“It gets a little crazy around this time,” says Alex Hawkins, a registered nurse, as he calmly uncradles the receiver. At 5pm on Monday, December 29, the clinic is about to open for the night. Hawkins fields calls from Charlottesville’s sick and uninsured, telling them that, unfortunately, tonight’s appointment schedule is booked solid. He adds names to the waiting list, informing callers their only hope of seeing a doctor is another patient’s cancellation.
Riiinnng—someone cancels an appointment, so Hawkins calls one of the 16 patients on Monday’s waiting list with some good news. A flu-stricken woman can see a doctor tonight. “The poor woman sounded terrible,” Hawkins says after hanging up the phone.
As the clock ticks closer to 5:15, the clinic’s official opening time, executive director Erika Viccellio is also scrambling for the phones. Only two of the night’s six scheduled doctors have shown up, and some of the 23 volunteers are also missing. It’s the holidays, Viccellio says, so volunteers are hard to come by. “What am I going to do, scold them?” Viccellio asks. “I’m just thankful they’re here.”
A female patient shows up at the front desk and tells volunteer Tony LeVere, “No hablo Ingles.” Now another volunteer is needed—a Spanish translator.
“We’ve had a significant increase in the number of our Spanish-speaking patients,” says Viccellio. “But finding Spanish speakers to help us translate is really tough.”
Volunteer coordinator Laura Young calls her husband, Ken, who learned Spanish as a child from his Mexican nanny, to come to the clinic and translate. “He’s married to the volunteer coordinator, so he’s always on call,” Young jokes.
This all-hands-on-deck mentality is business as usual at the Charlottesville Free Clinic, which shares offices with the local Virginia Health Department on Rose Hill Drive. On Monday, Tuesday and Thursday nights from 5:15 to 8:30pm, the clinic offers no-cost doctor appointments and free prescriptions for people who’ve fallen through the health care system’s widening gaps.
To qualify for a free clinic visit, patients (or a member of their household) must have a job, but no health insurance. Either their jobs don’t provide medical benefits, or they earn too much to qualify for Medicaid and other indigent care programs, but too little to pay for their own coverage.
Founded in 1992, the Charlottesville Free Clinic was started to save people with minor illnesses and no insurance a trip to the emergency room. In time it has evolved to become the only option for the working poor with chronic illnesses.
“Our motto was ‘Health care for people outside the system,’” says Dr. Mohan Nadkarni, who co-founded the clinic. “What’s happened since then, for better or worse, is that we’ve become part of the system.”
In the early 1990s, Nadkarni and Paul Demarco, both medical residents at UVA at the time, decided they were seeing too many patients ravaged by the later stages of diseases like cancer or diabetes. These people could have been spared a lot of suffering, Nadkarni thought, if they had been able to see a doctor earlier.
The problem was health insurance. Without it, Nadkarni says, people got by without care until they became extremely sick. Then they checked themselves into the emergency room, which by law cannot turn patients away for financial reasons.
The two doctors decided to start a free clinic, and the idea almost immediately became something of a local cause celebre. Nadkarni and Demarco (who now practices in rural South Carolina) met with local lawyer Leigh Middleditch, who helped the doctors assemble an all-star community advisory board with well-connected leaders like minister Rev. Alvin Edwards, Gordon Walker, head of the Jefferson Area Board for Aging, Albemarle County Supervisor David Bowerman and City Sheriff Cornelia Johnson.
When the clinic opened in 1992, it had $75,000. Today, the free clinic’s donor list takes up nine pages in its 2003 annual report and reads like a Who’s Who of Central Virginia. Last year, 42 percent of the clinic’s $483,453 budget came from donations by private individuals. Now, it has about 150 volunteer doctors, nurses, dentists and pharmacists and about 300 lay volunteers. Ten years ago, however, Nadkarni thought the clinic would soon be obsolete.
“The Clinton health care reform plan was being debated. We were hoping there would soon be some form of national health insurance. One of our goals was to be out of business,” Nadkarni says.
Since then, however, the political pendulum has swung away from health care reform. Now the ranks of the uninsured are growing—in more ways than one.
First, the number of people without health insurance is rising. In 2002, the percentage of uninsured Americans rose to 15.2 percent of the population—about 43.6 million people—from 14.6 percent in 2001. The U.S. Census Bureau attributes the decline in coverage to the erosion in private insurance coverage, driven by a weak economy, rising unemployment and increasing health care costs.
The Charlottesville Free Clinic reports that about 1.5 million Virginians—25 percent of the Commonwealth—went without health insurance during all or part of 2002. Virginia attempts to serve its uninsured population through the Federal Medicaid program, which covers about 700,000 low-income people who are elderly, disabled, pregnant or minors, at an annual cost of to the State of $3.75 billion. A program called Family Access to Medical Insurance Security (FAMIS) gives benefits to an additional 50,000 Virginia children.
These programs don’t cover everyone, especially not in Virginia, which spends about $1.5 billion a year less on Medicaid than other states its size. The Commonwealth ranks 43rd among all states in percentage of budget devoted to Medicaid programs.
Given these trends, the Charlottesville Free Clinic has seen the need for its services expand. The clinic booked 3,244 appointments in 2003, up from 2,570 in 2000. Using statistics from the Chamber of Commerce, Viccellio estimates there are between 8,500 and 10,000 people in Charlottesville who qualify for treatment at the free clinic—that is, people who have jobs but do not have health insurance.
“Most of our advertising is word of mouth,” Viccellio says. She says the clinic is working on a plan to recruit more doctors, to be followed by a plan to recruit more patients. “Right now, we’re able to get people an appointment within the week they call, and there’s never a night when we haven’t filled every single appointment,” Viccellio says. “If we get a lot more patients without more doctors, we’d be in a bind.”
When she took the job as executive director in May 2003, Viccellio was a veteran of the nonprofit world but lacked medical experience. She said she was shocked by how many people don’t have access to basic health care.
“It’s great we can be here, but we shouldn’t need to be. It’s sad we’re such a vital part of our health care system,” Viccellio says.
America’s uninsured population is growing in another way—girth. About one in five adults in Virginia is obese—twice as many as 10 years ago, according to the Centers for Disease Control. That number is likely to swell in the near future. Last year, the Virginia Health Department’s Childhood Obesity Task Force estimated that nearly 42 percent of public school third-graders in Charlottesville were either obese or significantly overweight.
The national obesity epidemic has changed the clinic’s mission in recent years, as doctors diagnose more patients with fat-related problems such as diabetes, heart disease, high blood pressure and high cholesterol. These conditions require long-term care and expensive medication that can tax any clinic’s resources. Charlottesville’s clinic is in better shape—in terms of both volunteers and donations—than many of the other 48 free clinics in the State.
“We have two great community hospitals here,” Viccellio says. “That gives us access to doctors that other communities don’t have, and we have a community that is willing to support us.”
Yet the increase in patients with chronic disease is forcing the clinic to make a trade-off, Nadkarni says: “One of our ongoing concerns is how we balance between acute visits and chronic illness.”
Viccellio estimates that between 60 percent and 70 percent of the clinic’s patients require long-term care, mostly for chronic diseases related to obesity. Indeed, on this Monday, 10 of the 31 patients on the schedule need treatment for one of these conditions, and the waiting room looks like a Weight Watchers meeting.
“It’s not even diabetes night,” says Hawkins. Once a month, he says, doctors from UVA’s endocrinology department visit the clinic to meet the growing diabetes demand.
The obesity epidemic also weighs heavily on the clinic’s pharmacy—one of only 17 licensed pharmacies among Virginia free clinics. Pat Tiedeman, a pharmacist who started working at the clinic shortly after its founding, says drugs and equipment like syringes that monitor and treat diabetes can cost thousands of dollars a year, and one diabetes patient can require eight to 10 prescriptions at a time.
While the number of patients at the clinic remains about the same from year to year, the number of appointments has gone up recently, and the number of prescriptions filled has skyrocketed [see chart]. Last year, the pharmacy accounted for about $166,941, or about 38 percent, of the clinic’s expenses.
On this particular evening, the pharmacy opened at 7pm. The demand for free medicine is evidenced by the line stretching from the pharmacy’s counter, through the waiting room and past the front desk. One young woman, who began visiting the clinic last year after she was laid off, is irritated to hear that she would have to wait another 30 minutes for her prescription. She takes the news without argument, unlike another client, who registers her complaint with Young. She manages her discontent.
“When a patient is angry, I can’t say ‘Wait, let me go get someone else,’” says Young. “I’ve been yelled at, almost physically assaulted. I had to get some attitude.”
Even though treating diabetes puts a strain on the clinic, Tiedeman and other volunteers argue that such care is a vital service.
“These people are all around us,” Tiedeman says. “And as a community, we want to help them. If you are a diabetic and you come to us, you get extremely good care. We keep a lot of people out of the hospital.”
As far as David Brinton is concerned, the Charlottesville Free Clinic didn’t keep him out of a hospital, they kept him out of a coffin. “The Free Clinic saved my life,” he says.
The 49-year-old moved to Charlottesville in 2000 after getting laid off from his job in Harrisburg, Pennsylvania. “Downsizing,” he says, with no small trace of bitterness.
On this Monday night, he sits in one of the clinic’s six examination rooms, on a brown patient bed with a yellowed pillow, covered by a strip of tissue paper. The smiling visages of Julia Roberts and Uma Thurman gleam from the magazine covers stacked on a nearby file cabinet. Besides a picture of Monticello, the dominant decor in the room consists of posters warning against sexually transmitted diseases. “First love? Not quite,” cautions one poster depicting a human pyramid that suggests your partner may not be so virginal.
Now Brinton works nights repairing audio-visual equipment for UVA. While his job is a full-time position, it does not include health insurance. If not for the free clinic, he says he probably wouldn’t have seen a doctor for the foot problem that prompted him to visit the clinic three years ago. He’s glad he came.
During the routine screening, a clinic nurse noticed that something was wrong with Brinton’s blood pressure. A doctor sent Brinton to a cardiologist who works for the clinic gratis, and the cardiologist confirmed that one of the valves on his heart had a very bad leak. A year and a half ago, a surgeon replaced Brinton’s faulty valve with a plastic one.
“I remember I was huffing and puffing just climbing a flight of stairs. I figured I was out of shape. I smoked. I was overweight. I never thought there would be something wrong with my heart,” he says.
Without the Charlottesville Free Clinic, Brinton says he could not have afforded the medical treatment. Even now, he is making monthly payments on $5,000 for other doctor bills.
Now Brinton is one of the clinic’s chronic patients, making appointments about every two months so the doctors can monitor his blood. On Monday, he tells Dr. Bob Kayser that when he eats pancakes for breakfast, he feels weak and shaky a few hours later. Kayser recommends Brinton try eating the pancakes without syrup, to see if that makes a difference.
“My first 49 years haven’t been too bad,” Brinton says. “I’d like to be around for another 40 or 50, now that I’ve got me a good woman.”
By about 8pm on Monday night, the clinic is winding down. Melissa Weimer, stethoscope slung around her neck, slumps in a plastic chair near a table of fried chicken, green beans and potato salad donated by Wayside Takeout & Catering, which, like other local restaurants, provides free food for clinic volunteers. Many volunteers leave day jobs to start work when the clinic opens at 5pm and don’t leave until 9pm.
Dr. Nadkarni still extends his workday by volunteering. After a day at UVA’s Medical Center navigating the bureaucratic byways of insurance companies, he says working at the clinic can actually be relaxing.
“It’s very refreshing. There’s much less paperwork, we’re not dealing with billing and insurance,” Nadkarni says. “The patients are very grateful. It feels like you’re providing a valuable service without all the red tape. It gets back to the reason we all got into medicine in the first place.”
This sense of purpose drives the 24-year-old Weimer, who now studies osteopathic medicine in Blacksburg, to return to the clinic as a volunteer when she’s home from school on Christmas break. She graduated from UVA in 2001 and for two years worked as the clinic’s patient-care coordinator, as well as in the pharmacy.
“I volunteer to feel like I have a purpose. In medical school you tend to lose that,” she says. “At the clinic you get to develop the relationship part of medicine, which is mostly what being a doctor is all about.”
Not all volunteers have a career in medicine, however.
“It’s interesting to meet the people,” says Dan Devereux, a philosophy professor at UVA. One of his favorite jobs, he says, is conducting the exit interviews to get feedback from patients after their clinic appointment.
“You find out how diverse the population is around here. I’ve interviewed patients from Tibet, Russia, Afghanistan and from countries in Africa. We get a lot of waiters and waitresses, and people who do artistic things,” says Devereux.
The interviews mean the free clinic has comprehensive statistics on its patients. More than 40 percent of the patients are between ages 41 and 64. Most are white, and 60 percent are women. About 80 percent live in Charlottesville and Albemarle. More than 70 percent have only a high school diploma, 66 percent are employed full time and about 25 percent say that without the free clinic, they wouldn’t have seen a doctor at all.
Like many of the other volunteers, Weimer speaks with conviction that quality health care is a right, not a luxury. She says the volunteering gave her the chance to see behind the science of medicine to the social impact of health care policy. Weimer says she has seen how cycles of poverty contribute to chronic health problems, ensuring that, despite its goal of going out of business, the Charlottesville Free Clinic will remain a key part of local medicine.
“It’s not just that people don’t have health insurance,” Weimer says. “They don’t have transportation to get to the clinic, they don’t have child care, they don’t have a safe place to come home to. They may not even know what it’s like to lead a healthy lifestyle.”