Our country’s health care safety net is built on the principles of poverty medicine—providing health care to the indigent and underserved. (see previous blog post “Poverty Medicine: Why We Need the Poor and Underserved” 5-4-11) The deeply entrenched American notion of charity care as the way to provide safety net services, engenders stigma, shame, dependency, and resentment among recipients. People do not want to have to depend on handouts, on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics and hospitals have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society into the haves and the have nots, into the worthy citizens and unworthy citizens. Charity care perpetuates poverty. Because of our extreme version of a capitalist economy, and the widening disparities between rich and poor, our health care safety nets—whether government supported or faith-based or otherwise—are struggling to provide basic social and economic support for patients along with health care. They can’t—and they shouldn’t have to—do this well.
Fewer physicians in private practice are providing charity care and a growing number of public hospitals are becoming insolvent and closing. Hospital administrators are getting desperate to reduce their rising level of uncompensated care. (see NYT article “Debt Collector Faulted for Tough Tactics at Hospital” by Jessica Silver-Greenberg, 4-24-12). Our safety net is shrinking.
Current health care reforms don’t address these fundamental issues. If we had more of a social justice approach where everyone had access to basic health care and socioeconomic support services—as occurs in most industrialized countries—poverty medicine would be an anachronism, or at least not as relevant. Even with universal health care there would still be a need for some safety net services for the homeless, undocumented people, and others. But the underlying anxiety people have of falling through the safety net—of being one major injury or illness away from homelessness—would be lessened. People would have more energy to actually live their lives, to be productive and happy. Unfortunately our country is founded on principles of charity, not solidarity.
I have worked in all parts of the US health care safety net: in federally funded community health clinics, in faith-based free clinics, in non-sectarian free clinics, in health departments, in the urgent care center of a large urban academic medical center—and even in a private practice whose physicians occasionally provided charity care to long-term patients. But despite compassionate and capable staff and providers charity care was always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive.
Free clinics are a growing part of the shrinking health care safety net. I find it fascinating that my home state of Virginia has the second highest number of free clinics in the country. (disclosure: I worked at two out of the three free clinics in Richmond). North Carolina has the most free clinics of any state and Georgia is close to Virginia’s number. Most are faith-based. These three Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free clinics part of the solution or the problem?