How are free and charitable clinics faring under the Affordable Care Act? Results from a national survey

Little is known about how free and charitable clinics are faring after the Affordable Care Act (ACA). Free and charitable clinics, volunteer-led nonprofits that deliver healthcare services to uninsured, low-income individuals at little or no cost, are estimated to serve 2 million patients and provide 3.5 million medical and dental visits annually. METHODS: AmeriCares, a global health nonprofit, conducted a web-based survey of its free and charitable partners in October-November 2014. It obtained information about how implementation of the ACA impacted clinics’ funding levels, fundraising, and amount of in-kind support as well as changes clinics have made to operations. RESULTS: Of the 355 eligible clinics, 156 responded (43.9%), but we detected no statistically significant differences between respondents and nonrespondents. While AmeriCares partners represent a relatively small slice of the overall free/charitable clinic sector, the responding clinics provide an early and important glimpse into how the ACA has affected the sector. The findings suggest that neither the impact nor the response is uniform across the country, but depends significantly on whether a clinic is located in a Medicaid expansion state. Nearly 60% of clinics in Medicaid expansion states reported that the ACA has made it harder to raise money (vs. 42% in nonexpansion states, p<.01). Twice as many clinics in expansion states reported that in-kind care has decreased (38% vs. 20%, p<.05). On average, clinics reported a 21.7% funding decrease. Nearly half of clinics in Medicaid expansion states reported decreases in the number of patients compared with 22% of clinics in non-expansion states (p<.01). Patient visits follows a similar trend, with 48% of clinics in expansion states reporting decreases (vs. 25%, p<.05). We also identified differences in organizational decision making. Clinics in expansion states were 3.5 times more likely to report having made a change in their delivery model (38.7% vs. 11%, p<.001); three times more likely to report a change in their clinic flow (50.8% vs. 17.4%, p<.001); more than twice as likely to report a change affecting technology integration (38.3% vs. 18.7%, p<.05); and twice as likely to report considering/having started/planning to start billing Medicaid (31.8% vs. 15.2%, p<.05). CONCLUSIONS: Clinics in expansion states are experiencing greater resource challenges than clinics in nonexpansion states, although all clinics are coping with decreased resources. The higher levels of operational changes among clinics in expansion states may be due to greater environmental uncertainty arising from more of the low-income population obtaining insurance.