., hospitals, specialists, mental health care, oral health care) are often strong or at least existent.

ON THE NEGATIVE SIDE: strangulation by regulation — free clinics and NGOs performed *much* better than government-sponsored entities in responding to health care needs after Hurricane Katrina for example. Similarly, care provided by volunteer practitioners can be providede immediately when the need presents itself. This works well during crises in the US and very well abroad where NGOs such as Doctors without Borders (Medicins sans frontiers) are very effective in providing care in profoundly under-resourced places.

Matt Anderson August 10th, 2013 at 2:23 pm

Virginia,

To follow-up on Ben’s question: Some people feel that anything free must be inferior or worthless. Yet medical care in Cuba is free.

nixonclinbushbama August 10th, 2013 at 2:26 pm

Dr. Brennan, thank you for your book and Dr. Anderson, thank you for your review and for hosting.

I don’t know a lot about free clinics, but I do run across people who need health care and cannot afford it. I never know what to tell them.

Is there any organization that keeps track of all free medical services in the US, so I could find out where to refer them?

Virginia Brennan August 10th, 2013 at 2:26 pm
In response to ben @ 15

Great question about Cuba:

Cuba has a number of characteristics in its medical system that make it enviable. Among them is free medical education for qualified students, and a generous number of physicians being trained every year. The proof is in the pudding: Cubans have on average better health than people in the US and have great life expectency.

They achieve this, not only by having a lot of doctors, but also by having a localized system where everybody “belongs” to a local clinic. The doctors and nurses in that clinic are responsible for keeping their 2000 or so people healthy. And they do! Often, by going and knocking on someone’s door who hasn’t shown up for her regular pre-natal check for example.

tHE AMAZING THING IS THAT THEY ACHIEVE THIS WITH EXTREMELY LIMITED RESPOURCES — EDUCATIED PERSONNEL, POPULACE, AND A LOT OF SHOE LEATHER GO A LONG WAY TOWARD GOOD HEALTH.

Matt Anderson August 10th, 2013 at 2:27 pm

I am still curious to know if anyone in the conversation has had an experience at a free clinic. And what that experience was.

Matt Anderson August 10th, 2013 at 2:28 pm

Virginia, And what led you to want to write a book about free clinics?

Virginia Brennan August 10th, 2013 at 2:28 pm

Thank you for an excellent question: Matt mentioned in his review The National Assn. of Free and Charitable Clinics, so check them out. Depending on where you are, there are also regional organizations of free clinics — e.g., a consortium of clinics in the Great Lakes states.

Virginia Brennan August 10th, 2013 at 2:31 pm

Matt —

I thought it would be helpful to the mnany good-hearted people who want to start free clinics to have one book where they could read about the varied and very place-specific sorts of clinics that have arisen around the country. I imagined them going to the book looking for models that might work in their own areas.

FDascinating larger questions have come up in the course of doing it, though, many of which you raise in your review as larger social questions. Some but by no means all of them are addressed in the book.

Matt Anderson August 10th, 2013 at 2:31 pm

There is, unfortunately, no centralized list of free clinics. They often tend to be very local – something emphasized in the title of Dr. Brennan’s book. When I am trying to find free and low-cost resources for patients, I troll the internet and then make phone calls.

Matt Anderson August 10th, 2013 at 2:33 pm

Virginia, Do you have a sense that with the full implementation of the ACA, there will be any less need for free clinics? Or will we still need them for those who are uninsured or underinsured? Matt

Virginia Brennan August 10th, 2013 at 2:34 pm

Yes: Free clinics are very local undertakings and for that reason may be much better than others (e.g., FQHCs and hospitals and private practitioners operating in the current corporate health care system) at *cultural competence*.

nixonclinbushbama August 10th, 2013 at 2:35 pm

Thank you.

I am in Boston, but the people who cannot afford medical care are all over the country. Some, I have seen in the flesh, so to speak. And some are internet friends.

nixonclinbushbama August 10th, 2013 at 2:36 pm
In response to BevW @ 25

Thank you!

BevW August 10th, 2013 at 2:37 pm

Matt, is there any support from pharmaceutical / medical companies for free clinics? or is the support from other medical professionals?

nixonclinbushbama August 10th, 2013 at 2:38 pm

Thank you.

When you “troll the internet,” do you just google free medical care or free dental care or whatever your patient needs?

If not, which search term do you start with?

Matt Anderson August 10th, 2013 at 2:38 pm

HRSA also has a list of federally qualified community health centers. Care there is subsidized for people who don’t have insurance: http://findahealthcenter.hrsa.gov/Search_HCC.aspx

I work at an FQHC in the Bronx.

Matt Anderson August 10th, 2013 at 2:40 pm

Bev,

Some pharmaceutical companies donate medications to clinics. I don’t know about providing actual monetary support.

With respect to trolling: I usually use the terms free low-cost health care and – in New York City – this brings up newspaper and internet articles that are helpful.

nixonclinbushbama August 10th, 2013 at 2:41 pm

Dr. Brennan, for those who do want to start a free clinic, does your book cover sources of funding?

Virginia Brennan August 10th, 2013 at 2:42 pm

Yes, the ACA is going to affect the world of free clinics, but certainly not eliminate them. It is likely that — of the 46-50 million people in the US who are currently uninsured (and thus candidates for treatment at free clinics — at the very best half will get insurance under the ACA.

So — we still have a 23 million to 25 million person problem (at best)even when ACA is in full gear. Since it’s estimated that 4 million people got care at free clinics in 2009, I assume the rolls of patients thre will not decline. Providence willing, the people who run the free clinics and work at them, see this already, as I imagine they do.

Who will remain uninsured even with ACA?
*Undocumented immigrants
*homeless people and others who live off the grid (by choice or by a constitutional i8nability to live on it)
*Very low-income adults and many working class adults in the 18+ states who have opted not to expand Medicaid. While these people will qualify for some help with premiums for health insurance bought through the federal exchange, they often will not be able to take advantage of it. They won’t have enough $ even with the subsidy and lowered premium costs. Often, they lack the education to fight through the bureaucracy and paperwork required to take advantage. We are talking about people who have may 10 or 20 thousand dollars a year to live on. There are so many and more in states that *aren’t* expanding Medicaid than elsewhere!

nixonclinbushbama August 10th, 2013 at 2:42 pm

Thank you very much.

I will bookmark all the great links on this thread as soon as this book salon ends.

Virginia Brennan August 10th, 2013 at 2:44 pm
In response to BevW @ 30

I believe the biggest support from pharmaceutical companies comes in the form of medication assistance programs. There are problems with those, though: unreliability of continuing availability of the drugs, use of drugs that are sub-optimal…

Matt Anderson August 10th, 2013 at 2:45 pm

It is really unfortunate that it is the most vulnerable people who are going to bear the brunt of this. I see this in my patient population. People who are elderly, frail, perhaps with language issues, or mental health/intellectual disabilities are just not able to go onto the internet, surf around and then find the “most rational” insurance plans.

Virginia Brennan August 10th, 2013 at 2:46 pm

Yes, the 20+ articles that describe particular free clinics around the country often talk about how they got/get funding.

nixonclinbushbama August 10th, 2013 at 2:46 pm

Thank you.

Matt Anderson August 10th, 2013 at 2:47 pm

Here is a site from the American Cancer Society that goes into some of the options for getting cheaper (or free) drugs:
http://www.cancer.org/treatment/findingandpayingfortreatment/managinginsuranceissues/prescriptiondrugassistanceprograms/prescription-drug-assistance-programs-toc

Peterr August 10th, 2013 at 2:48 pm

Back in 2009, while the Affordable Care Act was still simply a bill, the Kansas City Free Clinic organized a huge two-day clinic event at Bartle Hall, Kansas City’s cavernous convention center. I went there, not as a patient but as a pastor, and wrote it up here at FDL. One snip from that old post:

As I walked up to and through the hall, what struck me most of all was the ordinariness of the people waiting to see a doctor or dentist. If you changed the venue from a cavernous convention center to a suburban medical office building, you wouldn’t think twice about most of these folks. The area that was set up as the “waiting room” for pediatric appointments reminded me of the doctor’s office that I take my son to — nervous kids, sick kids, crying kids, sleeping kids . . . just lots and lots of ordinary kids.

It was a slice of America, and not one that many folks in DC seem to be aware of at all — or if they are aware of it, they don’t seem to care about it.

You tell me which of those two is worse.

Then there was this, when I got home:

My eight year old just popped in and saw me writing. “Whatcha doin’?” he asked, hoping to play a game or something.

“I’m writing about the people who were at Bartle Hall for a visit to the doctor,” I told him. He’d seen it on the news earlier, and I showed him some of the pictures online and told him some of the stories, like kids his age who had never been to the doctor or dentist because their families couldn’t afford it.

He looked at me very solemnly and said, “That’s just Not Right.”

I could hear the capital letters in his voice. “No,” I said, “it sure isn’t.”

When I grow up, I want to be as wise as my kid.

The very existence of free clinics is a damning indictment of the health care system. If our system were as great as many folks believe it is, there’d be no need for clinics like this.

Virginia Brennan August 10th, 2013 at 2:49 pm

Yes, FQHCs are the greatest thing since sliced bread, in my view. Care is often as good or better than in private physicians’ offices, the hours are better for people working other than business hours, and often the care is much more attuned to the cultural characteristics of the clientele/patients. Dr. Anderson’s clinic is a good example of this in many ways. Matt — do you want to talk at all about the program you have for people being released from incarceration (who are at great risk of many things, including poor health and health care)?

Virginia Brennan August 10th, 2013 at 2:51 pm

exactly — and the states that aren’t opting in to the Medicaid expansion are giving people NO help navigating. A state like Coolorade, in contrast, is out there with public service announcements, counselors, everything they can do to get people into care.

Matt Anderson August 10th, 2013 at 2:51 pm

Michael Moore chose to make the movie Sicko not about the people who didn’t have insurance but rather about the people who had insurance but could still not access care when needed. This is truly an issue that affects all Americans.

Virginia Brennan August 10th, 2013 at 2:51 pm

A great thing about ACA is that the number of FQHCs is going to grow exponentially

nixonclinbushbama August 10th, 2013 at 2:52 pm

It is really unfortunate that it is the most vulnerable people who are going to bear the brunt of this.

Of course they will. They bear the brunt of almost everything, starting with something as simple as the weather.

Virginia Brennan August 10th, 2013 at 2:53 pm

Yes, and that includes a lot of working people (for *any* care because of costs) as well as people in rural areas, people impeded by literacy/time/competing obligations/limited English proficiency

Matt Anderson August 10th, 2013 at 2:54 pm

Virginia, Our clinic in the Bronx for ex-prisoners is not really a free clinic. It’s a special clinic though because we give expedited care to people coming out of prison who often have problems getting needed attention quickly. One of my former residents had a patient with a kidney transplant who was released from prison and could not get his medications. Rather than lose his transplanted kidney he committed a parole violation so he could go back to prison. This is why we set the clinic up.

nixonclinbushbama August 10th, 2013 at 2:54 pm

Wonderful. Thank you. As you know, sometimes, drugs are more of a problem than the care itself

Virginia Brennan August 10th, 2013 at 2:55 pm
In response to Peterr @ 42

You are absolutely right about this. My journal (J. of Health Care for the Poor and Underserved) will be out of a job when things are as they should be. Unfortunately, we still have tons of business to do.

eCAHNomics August 10th, 2013 at 2:55 pm

I’m interested in the economic aspects of free clinics. Part of the answer to my questions was above in association with government funding.

The intro also mentions that funds are cobbled together from various sources. I’ve been involved with fundraising local college, so I have some idea of the complications.

Can you address the funding in a bit more depth? For example, what % of staff, volunteers, and collected funds must be used for attracting additional funds. Are any free clinics able to set up endowments.

Also appreciated description of Cuban system above.

Peterr August 10th, 2013 at 2:55 pm

Who is setting them up?

BevW August 10th, 2013 at 2:55 pm

Have you seen this about Montana health care?

Montana’s State-Run Free Clinic Sees Early Success

A year ago, Montana opened the nation’s first clinic for free primary healthcare services to its state government employees. The Helena, Mont., clinic was pitched as a way to improve overall employee health, but the idea has faced its fair share of political opposition.

A year later, the state says the clinic is already saving money.

nixonclinbushbama August 10th, 2013 at 2:56 pm

Many of the couples who end up in bankruptcy because medical expenses were both insured. That is one of the horrors that ACA will not solve.

Virginia Brennan August 10th, 2013 at 2:57 pm

Yes, I do understand that. It’s a great illustration of why special efforts remain necessary for people vulnerable to being left out of care entirely as the example you mention makes vividloy clear.

Matt Anderson August 10th, 2013 at 2:58 pm

The medical students at Albert Einstein set up a free clinic about 10 years ago. They organize the clinic themselves and see patients under the supervision of volunteer physicians. They see patients on Saturday mornings at a doctor’s office (that doesn’t have Saturday hours). One of the local hospitals ate the cost of the tests (which are really not that expensive). They got donated medications. This was the model for a number of years.

BevW August 10th, 2013 at 2:59 pm
nixonclinbushbama August 10th, 2013 at 3:00 pm

I am sorry that I need to sign off now, but I will revisit the thread after the salon ends and catch up.

thanks to everyone for the links, the other info and a great discussion.

ben August 10th, 2013 at 3:00 pm

One of my former residents had a patient with a kidney transplant who was released from prison and could not get his medications. Rather than lose his transplanted kidney he committed a parole violation so he could go back to prison.

Any idea how often this happens? Any data on people who are so in need of medical attention that they are willingly incarcerated? That is a mind-blowing story, Dr. Anderson.

eCAHNomics August 10th, 2013 at 3:01 pm

Disclosure.

As a macroeconomist I discovered the malfunction of the U.S. medical industry and wrote about it in 1991. Was in the context of an ordinary investigation of the structure of inflation.

I’ve been watching the U.S. economy commit slomo suicide over medical costs for 22 years.

Continue to be interested in the subject, looking for microeconomics examples of interest. On the high income end, concierge docs, on the low income end, free clinics.

Virginia Brennan August 10th, 2013 at 3:03 pm
In response to eCAHNomics @ 52

The first article in our book is by Emily Schiller and Mike Fetters. They review the literature on free clinics. They include a section on funding. They report (as a synthesis of the literature) that:
a) obtainign start-up funbds is easier than maintaining funding as ongoing costs (esp. personnel) can sap funding.
b) free clinics rely heavily on private donations — individual, church, corporate
c) grant funding also used

d) sustainging operations: some clinics (not most) charge a small fee to patients; fundraising activities are necessary (thus there’s a need for personnel dedicated to that, aside from the caregivers)

e) use of group appointments for some parts of care for some conditions (e.g., pregnancy, chronic conditions); encouraging people to practice healthful; behaviors and get preventive care is also good for the bottom line.

BevW August 10th, 2013 at 3:04 pm
In response to ben @ 60

Ben, in my previous career (federal prisons) I saw a lot of people with mental illness and medical conditions violate the law to get medical care. The largest caregiver at that time were prisons, 30+% were mental patients.

Matt Anderson August 10th, 2013 at 3:05 pm

Ben,

I know of anecdotal cases but no studies. There is pretty solid evidence to show that death rates among people released from prison are much higher than the general population in the two weeks following release. This is likely due to people binging on drugs but the immediate loss of medical care may be another issue, as well as the fact that prisoners are often not very healthy – either mentally or physically.

Peterr August 10th, 2013 at 3:06 pm

Virginia, does your book get into the subject of rural health care needs? As a child, I remember taking regular two-hour car trips to visit grandparents, and along the way we’d pass a sign that said “No doctors in this county” as it pleaded for some doctor to move in and set up a practice.

Virginia Brennan August 10th, 2013 at 3:07 pm
In response to ben @ 60

I don’t have data on how often people get re-incarcerated intentionally in order to get care. I do know from volunteer work at the Tennessee Prison for Women over the past 20+ years that the poverty most inmates live in on the outside makes prison a reasonably attractive option for many for health care; safety (relative); housing; food.

My journal publishes a lot on health and health care of presently and formerly incarcerated people. It’s a complicated subject.

Dr. Homer Venters (in NYC) is a strong advocate for incarcerated people, esp. incarcerated refugees.

eCAHNomics August 10th, 2013 at 3:08 pm

group appointments

Thanks for your answer. The quoted portion above gives me a new insight. What other efficiencies and innovations do free clinics have that might be replicable in U.S. medical industry in general?

Matt Anderson August 10th, 2013 at 3:13 pm

Peter R, There is an enormous shortage of rural physicians in the US. There is an old adage that doctors follow the money. We see this in NYC where our county – the Bronx – is the sickest in the state but our ratio of primary care providers to population is the lowest.

Virginia Brennan August 10th, 2013 at 3:15 pm
In response to Peterr @ 65

The National Rural Health Association is a great advocacy group for people in rural areas. The Journal of Rural Health is also good and something to look into.

It is certainly the case that rural areas have greatly reduced access to caregivers (doctors, nurse practitioners, others) as well as facilities (e.g., hospitals). They are very likely to be categorized by the federal government as Medically Underserved Areas.

Our book includes examples of programs set up to serve rural populations (e.g., the Charlottesville Health Access)

Rural areas are more likely to have residents who are elderly and residents who suffer from major health problems including obesity, cardiovascular disease, alcohol abuse,and depression. This is compounded by the fact that rural states more often than urban states have decline3d to expand Medicaid under the ACA.

Matt Anderson August 10th, 2013 at 3:17 pm

Virginia,

Let me ask you a hard question and quote from Peterr:

It was a slice of America, and not one that many folks in DC seem to be aware of at all — or if they are aware of it, they don’t seem to care about it.

So, do they care? If they don’t what do we do about it?

eCAHNomics August 10th, 2013 at 3:18 pm

Also has the worst nutrition. Interrelated.

Virginia Brennan August 10th, 2013 at 3:20 pm
In response to eCAHNomics @ 67

That’s a great question and gets at something Matt raised in his review: some of the reason free clinics are good at what they are good at is that they are flexible — outside the big corporate health care system — and small. There’s a sort of freedom to do what works that comes with a very striking absence of regulation.

Here’s another example: one small city got all the psychiatrists in town to each agree to see one homeless person in need of mental health care pro bono. Thus, they got 200 homeless people in regular care with a psychiatrist — right in that psychiatrist’s regular office. So, those 200 people had all the benefits of a private psychotherapist with an MD. How could the government do something like that? I can’t imagine, and that is the problem: the big solution (not the drop-in-the-bucket solutions that are good for the few they reach but overall completely imperceptible)seems to me to require government institutionalizaation.

Virginia Brennan August 10th, 2013 at 3:21 pm

Very hard question. You might ask about the vast majority’s denial of the fact of poverty as well.

Virginia Brennan August 10th, 2013 at 3:22 pm

When Katrina happened, for about a week the fact US poverty was in front of everyone in the country and many in the world. People seemed shocked, angry, and ashamed of it. Mostly, they get to not think about it.

Matt Anderson August 10th, 2013 at 3:22 pm

I guess that’s a pass. :)

Matt Anderson August 10th, 2013 at 3:25 pm

Another advantage of free clinics – and something incorporated into our transitions clinic for ex-prisoners – is that people don’t need to feel stigmatized or like beggars. This allows you to have a different kind of relationship with people.

BevW August 10th, 2013 at 3:25 pm

With increasing population of the elderly, is there a free clinic response to the house-bound?

eCAHNomics August 10th, 2013 at 3:25 pm

Well, you won’t win me over with “mental health professionals” but that’s another story.

Flexibility is good example. Once the corp model gets cemented in, all innovation is lost.

Must exit now, but will check back later to see how discussion develops.

Many thanks for your efforts to provide medical care to those who need it most, for your efforts to bring this into public view when empathy has become a term of mockery in high circles.

Virginia Brennan August 10th, 2013 at 3:28 pm

yup

Matt Anderson August 10th, 2013 at 3:30 pm

Virginia,

Now that the book has been published, what are your plans with this topic? Your book lays out a series of research topics regarding free clinics. And – as we have seen in this discussion – there is a lot of interest in finding them. Do you see yourself following up the book?

Peterr August 10th, 2013 at 3:31 pm

The word “denial” suggests that they are aware but don’t want to acknowledge the fact.

For some in DC, anything that requires spending more money is to be shunned and avoided. Similarly, anything that threatens to scare potential donors away is to be shunned and avoided.

Finally, there’s the sad fact that while Big PhRMA and Big Medicine and Big Insurance have Very Big Lobbying Operations, the only lobbyists that the poor have are those that operate non-profit medical programs (like the Lutheran church of which I am a pastor, or the Catholic church). Simply getting a message through that isn’t drowned out by big money is a very tough thing.

Virginia Brennan August 10th, 2013 at 3:31 pm

Yes, and I think a lot of that is that your Transitions Clinic integrates people who had been prisoners *earlier* as patient advocates. They can build the bridge. I’m not a big fan of the term cultural competence, but whatever it is that ensures that a patient — possibly a person very unfamiliar with the system or with good reason to be nervous and maybe even defensive — feels respected and udnerstood is hugely important.

Peterr August 10th, 2013 at 3:33 pm

Have you gotten any reactions to the book from those in the political arena (legislators, mayors/governors, political party operatives, etc.)?

RevBev August 10th, 2013 at 3:34 pm

In a broad sense, do you think most people are even aware of this problem and/or solution? For myself, I can certainly think of the emphasis on hunger, or even homelessness, but I am much less aware of the medical issues.

BevW August 10th, 2013 at 3:34 pm

Virginia earlier you mentioned to me that your Journal article are read / downloaded internationally. Do you have any thoughts on the interest internationally? What country is the most active downloading articles?

Virginia Brennan August 10th, 2013 at 3:35 pm

Right now I’m trying to finish a book of comepletely new material on Obesity Interventions in Underserved US Populations: Evidence and Directions (I am the lead editor and my invaluable co-editors are Dr. Shiriki Kumanyika and Dr. Ruthg Zambrana). And I’m finishging editing a book by an amazing woman named Dr. Iris Shannon — a history of bthe Meharry Medical College Nursing Program, which lasted from 1900 to 1962. The interviews with grauates, Dr. Shannon’s decade-by-decade “Contextual Notes), and the fantastic sepia photographs from Meharry’s archives make this a hugely imnportant book thgat I am honored to play a part in. After all that, maybe it will be time to look again at Free Clinics? We do continue to publish on them — esp. the student-run clinics — in the journal.

Virginia Brennan August 10th, 2013 at 3:37 pm
In response to Peterr @ 83

i’ve gotten reactions mostly from people woprking in free clinics. they’re glad to be represented.

Virginia Brennan August 10th, 2013 at 3:40 pm
In response to BevW @ 85

Bev,

JHCPU covers populations in North and Central America, the Caribbean, and sub-Saharan Africa (the English-speaking African Diaspora). About 150,000 articles from our (subscriber-access) site are downloaded each year. For reasons that are entirely unknown to me, the institution at which more of our articles are downloaded than any other….is a university in Turkey! But lots and lots downloaded in our bailiwick, too.

Matt Anderson August 10th, 2013 at 3:40 pm
In response to RevBev @ 84

RevBev, Medical issues are more episodic in life than poverty or hunger. Middle class families won’t realize that their health insurance is inadequate until something catastrophic happens and – all of a sudden – they get hit with huge bills and insurance company denials. And the problems of the poor are – as Virginia points out – largely invisible.

Peterr August 10th, 2013 at 3:43 pm

You might want to send 535 copies of the book to the local offices of every member of Congress.

Virginia Brennan August 10th, 2013 at 3:45 pm
In response to RevBev @ 84

I think people are *not* aware of the facts. People of color, especially African Americans, for example, are more than twice as likely at White people in the US to lose a child in infancy. They suffer disproportionately from heart disease, die disproportionately often from numerous cancers, and develop kidney disease and worse access to replacement organs, too.

We published an article from the Unviersity of California at San Francisco recently about work the authors had done holding community meeetings with African American residents about the issue of infant mortality disparities. Even the aggrieved party–the people attending the meeting–were shocked by the facts. I think most Americans are completely unaware of it. Neil Calman and others in the Bronx have done excellent work holding community meetings of this kind as well (and I think Matt could tell you much more about that).

Virginia Brennan August 10th, 2013 at 3:46 pm
In response to Peterr @ 90

I like that idea. I have some.

Matt Anderson August 10th, 2013 at 3:46 pm

Since the House just voted for the 41st (?) time to repeal the ACA, I doubt this would have much impact.

Virginia Brennan August 10th, 2013 at 3:49 pm

well, the Congressman for my district — Jim Cooper — is a smart guy ( na Rhodes Scholar) with expertise in health care. He’s a Blue Dog, fiscal hawk though, so I think he’s on the wrong side of a lot of issues affecting low-income people and I’d like to shake him up.

RevBev August 10th, 2013 at 3:50 pm

Or just get rid of Medicare or esp. health care for women. Great discussion.

Peterr August 10th, 2013 at 3:50 pm

This points to the larger issue of getting this discussion out of the academic/medical press and into the mainstream media. You publishing articles like that is one thing; getting the local television stations to send cameras to those meetings is something else entirely.

Virginia Brennan August 10th, 2013 at 3:51 pm

This has been very lively and invigorating. Thanks Matt and Bev and everyone who took part!

BevW August 10th, 2013 at 3:51 pm

As we come to the last few minutes of this great Book Salon discussion,

Virginia, Thank you for stopping by the Lake and spending the afternoon with us discussing your new book and Free Clinics.

Matt, Thank you very much for Hosting this great Book Salon.

Thank you both for all you are doing.

Everyone, if you would like more information:

Virginia’s website and book

Matt’s website

Thanks all, Have a great weekend.

Tomorrow: William P. Jones / The March on Washington: Jobs, Freedom, and the Forgotten History of Civil Rights; Hosted by Eric Arnesen.

If you would like to contact the FDL Book Salon: FiredoglakeBookSalon@gmail.com

Matt Anderson August 10th, 2013 at 3:51 pm

This is a very complex topic. The Bronx used to be far more politicized in the past and people felt entitled to demand their rights in an organized fashion. This is not so much the case now. I suspect that part of the problem is the large body of undocumented workers who are essentially disenfranchised and will avoid anything that brings them to the notice of the police. On the other hand, young minority boys get arrested at the drop of hat – I see this all the time in the neighborhood around my clinic; mostly it’s for minor offenses (like marijuana possession). This put them in a defensive position with respect to any protests. The public educational system in NY is also in shambles with only about 70% of 9th graders graduating from HS within four years.

Matt Anderson August 10th, 2013 at 3:53 pm

Bev, Thank you so much for hosting us.

Viriginia, It was a pleasure to hear your “voice.”

Thanks to the participants.

ben August 10th, 2013 at 3:55 pm

Great discussion! Thanks!

Virginia Brennan August 10th, 2013 at 3:56 pm

agreed. (Btw, even 70% graduating sounds good from the point of view of Nashville, I hate to say.)

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