One of the most common misconceptions about how the United States will look after the Affordable Care Act is that there will no longer be a need for free and charitable clinics. Many are surprised to hear that even after full implementation of the ACA, according to the Congressional Budget Office, 31 million people will probably still lack insurance.
Obamacare is not only hotly contested but also widely misunderstood. As the debates rage, good people continue to still slip through the cracks.
A big part of the ACA was Medicaid expansion. However, the Supreme Court decision allowed states to opt out of this requirement and keep their existing Medicaid eligibility categories. Fortunately, New Jersey agreed to the expansion, but in states that did not, there is a huge number of people who will lack coverage and who have very few options. Supposedly, under the ACA, Medicaid and Children's Health Insurance Program eligibility determinations have been greatly simplified. This may or may not be true; however, those eligible continue to face many barriers to getting enrolled, and many choose not to enroll.
Another big category of individuals whom the ACA leaves behind is the undocumented, who constitute about 25 percent of the total uninsured. This group is not eligible for advance premium tax credits for Medicaid or CHIP and will not be eligible to purchase private insurance with their own money through the exchange.
Another crack in the system is the people exempt from the mandate. If you cannot purchase a bronze policy in the individual market, through the exchange or through an employer, for 8 percent or less of household income, you are exempt. Mostly, this applies to people with incomes between 150 percent and 300 percent of the federal poverty guidelines - too high for Medicaid but barely enough to make ends meet, let alone pay for premiums, deductibles and co-pays.
The CBO estimates that about 18 to 19 million Americans will be exempt from the mandate. These are the people who have traditionally been served by free and charitable clinics, like Volunteers in Medicine of Cape May County.
Lastly, there will also be those who are subject to the mandate but who, for whatever reason, remain uninsured. This may be particularly true in the first couple of years when the penalty is very low (only $95 the first year). According to CBO estimates, about 6 million Americans, including dependents, will forgo insurance and pay the penalty.
There is one more crack worth mentioning. What happens to all those patients now on Medicaid? This system was already overburdened with too few doctors who accept Medicaid.
Or consider someone who earns about $20,000 a year - too much for Medicaid, not enough for premiums and deductibles. I have a particular patient in mind. Bill is a pizza cook. He has diabetes. Before coming to our clinic, he was in and out of the emergency room numerous times because he could not afford his insulin. He is under 26 so the ACA says he can stay on his parents' plan - only his parents don't have insurance either. Before coming to us, he stretched his insulin - underdosing and skipping doses completely. I submit the ACA has not made a bit of a difference in his life, but Volunteers in Medicine has and all of the volunteers and donors who support VIM have too.
Bill is typical of our patients. VIM patients tend to have multiple chronic conditions; they struggle to find and keep steady work. Transportation, nutrition and family care are often real concerns. They do respond very well, however, to what VIM refers to as our culture of caring. As we take a greater interest in their lives, they become a more proactive partner in the management of their health.
So although free and charitable clinics are still necessary, thanks to the ACA, it is harder and harder to continue to do what we do - harder to attract volunteers, harder to raise money. Volunteers in Medicine operates at the grassroots level, not the government level. Our clinic receives no state or federal funding. Yet we provide excellent care to about 500 uninsured families each year, with an annual operating budget of less than $300,000. We do this thanks to a generous community that understands free and charitable clinics are a vital part of the safety net.
If you are interested in becoming a patient or supporting our efforts, visit www.vimcmc.org.
Jacqueline Meiluta is executive director of Volunteers in Medicine of Cape May County.