Introduction

Free clinics provide care to the uninsured, to the working poor and to many others. Despite the tight budgets and understaffing seen at most free clinics across the country, many continue to operate. This study demonstrates that there is a need for free clinics in the United States, a need from both the patient perspective as well as from a national, systems-level perspective. Additionally, with health care reform just around the corner, the role of free clinics will almost surely be changing in the next decade. This study documents the current role free clinics are playing in today’s health care system so that we may trace the evolution of that role in the coming years.

During the past several decades, free clinics have served a variety of populations [1]. Since the 1970s, there has been a dramatic increase in free clinics due to the rising numbers of uninsured and underinsured [2–6]. In 1980 the number of people without insurance was 30 million; that number has risen in the past 25 years by 50% and now hovers around 45 million. These numbers are even higher in minority and lower socioeconomic populations [7–9]. Free clinics face many challenges, including operating on shoestring budgets, a constant need for grant support, and continual reliance on their local communities. Yet, despite these challenges, many continue to operate efficiently while still providing high-quality care [10].

In the last two decades, a number of published studies and reports have focused on free clinics in specific regions of the country, single states, and two on the nation as a whole. Directors of the free clinics, providers at free clinics as well as other free clinic staff, have additionally frequently written descriptions of individual free clinics and their operations [10–48]. The descriptions of individual clinics vary widely in terms of locations, staff, and services offered, but many report having one ore more of the following characteristics: (1) Most tend to target particular populations, such as the uninsured, working-class poor, immigrants, or homeless; (2) Many serve indigent populations and minority groups; (3) Many offer primary, urgent, or acute care; (4) Most provide prescription drugs; (5) Many offer additional services such as dental, addiction treatment, obstetrics and gynecology, and mental health services; (6) Many are associated with other community organizations; (7) Many are open only a few days per week; and (8) Most offer at least some sort of preventive services such as screenings and counseling [10–48]. There is a large body of health utilization research among underserved populations [29, 49–56] but little focused specifically on free clinics at a national level.

The specific aims of the current research were to identify difference among types of free clinics in the US; to identify which services were commonly used; and to determine where else patients would seek care if not at the free clinics.

Methods

Study Design

This study employed a cross-sectional survey design. Two distinct surveys were conducted of a convenience sample of both free clinic directors (for the provider survey) and patients (for the patient survey).

Nationally, 1,141 free clinics were identified; of these, e-mail addresses for 465 were found. Of those, 368 were functional. From the 368 emails sent, 172 providers participated in the online survey of providers. A second distinct, paper survey was sent to all of these clinics to be handed out to patients. Ten paper surveys were sent to each clinic Forty-one free clinics returned some or all of the paper surveys. In all, 362 surveys were received that were completed by patients. Patient surveys were sent via priority mail and clinics were provided with return priority mail packaging. All clinics that returned any of the 10 surveys were sent a check for $25 as a donation to their free clinic. A study flowchart can be seen in Fig. 1.

Fig. 1
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Study flow chart

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To be eligible to complete the provider survey, subjects were required to meet the following inclusion criteria: 18 years or older and a health care provider at a free medical clinic in the US. Directors of the free clinics were encouraged to fill out the survey themselves, but proxies for the director were also acceptable respondents. People unable to understand written English were excluded. To be eligible to complete the patient surveys, patients had to be 18 years or older; however, if a patient was younger than 18 but with his/her parent or guardian, the parent or guardian was allowed to fill out the survey on behalf of the child.

Survey Development

The majority of the questions used in the surveys were revised versions of questions used in the health service utilization survey developed by Aday et al. [49, 50]. Building on findings from Aday et al., we hypothesized that health service utilization would be influenced by different factors at free medical clinics, in a similar manner to that of other health care settings. Characteristics investigated such as environmental related stressors, health stressors, and characteristics of the clinics themselves, have been identified as factors that determine utilization in hospitals and community settings [49–55].

Cognitive testing of questionnaires was performed using 10 patients and 10 providers in order to ensure readability and understanding of the questionnaire and to ensure that participants would have a common understanding of the meaning of questions. Eligibility criteria for participation in the cognitive testing were described above.

Analysis

JMP version 7.0 [57] was used to analyze patient and provider characteristics. For observational data reporting, missing data in each category listed was less than 10% and therefore excluded from the tables and observational analyses. Contingency tables were created for each variable of interest. Each variable identified was analyzed to look for difference in demographic information, clinic characteristics, structural information, and service question responses. Pearson chi-squared tests determined significant difference in the observational data and two tailed Fisher-exact t-tests determined significance in the association data analysis.

Results

Clinic Characteristics and Provider Responses

The provider survey results (which can be seen in Table 1) demonstrated similar findings (for those measures that were comparable between studies) to the only other nation-wide study published by Nadkarni et al. utilizing the Free Clinic Foundation Database. In the Nadkarni study, only providers were surveyed and it is unclear whether there was a substantial number of student-run clinics included [12]. The patient demographics seen in both studies reflect demographics of the uninsured population in the US. In both studies, free clinics reported between 4,000 and 6,000 mean patient visits per year, a mean annual budget between $4,40,000 and $4,60,000, 156.7 volunteers on average, 6.9–7.5 paid staff, and a majority of free clinics located in the South. Most clinics reported a target population of the uninsured, seeing a majority of female, adult, non-Hispanic, Caucasian, adult patients [14].

Table 1 Provider responses: characteristics of responding free clinics
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Results from the student run clinic group were also comparable to the only other published nation-wide study of student-run clinics, conducted by Simpson and Long in 2007 [58] In Simpson and Long’s study, 59 clinics reported a total of 36,000 annual patient visits (610.2 per clinic), while in this study 39 student-run clinics reported a total of 21,386 annual patient visits (548.4 per clinic). Simpson and Long reported that student-run clinics saw mostly minority patients: 31% Hispanic, 31% African American, 25% non-Hispanic White, and 13% other, while in this study student-run clinics reported seeing on average 5.5% African American, 25% non-Hispanic White, 53% Hispanic, and 17% other. In their study, most clinics were funded by private grants (71%) with a median annual operating budget of $12,000, while in this study the main source of funding listed by student-run clinics was foundations (59%) followed by grants (22%), and the median annual budget was $10,000 [58].

Table 2 describes clinic characteristics by clinic type. On average, clinics reported being open 4.04 half days per week (median 2, SD 3.6), with independent free clinics open most (5.6 half days per week, on average) and student-run free clinics least (1.2 half days per week, on average). Clinics reported a mean of 7.5 (median 3, SD 16.9) paid employees (most in church-run free clinics, 12.9 on average; least in student-run free clinics, 1.0 on average) and a mean of 156.7 (median 84.5, SD 235.5) volunteers (most in Other free clinics, 224.9; least in church-run free clinics, 76.6). The mean clinic age was 13.3 years (median 10, SD 11.3). Clinics reported having on average an annual budget of $447,730 (median $150,000.00, SD $1,148,812.00). Largest budgets were for independent free clinics ($654,292.90), smallest for student-run free clinics ($34,300.00). The mean annual number of patient visits was 4,310.15 (median 1,741, SD 8,312.6). Independent free clinics saw the most patients annually (6,412), Student-run free clinics the least (548). The mean number of new patients annually was 797.6 (median 410.5, SD 1,105.9). The mean number of established patients returning on a weekly basis was 68.9 (median 23.5, SD 159.2). Other free clinics demonstrated the greatest degree of continuity (129 weekly returning patients). The mean number of patients turned away each week was 7.8 (median 2, SD 12.3). Church free clinics turned the most patients away per week (13.0), student-run free clinics the least (5.7). The mean reported proportion of patients without insurance was 87.3% (Median 95%, SD 19.4%).

Table 2 Provider responses: difference in free clinic characteristics among different types of free clinics as well as totals
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Patients’ Characteristics and Responses

The patient survey results demonstrated that most patients reported being between the ages of 18–64, speaking mostly English or English plus another language, and nearly all patients made less than $41,600 per year. Although no participants were under the age of 18, a small group of parents filled out surveys on behalf of a child who was the free clinic patient attending. The majority of patients had a high school diploma/GED or less education. Most patients said they were working or enrolled as a student. Overall, 6.1% identified their sexual orientation as lesbian/gay/bisexual/transgender (LGBT).

Table 3 also demonstrates patterns of patient characteristics by free clinic type. Most patient responses came from independent free clinics (70.2%) with nearly equal numbers from church (12.7%) and student-run free clinics (11.9%). There were significant differences among patients seen in free clinics by region, race, language, and age group; no significant differences were seen in gender, income, education, employment, or sexual orientation.

Table 3 Patient responses: difference in patient demographics among different types of free clinics as well as totals
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Table 4 shows that a majority of free clinic patients reported using the emergency room at least once in the past year (51.2%), while 32.6% of patients reported using a community hospital, 29.1% reported using a public hospital, and 28.2% reported using another free clinic. Nearly one-quarter of patients (23.9%) said they would not seek care if the free clinic did not exist, with the most frequent reason being cost (20.7%). Among patients reporting on where they would seek care if the free clinic did not exist, most said they would seek care at another free clinic (47.0%), followed by the emergency room (22.7%) and a public hospital (15.2%). Their usual place of care for patients prior to the free clinic was most often private practice (32.6%), followed by the emergency room (26.2%) and a public hospital (13.3%).

Table 4 Patient responses: services that patients reported using as alternatives to their free clinic, differences among different types of free clinics as well as totals
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Of patients reporting on satisfaction with their current free clinic, the majority in all categories reported being satisfied with the care they received in their current free clinic (97%). The majority of patients reported that the care they received at the free clinic was better than the care they received at their prior health care provider (77.3%). Ninety-five point three percent said they were likely to use their free clinic again, and 66.1% said they were likely to use any free clinic again. Significant differences were noted only in the LGBT/other versus heterosexual variable (88.2% of LGBT vs. 97.4% of heterosexual patients reported being satisfied; Pearson test P = .0358, two tailed Fisher’s exact t-test P = .0936). This observation is in accord with data from other health care settings, which often shows that the LGBT population is in general less satisfied with their health care services than the heterosexual population [53].

Analyses were conducted regarding four types of health care services: primary care, women’s health care, psychiatric and counseling care, and pharmacy services. Table 5 describes these results. Most patients reported using primary care (86.0%) and pharmacy services (79.9%) at the free clinic, while 33.5% reported using women’s health services, and 22.6% reported using psychiatric or counseling services.

Table 5 Patient responses: services patients reported using at their free clinics and their associations with patient demographics and satisfaction
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Discussion

Interpretation

The most meaningful findings from this study concern the high percentage of patients utilizing free clinics as primary care providers and for routine women’s health services. Patients report a very high degree of satisfaction with these services, to the point that they would first choose to attend another free clinic if their current free clinic were to closed (47%), followed by care seeking at emergency rooms (22.6%), and public hospitals (15.2%). Patients also report greater satisfaction with their care at free clinics than with care in other health care settings, and a high degree of intent to continue pursuing care at their present free clinic. This is particularly true for those patients receiving primary care, women’s health care, and pharmacy services. While it is difficult to estimate the cost savings resulting from free clinic care, 76.1% of patients report they would seek care elsewhere if the free clinic were not available. More than half of free clinic users had also used the emergency room during the past year, with about one-third also using community hospitals and another third using public hospitals.

This study identifies meaningful differences between various types of free clinics that have not been previously examined. The majority of clinics are located in the South. Independent free clinics are distinct from student and run free clinics church based free clinics, and other types of free clinics in a number of ways. They are usually larger and better staffed, and have larger budgets. Church-run and student-run clinics are generally much smaller, with fewer staff, and are open fewer days per week. Another large difference is that while overall clinics reported seeing a majority of non-Hispanic White patients, student-run free clinics reported more than a third of their patients to be Hispanic. Church-run clinics reported having been open for the longest amount of time, yet were less likely than other types of clinics to offer primary care, and the least likely to require appointments ahead of time. Student-run free clinics were evenly distributed throughout the country, most likely reflecting the distribution of medical schools rather than areas with greater need for a free clinic.

Conclusions

Free clinics constitute a large part of the current health care safety net with over 1,000 identified in the US each with an average of over 4,000 patient visits per year and almost 800 new patients per year. Free clinics are a medical home for many patients in the US, especially for the underserved, uninsured, and working poor. Though some may not always be fully equipped, often offering fewer services than a large community hospital or private practice, many free clinics are large-scale operations offering more than the average private practice group or community hospital. By decreasing the number of patients who might otherwise be using the emergency rooms as their only source of primary health care, free clinics are saving hospitals huge amounts of money that may otherwise be spent on unnecessary emergency room visits. For-profit hospitals and private practices (apart from emergency room services) also benefit from their services as free clinics care for patients who might otherwise end up as patients unable to pay for care at these hospitals and clinics. Whatever the size of the free clinic, it is clear that they are providing an important service to both the individuals they serve as well as the US health care system.

Free clinics provide primary care to a substantial number of uninsured and working poor. They provide an alternative to patients who might otherwise seek primary care in the emergency room. Even with reform of the national health care system, free clinics will provide primary care to millions of uninsured. How they will adapt to provide this care is yet to be seen.