Two new exam tables have just arrived at the Birmingham Free Clinic on the South Side. This would not be a ticker tape moment for a hospital or a well-heeled primary care office. But in this austere first-floor space, where the medical staff is almost fully volunteer and the patients range from indigent to merely uninsured, where the annual budget of $200,000 is enough to treat 3,200 patients, the two new exam tables are indeed a big deal.
So are the new defibrillator and EKG machines, not to mention the new printers and laptops, which have helped pull the free clinic away from illegible doctors' notes and into the era of electronic health records.
All of which suggest that the Birmingham Free Clinic is planning ahead -- even as the future of the clinic, and all clinics like it, are clouded by the Affordable Care Act, whose provisions will theoretically inject millions of newly insured patients into America's health care system.
Change has been constant at the free clinic since its opening nearly two decades ago. The clinic -- a joint project of UPMC, the University of Pittsburgh's Program for Health Care to Underserved Populations and The Salvation Army, which donates space and utilities -- has changed its home address. It has seen major changes in its patient census. And its pool of physician and pharmacist volunteers is constantly churning, too, as young residents and medical students move in and out of the region.
But the changes coming by way of the Affordable Care Act have the potential to upend the status quo: When people have insurance, they may not need the services of free clinics.
It's a good outcome, on the balance, says Mary Herbert, clinical director at Birmingham. The clinic's guiding mission is to steer people into the health care system, and any policy that achieves that is largely in harmony with the clinic's goals.
Still, the implementation of Affordable Care Act, and Gov. Tom Corbett's lack of clarity on when, or if, Pennsylvania will ever expand its Medicaid program to include more patients, figure to make for an unpredictable five to 10 years.
"None of us know exactly how it's going to fall out," Ms. Herbert said.
The clinic is preparing for that fallout regardless, with help from two state grants that paid for the new furniture and hardware and, more vitally, are supporting a physician for 12 hours week and a partially supporting a full-time nurse manager.
"We never even had a part-time nurse on site, let alone a full-time nurse," Ms. Herbert said. Having more paid staff on hand -- even if it's a staff of only four -- reduces some of the chaos that comes with relying on a volunteer pool of about 70 physicians and a dozen or so pharmacists, some of whom donate their hours more regularly than others.
The clinic is also plowing ahead with its new electronic records system, which was donated through UPMC and is tied into UPMC's own records.
"We were all paper charts for 18 years, up until March," said Ms. Herbert, an Erie native who began her work here 15 years ago as an AmeriCorps volunteer, eventually becoming clinical coordinator and earning a master's degree in public health from Pitt.
But today, when a patient shows up at the free clinic, the clinicians can check to see if that patient has spent any recent time in a UPMC emergency room and, if so, can find out what he was treated for, and what medications may have been prescribed. The reverse is true, too -- uninsured patients who show up at an ER can be cross-referenced against the clinic's records to see if the patient has any recent or chronic health issues.
"That's really helpful," Ms. Herbert said. "Most [patients] have been chronically uninsured for a very long time, and have used the ER for acute issues" for a long time, too. Using electronic records also makes it easier for those rotating clinic volunteers to read each other's notes and keep up-to-date on the patient's medical history.
"Because we have such a large rotating team of volunteers, it's unusual for patients to see the same doctor every time," Ms. Herbert said.
As the clinic changes, so does the landscape in which it operates, seemingly on an annual basis. Over the past few years, the clinic has noticed that an increasing share of its patient population was previously employed and lost employer-sponsored health care during the Great Recession.
The clinic's patient census looks much different now than it did two decades ago, when it served homeless men almost exclusively because of its location next to a homeless shelter.
While the past few years brought in higher numbers of formerly employed and the working poor -- those who fall below the federal poverty line but still make too much to qualify for Medicaid -- the next few years could see a reversal in that.
The centerpiece of the Affordable Care Act -- the online exchange that will allow people to shop for health policies -- should go live in January 2014. It will provide subsidies for those who want to buy a policy but fall below certain income thresholds.
And around the nation, Medicaid programs will be expanding, reducing the number of uninsured. That's not an issue in Pennsylvania just yet, because of Republican and gubernatorial reticence, but it could come to pass in 2015 or thereafter.
"If the governor were to change his mind, I think a lot of our patients in free clinics would be eligible" for Medicaid, Ms. Herbert said. And if her patients start carrying Medicaid, would the free clinic -- which has never charged for medical care or prescriptions -- start accepting it?
"Do we start billing? And how does that affect our model?" she mused. "That would be a huge philosophical change for us. ... Could we sustain ourselves if the vast majority of patents were eligible for Medicaid?"
Another unintended side effect of Obamacare: As more people gain health insurance and prescription coverage, there is less need for -- and less incentive to provide -- the various discount medicine programs now offered by America's pharmaceutical manufacturers.
"Some of the companies are discontinuing a lot of their meds on the assistance programs, [including] very common meds that we use," Ms. Herbert said. But "for our patients here, we still need these meds somehow. ... How do we reframe our formulary?"
It could mean relying on substitute medications, or charging for over-the-counter drugs that are now given away for free.
"We have learned to be very nimble about making changes," said Peggy Dator, executive director of the Free Clinic Association of Pennsylvania. "Because we have to be. We don't have a steady source of funding coming in."
At the association's annual meeting in May, the Affordable Care Act was the primary discussion topic. Would the act eliminate the need for such clinics altogether? Will changes in Medicare payment rates further squeeze hospital networks, forcing them to cut back on their financial support for such clinics?
"The biggest challenge for all the clinics [is] the uncertainty of the health care situation, at this point," Ms. Dator said. "It's been very difficult for them to plan for how they are going to evolve."
Different clinics will surely evolve in different ways -- among Pennsylvania's 40-some free clinics, some operate on shoestring budgets in a church basement, while others have multimillion-dollar budgets with 18 full-time employees. Some smaller ones may indeed close; others may shift into more of an advocacy role, providing care when necessary but also helping the chronically uninsured find the coverage that works best for them, and helping them navigate and utilize the health care maze.
While free-clinic closures seem an inevitable outcome when more people have health insurance -- "I have transferable skills," Ms. Herbert joked -- clinics in urban areas will likely remain open. That's because cities will probably always have an indigent underclass that does not carry insurance and that falls through that safety net, until finally landing at Birmingham.
For that population, regardless of how the Affordable Care Act and Pennsylvania's Medicaid expansion play out, "I think they're going to stay here," she said.
Bill Toland: firstname.lastname@example.org or 412-263-2625. First Published July 14, 2013 4:00 AM