Where are the Free Clinics in Rural America?

Purpose: The Affordable Care Act (ACA) seeks to reduce the uninsured population through Medicaid expansion and health insurance exchanges. Gaps in ACA implementation, coupled with the concentration of rural populations in non-expansion states, suggest that free clinics may be particularly important to rural residents.

Methods: We used the National Association of Free and Charitable Clinics (NAFC) clinic locator to identify the address of each participating free clinics across the U.S. Of 779 clinic addresses, 759 were complete enough to map to a county. Rurality was measured at the county level.  Qualitative information from a telephone survey of 15 of 25 free clinic associations was used in assessing the impact of geographic findings.

Results: Overall, 21% of free clinics were located in rural areas, however, these were concentrated is selected states.  Fifteen states had no free clinics located in rural counties; an additional 10 states had only one rural clinic. The majority of clinics (52%) were in states that have not expanded Medicaid; however, the majority of these clinics (81%) were in urban areas.  

Conclusion: The rural safety net has proportionately fewer free clinics than urban communities, despite higher proportions of uninsured residents. With many states not participating in Medicaid expansion, free clinics will remain an important source of care for uninsured individuals.  Facilitating relationships between state offices of rural health and state free clinic associations may help rural systems adapt to the changes resulting from the implementation of ACA.