Traditional health care neglects the working poor.
A church-based clinic steps in
After more than a decade of providing health care for the working poor of Memphis, Tennessee, I have grown certain there is no single solution for providing quality medical care to the nation’s poor. No government agency or program will be able to meet all of their needs. Quality health care for the poor must always include a variety of not-for-profit, privately funded solutions alongside publicly supported programs.
I base this conclusion on 10 years’ experience in starting, operating, and expanding the Church Health Center of Memphis, which provides primary health care for the community’s working poor and their families. Over the years, we have provided care to more than 22,000 patients, and we now handle about 30,000 visits a year. We are open about 70 hours a week, from 7:30 a.m. until 9 p.m. on weekdays and from 8 a.m. to noon on Saturdays.
We work these long hours because minimum-wage employees cannot easily leave work for daytime visits to the doctor. During the workday we have a paid staff, but we can offer evening and Saturday office hours only with the volunteer assistance of more than 400 Memphis physicians and hundreds more nurses, dentists, and nonprofessionals. Medical specialists agree to see patients in their own offices, free of charge. We ask each of our volunteers to help out just once every two or three months because we want them to avoid burnout and stay with us for 30 years.
Our targeted patient population is working people who have fallen through the health-insurance safety net. These are the people who, without complaint, cook our food, shine our shoes, and will one day dig our graves—in short, who make our lives comfortable. They do the best they can but when they get sick, they are stuck. They may sit at home and hope they get better. If they do not improve, they seek other options, but in the last few years, those options have shrunk. Fortunately, thousands of the uninsured working poor in Memphis have found the Church Health Center.
Regular patients must meet certain criteria. We treat anyone under 18 or over 65 who is uninsured or who has only Medicare. All other adult men must be working at least 30 hours a week, and women at least 20 hours a week, except moms with children under six. We discourage patients with health insurance, because they have other options.
We are not a free clinic. Our experience teaches us that poor people are not looking for a handout, but for something they can afford. Therefore we charge on a sliding scale according to income. The minimum payment per visit is $10 and patients with an outstanding debt are expected to pay at least $2 a week. If you fail to keep your appointment or pay your bill, you cannot come back. (We rarely have to enforce this policy.)
A Flawed Solution
The Church Health Center has thrived amid the nationwide debate over health care and the state’s reform of Medicaid. Now with the advent of the federal "KidCare" program, which provides billions of dollars for uninsured children, we are hearing once again that only government can address the unmet needs of the poor and uninsured. Although the funding for "KidCare" may create innovative new programs, no state should claim that all children will now have health insurance. We know from our experience in Tennessee that it will never happen.
In 1994, Tennessee reformed its Medicaid program and renamed it "TennCare." The theory behind it was that the state could save money by operating Medicaid along the frugal principles of managed care and use the savings to insure more people, particularly the working poor. In fact, its sponsors said it would extend health care to all the citizens of Tennessee still uninsured. But it has done no such thing.
Today a person working in a minimum-wage job has a more difficult time receiving medical care than before the arrival of TennCare. When the program began, the state intended to divert every dollar that had gone into Medicaid into 11 new managed-care organizations (MCOs). At the same time, it planned to add another 200,000 working but uninsured patients to TennCare rolls. But the state miscalculated the costs of operating the MCOs and extending coverage. The savings from managed care were not enough to fund both the expenses needs of new insurance companies and health care benefits for the working poor. As a result, in January 1996, TennCare changed the rules to make the uninsured working poor essentially ineligible.
At about the same time, under TennCare the state cut back on funding for medical education. Memphis’s city hospital (the "Med"), a teaching hospital that had served many of the working poor, suffered a cut of $27 million. To cope with this loss, the Med effectively eliminated services for the working poor, who had been receiving routine health care in its emergency rooms.
Of course, some people are better off under TennCare. The program has been a godsend to everyone who had previously been uninsurable due to pre-existing conditions and did not qualify for Medicaid. TennCare has been bad, however, for the working poor who have been eliminated from the state’s rolls and shut out of institutions that have traditionally cared for them. In addition, the people who designed TennCare acknowledged that, even if it were fully funded, it would not extend coverage beyond about 95 percent of the population. At any given time, tens of thousands of people are experiencing changes in their eligibility, and the bureaucracy cannot keep up. In Memphis, a 5 percent gap would leave at least 50,000 people uninsured.
Despite TennCare, demand for our services remains high. A mother recently brought her baby to our center with a fever of 104 degrees. She had already been turned away from three other facilities because her baby was "not sick enough" and she did not have TennCare. She had applied for TennCare twice and been turned down without explanation. Fortunately, we were able to care for the baby that day and make him a regular patient.
Last year, I saw a 10-year-old boy who could not speak a word. His tongue was bound to the floor of his mouth, a congenital condition commonly referred to as being "tongue-tied." This problem calls for a relatively simple surgical solution, but the boy’s TennCare MCO repeatedly refused to pay for the procedure because it was considered "cosmetic surgery." The family’s surgeon and I had to document the problem and make repeated calls before the procedure was approved.
Filling a Gap
The Church Health Center responded to these changes in 1996 by opening a walk-in clinic. Every day we typically see about 20 uninsured patients who come to the clinic without an appointment and need immediate treatment. Their problems range from colds and sore throats to broken bones and life-threatening diseases. In the past year, we have treated four people with gunshot wounds who had been turned away at hospital emergency rooms because they were uninsured.
Our walk-in clinic has provided unexpected benefits for the health of our community. We now care for more African-American men than ever before. Many poor black men do not seek health care until their condition is dire, but our walk-in clinic is changing that pattern for a growing number of them. The scenario usually unfolds like this: A man comes to our clinic because he is too sick to go to work. As we treat his acute illness, we note that he has diabetes or hypertension or some other significant chronic medical problem. We then offer him an appointment at the health center. Because his experience at our walk-in clinic is so positive, he agrees to become a regular patient. In a similar fashion, we have captured entire white and Hispanic families who first come to us because their babies are sick and they cannot afford a private pediatrician.
The Spiritual Dimension
Our center differs from government-funded facilities in several ways, but perhaps none is as important as our efforts to address the spiritual dimension of patients’ lives. I would estimate that 50 percent of the people who come to primary-care doctors have no medical problem. They may complain of back pain but in reality suffer from a broken heart. I cannot cure such maladies in a 15-minute office visit, but we are always aware that every patient’s life and illness involve matters of both body and spirit, so we have two full-time pastoral counselors on our staff. Although we do not actively evangelize patients when they are sick, we do believe that our care for those who are ill and have nowhere else to turn is a powerful display of faith to many people who feel lost and alone.
We view our work as a ministry of all the people of faith in Memphis, and this is reflected in the way we raise our operating funds. More than 150 local congregations together contribute $1 million a year to our work. They range from conservative to liberal, comprising black churches as well as white, Baptist and Presbyterian congregations as well as Jewish and many others. We are united in our belief that God calls us to care for our bodies as well as our spirits and to care for the poor who are sick.
The government cannot treat spiritual ailments alongside physical ones and we should not ask it to. For this reason, we do not seek any government funding. I believe that government has a large role to play in health care for the poor, but our mission is beyond the scope of government. We are trying to develop the means within our community to take care of our neighbors, and we cannot look to Washington to make it happen.
After 10 years, there is little doubt about the long-term viability of the Church Health Center, but unnecessary barriers continue to hinder the effectiveness of our work.
Consider my experience with a program we call the "MEMPHIS Plan." In 1991, in an effort to expand the services of the Church Health Center, we created a network of physicians, hospitals, and laboratories that volunteer their time and resources to care for uninsured patients. The program works like this: Doctors all over the city are each asked to admit about 20 patients into their practice gratis and treat them as they would anyone else. Every hospital and every laboratory in the city provides free diagnostic procedures whenever these patients require them. For serious cases, two hospitals in town have agreed to admit patients on a charitable basis.
Patients enroll in the MEMPHIS Plan through their employer. To qualify, the employee must make less than 150 percent of the federal poverty line. The program charges only an administrative fee of $35 per month, of which at least $10 must be paid by the employer. Blue Cross of Memphis handles the collection of these monthly fees and the Memphis and Shelby County Medical Society recruits physicians to volunteer for the program.
In 1991, we were ready to begin the MEMPHIS Plan when we were told by the state Department of Insurance that the program was illegal! It claimed we were starting a new insurance company and had not met all of the state requirements, which include setting aside adequate financial reserves and guaranteeing chiropractic care.
To counter this objection, the Tennessee Medical Society presented a bill to the state legislature that proposed to exempt the MEMPHIS Plan from such regulation. The day I had to become a lobbyist for this bill was truly one of the worst days of my life. When I introduced myself to legislators as a physician, I was treated like a henchman for Saddam Hussein. Elected officials could scarcely believe the bill furthered no hidden agenda or financial payoff. State legislators seem unaware that most physicians are primarily driven by the desire to provide better health care for their patients.
The good news is that this law passed unanimously. Soon after we began, the state even agreed to indemnify doctors volunteering for the MEMPHIS Plan against malpractice suits. This offered a sense of security to our physicians and helped in recruiting new volunteers. Then suddenly, in early 1997, I was told that the new TennCare regulations had eliminated the plan’s liability protection. No explanation was given. We have never had a malpractice suit. I was told only that the regulations had changed. Through the efforts of several state and local officials, the liability coverage was finally reinstated at the end of 1997. The MEMPHIS Plan has so far cared for 2,000 patients and now has the capacity to grow to cover more than 7,000 lives.
This was not the end of our troubles with the regulatory state. Ever since the Church Health Center opened, we have had a wonderful relationship with Memphis’s city hospital. It has given us $3,000 worth of vital pharmaceuticals such as penicillin and insulin every month. Last Christmas, however, the Med told us that it would no longer be able to supply this medicine, because the federal government had recently begun to aggressively enforce anti-kickback legislation that prevents a hospital from giving doctors a financial incentive to refer patients there. What a Christmas present! Fortunately, William Frist, a physician and a U.S. senator from our state, persuaded the inspector general of the U.S. Department of Health and Human Services to grant us an exemption before our medicine supply was cut off.
The Church Health Center is an example of a program that can make a difference. Recently we hosted a conference at which people from 35 cities came to learn how they could replicate the projects of the Church Health Center in their own communities. We need to recognize and nourish the many creative endeavors going on all over the country. The best ideas may be those we have not yet thought up. To policymakers in the health-care arena, I say: These programs are looking to you simply to pat them on the back, stand aside, and let them work.