Doctors Without Bills

Saving the world a patient at a time

The city of Roanoke, near the base of Virginia's Blue Ridge Mountains, is a place much like any other medium-sized American town. It has an older, sleepy downtown and bustling suburbs. It has a rich section and a poor section, crime that is troubling but not overwhelming, schools that are good but could be better.

But on a tree-lined side street, not far from the city center, stands a sprawling one-story building that has made Roanoke something of an example for the rest of the country. It is the Bradley Clinic, a free clinic where all the doctors and nurses are volunteers, and where none of the thousands of area residents served every year are charged a penny for the care they receive or the drugs they are prescribed.

There are hundreds of free clinics like this in cities around the United States, privately run volunteer groups providing free health care to some of the 31 million Americans without insurance. Few, however, have been as successful as Bradley in attracting community support and providing quality care. While other charity groups rely heavily on lay help and have difficulty attracting medical professionals, the Bradley leadership has convinced 120 of the city's 411 physicians to donate their time. Dozens of the city's most prominent businesses supported the clinic's recent fund-raising drive, and the clinic's board of directors reads like a local Who's Who.

And while many free clinics are run on a shoestring, often out of the backs of churches, Bradley has a 1-year-old facility indistinguishable from a paying clinic. Equipment is state of the art. The grounds are immaculately landscaped. There is a full-service pharmacy.

The success of the Roanoke clinic has inspired the creation of at least eight other clinics around the country and led the White House to name the organization one of the nation's "thousand points of light." It has also thrown a hitherto ignored question into the ongoing national debate over how best to solve the nation's health-care ills: To what extent can volunteerism and old-fashioned charity answer the needs of the country's uninsured?

The conventional wisdom says they can't. The idea of charity cannot be found in the current debate in Washington over health-care reform. Even other free-clinic operators, who have had little of the success of the Roanoke group, consider their efforts only a stopgap measure before Congress enacts a more comprehensive solution.

But the physicians and volunteers at the Bradley Free Clinic have become crusaders for charity care. They are planning a national foundation to encourage and assist in the establishment of free clinics all over the country.

"We've got institutionalized thinking in this country," says John Rocovich, a Roanoke tax attorney who serves on the Bradley board. "Everyone is in institutionalized government, institutionalized medicine, institutionalized health insurance. What we have here is a simple, straightforward idea. In America we have a level of volunteerism you just don't see elsewhere. With volunteerism we can take care of those people who slip through the cracks so much more cheaply than the government that it makes sense."

"People in this country have a sense that local solutions, not sweeping solutions, can't accomplish anything," says Kevin Kelleher, a volunteer physician at the Bradley clinic. "They are wrong."

Free health care for the poor is a concept as old as American medicine itself. In the 19th century, many hospitals were set up by churches or nonprofit groups explicitly to provide services free of charge. Even as late as the early 1970s, many American hospitals had rules requiring that physicians provide a certain number of hours of free care every week in exchange for hospital privileges.

With the introduction of Medicaid and Medicare in 1965, the need for organized charity greatly diminished. At the same time, formal programs to encourage charity care also disappeared.

But there are still an estimated 31 million Americans who do not have health insurance, either because they are ineligible for it because of serious health conditions, because their jobs do not offer it, or because they cannot afford it. These people are too young for Medicare and too well paid for Medicaid.

Without medical coverage, the uninsured pay directly for about half of the care they receive. For the rest, they depend on the kindness of others. Hospitals, for example, spend about $10 billion a year providing free care and forgiving patients' debts. Private philanthropy pays for $2.7 billion in hospital care, while federal, state, and local government sources kick in another $45 billion for public clinics and other services outside of the mainstream of Medicaid and Medicare programs. In addition, individual physicians make countless decisions to reduce or waive the cost of their services for those without insurance.

The patchwork of services gives the uninsured far less care than they would receive were they fully covered. Overall, annual per capita health-care spending for the uninsured, for example, is $866, compared with $1,437 for the insured population.

This doesn't mean that the uninsured don't get life-saving operations when they need them. No hospital turns away a patient with a burst appendix. Rather, the uninsured get less primary and preventative care than the insured. Because of Medicare, the uninsured are younger than the insured, but they appear to be in poorer health than insured people of the same age.

The uninsured see a doctor only two-thirds as often and are three times more likely to be hospitalized for a preventable condition or disease, according to a 1990 study for the Health Care Financing Administration. Markedly fewer uninsured than insured women have their blood pressure checked or a Pap smear or breast exam done. Pregnant uninsured woman are far more likely to have little or no prenatal care and to have low-birth-weight babies than the insured.

The uninsured also receive much less elective surgery than the insured do. According to a Georgetown University study reported in the January 16, 1991, issue of The Journal of the American Medical Association, they are 75 percent less likely to receive a knee replacement, 45 percent less likely to receive a hip replacement, and 29 percent less likely to receive a coronary bypass.

It was to meet this need that free clinics began to spring up in the late 1960s and '70s. Today, there are about 200 of them nationwide—chiefly small, shoestring operations serving inner-city areas and surviving largely on a combination of volunteers, individual donations, United Way money, and some tax dollars.

The free-clinic model has clear advantages. By using volunteers and donated drugs and equipment, clinics provide highly cost-effective care. Studies have shown that free clinics can deliver between $5.00 and $6.00 of medical care for every $1.00 in revenue. The Bradley Clinic provided just under 7,000 physician visits in 1990 and filled more than 10,000 free prescriptions on an operating budget of just over a quarter of a million dollars.

Clinics are found in poor neighborhoods, where the need for medical service is greatest. This solves transportation problems that can inhibit the use of hospitals and other medical services by the uninsured. And clinics remain open after working hours to accommodate their volunteer staffs and their patients.

"Access and transportation are big problems for the uninsured, and accessibility is limited by any other solution," the Bradley Clinic's Kelleher wrote in a recent JAMA article on the free-clinic phenomenon. "Familiarity also encourages use.…A strong identification occurs with a neighborhood clinic that encourages responsibility, pride and additional volunteerism." As loosely structured local groups, free clinics also have the virtue of flexibility. At the Washington Free Clinic in the District of Columbia, for example, where the typical medical need is obstetric and gynecological care for the local Hispanic population, the clinic tailors its services to its neighbors.

"Using lay workers we're able to take the time to really explain to each patient how their body works, what problems they are having," says clinic director John Clark. "To give an example, an adolescent coming in for her first gynecological exam here will get an hour and a half of education. In a doctor's office, she might get 15 minutes."

But few free clinic operators tend to share the optimism of the Roanoke group about their ability to meet the needs of the huge numbers of uninsured Americans. In a typical day, Clark says, the D.C. clinic probably turns away 20 to 25 people because it simply doesn't have the staff or resources to deal with them.

"I think there are 114,000 people in D.C. without health insurance," he says. "In a year we probably see 4,000 of those. We're only scraping the surface. To serve the need in this city we would have to turn into a multimillion-dollar, several facility organization."

Clark has difficulty recruiting doctors, although the Washington, D.C., area has the highest number of doctors per capita of any urban area in the country. While locating the clinic in an economically depressed area makes it most accessible to those in need, he says, it also makes it almost impossible to convince doctors to volunteer.

"We're located in a drug area where there are lots of concerns about safety," Clark said. "Doctors get their cars broken into. The clinic is oppressively hot in the summer and freezing cold in the winter. They have to work without a lot of medical support. It's a difficult setting."

These complaints are echoed by other free-clinic operators around the country. At the Cleveland Free Clinic, one of the largest in the country, about 32 physician volunteers see about 20,000 patients a year in a city that has about 200,000 people without health insurance.

The clinic would like to have at least twice as many doctors. "There is never a night here when we don't have more people in the waiting room than we are able to see that evening," says clinic director Marty Hiller.

A veteran of the free-clinic movement, Hiller has grown skeptical of the role clinics can play in solving America's health-care problems. "We are the crisis response," he says. "We exist because there is a problem and we are able in the short run to meet the needs of some. But I don't see free clinics as necessarily being the solution. When the health-care system takes care of people without insurance, we will no longer have to be here. Our long-term goal is not to exist."

Which of these two very different pictures—the optimism of the Bradley Free Clinic or the pessimism of other free-clinic operators—represents the most realistic picture of free care is difficult to say.

Certainly, the Roanoke movement has clear advantages over its predecessors. The majority of the nation's free clinics were formed—and remain—philosophically and operationally in opposition to the local medical establishment. As part of their late-'60s counterculture heritage, many clinics remain outsiders in their communities, highly critical of the status quo.

The Bradley Clinic, by contrast, is very much a creature of the local city establishment, which has made attracting financial and volunteer support much easier. While the Washington Clinic's board of directors is chaired by a free-lance writer and peopled largely with clinic volunteers, the Bradley Clinic's board includes prominent local attorneys, businessmen, and physicians. In a recent fund-raising drive, headed by the publisher of the local paper, one wealthy Roanoke patron gave the clinic a $1-million gift.

The clinic has been so integrated into the local medical community that volunteering is almost seen as a routine extension of the obligations of the profession; more than a quarter of all local M.D.s volunteer. In all, the clinic has close to 400 volunteers, including 120 physicians, 58 nurses, 29 pharmacists, 12 laboratory technicians, 20 dentists, and 15 dental assistants. Unlike its counterparts, it has no staff shortage.

But if generating a strong community spirit is possible in Roanoke, it might not be in a larger, less close-knit community. So far clinic officials have found the biggest audience for their ideas in other medium-sized cities or large towns. Whether the medical communities of bigger cities could produce the same level of support is something that even some Roanoke volunteers doubt.

And they concede that their clinic does not entirely meet the needs of their own community. With 7,000 patients visiting a year, the organization probably serves about 16 percent of Roanoke's uninsured.

The difference, though, is that Bradley volunteers see this fact less as a reason for defeat than as an inducement to work harder. The clinic is planning additional nights of operation and setting up a cancer-screening program. A network of specialists who will accept referrals without charge has been organized.

"I don't know if a free clinic will provide all the answers, ever," says Kelleher. "But it does provide an immediate solution. It is something we can do now."

Nor does everyone think a national health-care plan would eliminate the need for free clinics. "In all the thousands of years of recorded history, we have yet to have an adequate health-care system," says John Gavin, a Roanoke emergency room physician involved with the clinic since its founding. "I don't think that in my lifetime we will see a system that will properly fill all the gaps. The gaps will change, but they will still be there.…We will always be able to make a difference."

Malcolm Gladwell is a reporter at The Washington Post.