Introduction

The Patient Protection and Affordable Care Act (ACA), also known as Obamacare, aims to increase health insurance coverage through government subsidies for individuals earning less than 400% of the Federal Poverty Level (FPL). Through expanded insurance coverage the ACA aims to improve population level health outcomes and reduce inappropriate use of emergency services that place undue financial burden on the healthcare system as a whole [1–4].

The ACA established and subsidized the creation of online insurance marketplaces where individuals and small businesses are able to purchase private insurance plans [5]. A frequently cited barrier to gaining coverage is the enrollment process, which is time-consuming, requires internet access and basic health literacy [6–9]. The New York State Marketplace has an overwhelming 860 available plans from which to choose [5]. Adding to the difficulty of enrollment, the uninsured are less knowledgeable about the ACA than the average American [10].

Under the ACA, states are also incentivized to expand Medicaid since federal spending covers all costs for newly eligible Medicaid recipients up to 2016 [11]. Only 32 States have chosen to expand Medicaid. In New York, Medicaid has been expanded to included legal residents earning up to 138% of the FPL (or $16,394 for an individual in 2016) and provides coverage for approximately a quarter of the state’s population [12]. Still, 63% of eligible adults report that they did not apply for insurance coverage [13].

There are at least 111 medical student-run free clinics (SRFC) in the United States with 37,000 patients seen annually [14]. The majority, 88%, of SRFCs primarily serve uninsured individuals with higher rates of chronic disease, lower physical and mental health functioning, and infrequent contact with primary care providers [15, 16]. SRFCs are an important potential point of entry into the healthcare system for the uninsured [14]. However, not all SRFC offer on-site assistance or have formalized processes for enrolling patients [8, 17].

In addition to New York State’s decision to expand Medicaid, New York City has one of the highest densities of SRFCs in the United States. In this study we describe enrollment processes at SRFCs throughout New York City and to identify barriers to gaining insurance coverage at the Weill Cornell Community Clinic (WCCC), a SRFC in Manhattan. We believe that our experience can guide other SRFCs seeking to adapt to the most significant regulatory overhaul of the American healthcare system in over 50 years.

Methods

Survey of New York City Student-Run Free Clinics

The New York SRFC Conference began in 2013 and is attended annually by representatives of all 13 regional SRFCs. Student board members that attended the September 2015 conference were contacted via email and asked standardized questions regarding the enrollment processes at their respective SRFC. If no response was received at 1 and 2 weeks, follow up emails were sent. Alternative board member emails were used if available.

WCCC Patient Population

WCCC is a SRFC that was founded in 2006 and is located on the Upper East Side of Manhattan. WCCC provides primary care to uninsured individuals over the age of 18. All appointments are scheduled and walk-ins are not accommodated. Our patients are referred from multiple sources, including online searches, Emergency Department visits, and non-governmental organizations. Interpreter services are available to all non-English speakers. WCCC provides follow up to patients until they are transitioned to a primary care provider in the community. We included all 140 patients seen between October 1st, 2013 and October 31st, 2015 in the current study.

Facilitated Enroller Referral Process

WCCC patients are screened by a licensed social worker to determine insurance eligibility, which is based in part on New York residency and citizenship status. Eligible individuals are referred to a Facilitated Enroller at NADAP, a New York-specific nonprofit organization dedicated to streamlining the insurance enrollment process [18]. NADAP provides education on the qualifying plans and assists individuals in completing enrollment paperwork. After submitting an insurance application through NADAP, individuals can access insurance benefits the following month, and individuals that qualify for Medicaid may receive up to 3 months of retroactive coverage. WCCC is the only SRFC in New York that has partnered with NADAP.

Data Collection

The authors performed chart review with pre-specified variables for all WCCC patients seen during the study period (N = 140). Follow-up phone calls were made to individuals with incomplete chart data or those who had failed to gain coverage. Open-ended questions were used to assess barriers to enrollment. A maximum of three phone calls were made before an individual was considered lost. This study is approved by the IRB at the Weill Cornell Medical College and is HIPAA compliant.

Statistical Analysis

Data analysis was performed using SPSS software (IBM Corp. Armonk, NY). Demographic data was analyzed using descriptive statistics. Associations between demographic variables and insurance status were analyzed using Chi square and t tests as applicable. Only p values <0.05 were considered statistically significant.

Results

Student Run Free Clinics in New York City

Table 1 describes the insurance enrollment processes at all SRFCs operating in New York City: Manhattan (N = 9), Brooklyn (N = 1), Bronx (N = 1), Long Island (N = 2). The median age of included SRFCs is 10 years. At all SRFCs, patients are seen by medical students under the direct supervision of a board-certified primary care provider.

Table 1 Insurance enrollment processes at student-run free clinics in New York city
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WCCC Patient Demographics

The median age of WCCC patients was 46 years (interquartile range, IQR: 33–58). The majority were female (66%, N = 92) and lived in 1-person (33%, N = 46) or 2-person households (29%, N = 41) with zero dependents (IQR 0–1). Of our patients, 51% were employed at least part-time. WCCC patients lived in all five boroughs of New York City, with a disproportionate number residing in Manhattan (33%, N = 46) or Queens (30%, N = 42). Four percent were exclusively Spanish speaking, and five percent spoke another non-English primary language. In total, 21% (N = 30) of our new patients were undocumented and therefore ineligible for Federal or New York State insurance plans.

Insurance Enrollment

Figure 1 shows that the majority, 84% (N = 118), of new patients met with our on-site social worker. In total, 22 patients were unable to meet with our social worker due to time constraints. On average, social workers spend 25 min with new patients, and took an additional 30 min to discuss Marketplace insurance options and Medicaid with eligible individuals.

Fig. 1
figure 1

Screening, eligibility and insurance outcomes for new WCCC patients

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Almost half of all eligible WCCC patients gained coverage during the study period (48%, N = 42). NADAP assistance was instrumental in about a third of these cases (N = 13) and 21% successfully utilized another facilitated enroller (N = 9). Only five individuals successfully navigated the Marketplace on their own. Among individuals that gained coverage during the study period, the majority enrolled in Medicaid (N = 27), a Marketplace plan (N = 10), or an employer-based plan (N = 4).

The ACA requires insurers to extend dependent coverage on a family plan until the age of 26 [19]. This provision did not impact any of the patients seen at the WCCC during the study period. In total only three eligible WCCC patients were under 26 years; only one of three gained insurance coverage through a Marketplace plan.

Predictors of Failure to Gain Coverage

Among eligible individuals that failed to gain coverage (N = 46), predictors included living in a household with more than two individuals (p = 0.02). Younger age approached significance as a predictor for remaining uninsured (p = 0.06), while gender (p = 0.89) and employment status (p = 0.73) were not significant.

Barriers to Enrollment

The most common barriers cited by WCCC patients were undocumented immigration status (N = 30), inability to afford health insurance premiums (N = 18) and lack of interest in obtaining coverage (N = 12). Among individuals citing a lack of interest, a subset reported public insurance being against their political beliefs, or satisfaction with accessing SRFCs and emergency rooms as needed. A few individuals were interested in insurance but preferred to wait for the next open enrollment period (N = 3). The two WCCC patients under age 26 who failed to gain coverage cited cost and lack of interest as barriers.

Discussion

Insurance enrollment processes at SRFCs in New York City are mostly ad hoc and outcomes are rarely tracked. Following implementation of the ACA, the WCCC stands out for its structured approach. Approximately half of all eligible individuals seen at WCCC have gained health insurance, with the majority utilizing either the New York State Medicaid expansion incentivized by the ACA (65%) or a Marketplace plan (24%). There are still significant barriers to gaining coverage, but targeted interventions may be effective.

Nationwide, Medicaid accounts for the majority of new enrollments in states that elected to expand the coverage threshold. In non-expansion states, fewer individuals gain health insurance overall and Marketplace plans feature more prominently [20, 21]. In the SRFC setting, meeting with an on-site social worker is a critical first step in determining eligibility and presenting the available insurance options. Our partnership with NADAP, a certified facilitated enroller, enabled our social workers to task-shift paperwork completion so that they could accommodate same day face-to-face meetings with 84% of new patients.

Among eligible individuals, demographic predictors of failure to gain coverage included younger age and household size greater that two individuals. Nationally, many studies have found large gains in enrollment among younger individuals through the dependent provision in the ACA [20, 22]. However, studies have also shown that younger patients feel healthier and are therefore less motivated to apply for Medicaid or pay premiums [23, 24].

Among SRFC patients, the most common self-identified barrier to enrollment is cost [8, 9]. Among individuals that do not qualify financially for Medicaid, there is data to suggest that out-of-pocket costs cause net income to fall below the 138% FPL threshold [25]. It is unclear whether larger households are disproportionately burdened by the cost of covering all members, and further studies are needed [25].

We found a fifth of WCCC patients were precluded from participation in Medicaid and the Marketplace because of their immigration status. Undocumented individuals have limited options for gaining coverage and the majority are predicted to remain uninsured [26]. For this vulnerable group, SRFCs remain one of the few access points into the healthcare system.

In the current political environment it is plausible that the ACA will be repealed, although the details of its replacement remain unclear. Any resulting fluctuations in coverage would inevitably increase the burden on safety-net programs, which include SRFCs. We anticipate that individuals who lose their insurance will turn to SRFCs and clinics with low out-of-pocket costs for non-emergent medical care. In an uncertain legislative future, advocacy for vulnerable and underserved populations is imperative.

In conclusion, SRFCs are an important entry point into the healthcare system and are uniquely positioned to assist patients in obtaining health insurance. In the wake of the ACA, enrollment processes at SRFCs remain undefined [17, 27]. The WCCC has developed a structured and effective enrollment process that may serve as a model for other SRFCs.