Describe rationale for free care in Providence Rhode Island, the mission and aims of the Clinica Esperanza / Hope Clinic, the current patient demographics, and plans for the future.

1. Building “A Place to be Healthy”Clínica Esperanza/Hope Clinic (CEHC): A new Free Clinic for the Medically Uninsured of RI A presentation compiled by: Rachel Simon, Rebecca Gerber, Craig O’Conner, Annie De Groot, MD Clinica Esperanza / Hope Clinic Volunteers

2. A True Story One of our patients: Eduardo is a baker who had/has no health insurance. He recently sustained a relatively serious heart attack that he managed at home despite having classic symptoms of angina on multiple occasions. When asked why he did not seek emergency care, he said that it took him a long time to pay his last hospital bill ($700) for a mere thirty minute visit at the emergency. He did not want to incur any further expense. Instead of going to the ER while he was having his heart attack, he elected to stay home, taking aspirin for his chest pain to avoid incurring any debt. This is one variation on a story we have heard many, many times.

3. Growing Need

4. How many uninsured? The medically uninsured of Rhode Island (RI): 120,000 uninsured < 65yo in 2005 Near doubling in % of adults < 65yo who are uninsured* Continued trend -> 19.5% or 1/5 people by 2010 One of the 1o reasons for the increase is erosion in employer-based insurance coverage * ↑ from 7% (2000) to 13% (2005)

5. Growth in Uninsured in RI according to 2010 study The number of uninsured Rhode Islanders is projected to increase to more than 15% of under-65 population in 2010. Thousands % of Population 7.2% 8.4% 8.6% 10.8% 11.3% 11.7% 13.0% 9.8% 12.1% 13.5% 15.7% Source: Historical data from U.S. Census Bureau Current Population Survey (CPS) and Mathematica Policy Research projection to 2010. Notes: Mathematica projection is based on analysis of Medical Expenditure Panel Survey (MEPS) data benchmarked to the RI population. Historically, MEPS estimates of the uninsured have tracked national CPS estimates closely. (Mathematica Policy Research team, March 2010). 5

6. Why is Free Care More Important Than Before? Adults formerly on Rite Care will be OFF within the next 6-9 months. From 2011 until Jan 1 2014, adults making more than 133% than FPL will most likely be uninsured. Thus the number of uninsured will increase by 6 to 10% until “the exchange” kicks in. Hence, free clinics are more needed than ever.

7. Health Care Access Problem: Disproportionate effect on Poor Lack of insurance increases vulnerability to The impact of lack of health insurance is significant. A recent paper published in the American Journal of Public Health found that uninsurance is associated with mortality (AJPH 2009;99). Nationally, compared with Whites, more Hispanic and Black individuals report issues associated with affording and accessing health coverage and care. Nearly 4 in 10 Hispanics (38%) report having trouble paying for health coverage or health care as a result of the economic downturn. One in four Blacks (25%), one in five Hispanics (21%), and about one in ten Whites (13%) have lost health coverage as a result of the economic downturn. And finally, a higher percentage of Hispanics and Blacks than Whites report postponing or skipping health care due to cost. About 1 in 2 Hispanics report relying on home remedies instead of seeking care (53%) or report forgoing dental care due to cost in the past year (48%) compared to 1 in 3 Whites (32% and 33% respectively). (KFF: The Effects of the Economic Recession on Communities of Color).

8. Effects Lack of insurance increases vulnerability to poor health outcomes. According to a survey of uninsured adults performed by the RI Department of Health, uninsured Rhode Islanders are less likely to have routine health screens and more likely to participate in unhealthy behaviors. Adults with household incomes below 200% of the federal poverty level have higher rates than households above this level for 11 of the 15 health risks that were evaluated in this survey (vaccinations, risk behaviors, health screens). A greater percentage of these lower income adults were uninsured (20% vs. 5%), had no regular health provider (26% vs. 10%), and had never had their cholesterol checked (27% vs.12%) than the insured.

9. Who pays for uninsured care? Looking only at the costs of uninsured Rhode Islanders while they are uninsured, we can identify who pays. The federal government pays most of the cost of care for the uninsured – ~$100 Million. Patients themselves pay the next largest share, in out of pocket expenses of $76 Million. $Million $350 $300 $256m $76m $250 Patients $60m $200 Private Physicians $19m Direct Care $150 $101m $100 Hospitals $50 $ - Total Federal State/Local Private Out of Pocket paid by other sources paid by patient * Note: Federal, state/local, and private estimates on this page are derived from administrative data. They exceed population-based estimates by approximately $10 million and may include some expenditures for Rhode Islanders over age 65. Out of pocket estimates are population-based. 9

10. Myths Dispelling the myths: MYTH: People without health coverage don't work. FACT: Eight out of 10 people who are uninsured are in working families. MYTH: Most people without health insurance are poor. FACT: In 2005, more than 32 million of the uninsured had household incomes of $25,000 or more, compared with 14.6 million in households earning less. (The federal poverty level for a family of four in 2005 was $19,350.) MYTH: Virtually everyone who works for a large employer has health coverage. FACT: In 2005, 23.1 percent of the nation's uninsured workers age 18–64 were in firms employing more than 500 people. http://covertheuninsured.org/events/index.php?StateID=RI&CityID=Providence

11. Working Poor The working poor: Erosion in RI employer-based coverage due to changes in eligibility RI vs. Massachusetts and USA, lower % of workers eligible for employer-based coverage Disproportionately low-income, childless, self-employed 92% ↑ in the uninsured = low-incomes 300% below federal poverty level (FPL) Includes immigrants, asylum-seekers, and refugees

12. Children The children of RI: In 2005, 6.8% are uninsured (↑ from 5.8% in 2004), approx. 19,000 children Numbers due to increase (see below) Revised S-CHIP: started October 1 - Eligibility requirements set at 250% FPL - $42 million shortfall in budget - New: Non-citizen/documented children excluded www.rikidscount.org, 3 year averages of CPS data, 2002-2004 compared to 2003-2005

13. What are the costs of providing health care to the uninsured? Hospitals and physicians shoulder the financial burden for the uninsured by incurring billions of dollars in bad debt or "uncompensated care" each year. Fifty-five percent of emergency care goes uncompensated, according to the Centers for Medicare & Medicaid Services The amount of uncompensated care delivered by nonfederal community hospitals grew from 6.1 billion in 1983 to 40.7 billion in 2004, according to a 2004 report from the Kaiser Commission on Medicaid and the Uninsured.

14. Mission Statement Clínica Esperanza/Hope Clinic (CEHC) Mission: Offer high quality primary medical care to RI-ers without health insurance Emphasize linguistically-competent, culturally-attuned care Focus on prevention and health maintenance Run by highly qualified health providers and community representatives Supported by an all-volunteer staff Welcomes bright ideas from volunteers and patients

15. Accomplishments Evaluated the need for primary care for uninsured Defined population Identified space for clinic Established infrastructure Established policies and procedures Ran temporary clinics (ACOS, OTC, IglesiaEsp) Recently moved our operation to 60 Valley Street Opened at new location November 2010.

16. Approach Literature Review - National and state need - Setup of other free clinics - Patient entry criteria Meetings with core working group Site visit meetings - Community members - Governmental representatives Delegation of tasks and setup of committees Contact with prospective and dedicated volunteers Identification of in-kind donors

17. Demographics RI uninsured adults and children: Includes working poor and undocumented adults and children of Olneyville and Washington Park Olneyville Washington Park www.provplan.org

18. Olneyville

19. Washington Park

20. Buildout Plan

22. Board established

24. Clinica Esperanza Patient Profile: Visits Income Race / Ethnicity Gender City Distribution

25. Total Unique Visits / Quarter Number of unique visits expected to reach 1,000 by Jan 2010

26. Results Patients Provided Care 2009-present Based on data collected so far, 58% of our patients are Spanish speaking/ Latino, and most (85%) live well below the poverty line (make < $15,000 per year).

27. Income Majority of CEHC patients make less than $15k per year

28. Race / Ethnicity Majority of CEHC Patients are Latino

29. Gender Slight Majority of CEHC Patients are Women

30. CityDistribution Almost all CEHC Patients are from Providence

31. A Unique Outreach Program CEHC Navegantes Provide Access to Care

33. Lesson 2 – All different kinds of people need help with their health care.

35. Information about Diabetes through teaching Diabetes Workshops

36. Free Blood Glucose Tests

37. Infectious Disease ScreeningsTarget Population Spanish-Speaking and minority CEHC clients are the target population for “Vida Sana” Navegantes Program. Based on demographic data collected thus far, our patients are Spanish speaking Latino (58%), overwhelmingly living below the poverty line (85% make less than $15,000 per year) and from Providence (77%). Our patients come from all walks of life - homeless, construction workers, factory workers, mothers, and artists. Many of the patients recently lost their health insurance due to the current recession.

38. The Navegantes Under guidance from the Access Coordinator, the Navegantes/Navigators plan, organize and implement church-based community health fairs and advocate for members of their community. Navegantes/Navigators will meet with community members and help them navigate the system to obtain preventative services, chronic disease management, support for medication adherence, health care access, and other essential health information. The proposed program, Vida Sana, has trained and deployed fiveNavegantes health access coordinators. These residents of Providence communities, received intensive training sessions (over four weeks) to become competent referral sources, organizers and community educators.

39. The Navegantes The Navegantes/Navigators will plan, organize and implement church-based community health fairs and advocate for members of their community. Navegantes will meet with community members and help them navigate the system to obtain preventative services, chronic disease management, support for medication adherence, health care access, and other essential health information. The Navegantes have also helped patients complete surveys that we will use to learn more about the CEHC patients.

40. The Survey The Navegantes performed a “street survey” to assess the need for the CEHC. 100 persons are being interviewed by the Navegantes. All gave their consent. The interview report is anonymous. Preliminary results are reported here. N=87

41. Olneyville Population Breakdown (N = 5,138)

46. Summary The CEHC: Is developed by a highly motivated group of volunteer medical professionals and community members Will serve the uninsured, including the working poor and children of Olneyville and Washington Park The need to provide a new medical home for Free Care is evident by the devastating and growing number of medically uninsured Rhode Island residents. Current statistics likely grossly underestimate the number of medically uninsured RI adults and children.

47. Unique Programs Medical Home for the uninsured One patient, one provider Linguistically appropriate, culturally attuned care Navegantes (Community Outreach) Program - Street outreach - Church/CBO outreach - Assistance with health care access Predominantly Volunteer - Including Administrative, Provider, IT

48. Other Aspects Sustainability - 501c3 status - Compensatory growth of volunteer base - Community involvement: Board, committees Quality Control - Appropriate management and follow-up Fundraising - Leasing, operational costs, furnishing

49. References ClínicaEsperanza/Hope Clinic Mission Statement National Association of Free Clinics, 2006 The Poverty Institute, “Rhode Island Will Have Insufficient Federal SCHIP Funding in 2007 Congress Must Act Now to Avert the SCHIP Funding Shortfall”, September 10, 2007 www.covertheuninsured.org www.dbr.state.ri.us/documents/divisions/healthinsurance/070910%20Final%20Uninsured%20Report.pdf www.freeclinics.us www.rikidscount.org www.provplan.org

50. Conclusion Eduardo will have “a place to be healthy” instead of having to go to the ER for care. Our motto: Healthy people, healthy families, healthy neighborhoods.

51. Acknowledgements CEHC wishes to thank the City of Providence for support, and to acknowledge the following inspiring, dedicated individuals: Ethan Colaiace, Tom Deller, Bill Struever, the SBER team, Pastor Duane Clinker, Chris Camillo of PNHC and ONHC, Gloria Rose, Pastor Israel Mercedes, Paul Fitzgerald and ACOS, Blue Cross Blue Shield RI,BankRI, Ninedot, Tom Lopatsky Painters, Computer Telephone (wiring), SBER (furniture), Mauricio Barreto our Architect, our Navegantes, and our wonderful Board and Volunteers.