Insurable but Uninsured

The Affordable Care Act (ACA), known affectionately as Obamacare, promises to insure more, spend less, and achieve better health for all.

As one of many medical students who takes care of the uninsured, I have been brainstorming ways to help our patients enroll in New York’s health care exchange. What hadn’t occurred to me is that our patients might opt for our free student-run clinic services instead of coverage under the ACA.

As a result, clinics are faced with a difficult question – do they accept patients who are eligible for insurance under a newly expanded Medicaid or subsidized private programs but nonetheless opt out and choose free clinics for treatment? This is an ethical challenge compounded by the limitations of volunteer staff, one-time donations, and philanthropic grant-based funding.

Some clinics consider their limited resources and decide no, that they ought to turn away the patients that are insurable but uninsured. If a clinic can only make appointments for 10 patients per week, should it not reserve those spots for patients who have no other option? The large population of undocumented Americans is one of the groups who still need health services outside of the ACA.

It’s important to understand that turning away patients does not guarantee that patients will indeed enroll in the ACA or Medicaid. Instead, it is entirely plausible that many will go untreated and progress to more serious conditions. This is particularly dangerous for our diabetics who need support in reducing their risk of heart attacks, strokes, or deadly diabetic comas.

After discussing this issue with fellow clinic leaders, we decided that our free clinic will not turn away a patient who believes that we are their best option for health care. The ACA has enormous potential, but there is still substantial progress to be made in terms of coverage. Ultimately, we cannot, in good conscience, force our patients into a program that healthcare providers like us struggle to understand.

When our volunteers ran a survey for the month of December, we learned that 2/3 of our own patients hadn’t even heard of the ACA. According to the latest polls, more than 40% of Americans didn’t know that states had the opportunity to expand Medicaid coverage to more low-income, uninsured adults.

This issue goes beyond finances or legalities. It goes back to the reason why our clinics were created in the first place – to fill the gap between patient needs and the realities of our health care system. To close the door on our patients who have grown with us over the years would only perpetuate a failed mentality of our healthcare system; one that favors independence over collaboration. Our commitment as student practitioners is to work alongside our patients as they learn to take control of their own health.

As the ACA health exchanges evolve, our clinic will offer support for those who are eligible for federal programs but choose our services in the meantime. We will partner with them to address their concerns with the ACA, provide individualized education, and empower them to make decisions about how and where they receive care.