The prime cynic, la Rochefoucauld, maintained that the prime spur to charity was self-interest. (A famous maxim: "The virtues join with self-interest as the rivers join with the sea.") He had a point. Corporate philanthropy (an oxymoron) pays – or it wouldn’t happen. In this age of Enron, accountants weigh the comparative gains: Should we sponsor a museum exhibit? scholarships? a hospital wing? Whatever the MasterCard commercials say, corporate good will is not priceless: it can buy inclusion on a "socially conscious" investment list, or tolerance for egregious acts. Individual philanthropy also has a whiff of self-interest: People on top of the totem pole generally get palpable satisfaction from helping people stuck on lower rungs. Visit a soup kitchen to see smiling volunteers doling out food to unsmiling diners. In a truly just world, the totem pole would not be so elongated – a truth known to those on the bottom as well as those on the top.
Yet without good works — corporate and personal — the American landscape would be bleaker. Libraries, museums, universities, hospitals, social service agencies – all depend on the kindness (however self-interested) of strangers.
So we should welcome the new kid on the health care block – clinics for the uninsured, built upon volunteer labor, donated services, and philanthropic dollars. The Rhode Island Free Clinic, newly licensed, is open for business in Providence. Stephanie Danforth Chafee chairs the board. This clinic joins dozens like it – the brainchild of philanthropists married to volunteers – the kind of brainchild deTocqueville lauded in the 19th Century.
These clinics fill a gaping vacuum – one that government has not rushed to fill. Medicare, Medicaid, state insurance programs for children, special subsidies for people with special diseases – the government has helped pockets among the uninsured. The remainder – more than 40 million Americans – must fend for themselves.
Private HMOs, particularly for-profit ones, are not in the business of charity. Although many enroll Medicaid patients, they close their doors to people who cannot pay.
Nonprofit neighborhood clinics and hospital outpatient departments serve the uninsured reluctantly. In the pre-managed care past, the poor, who had "fee-for-service." Medicaid, generated enough of a cushion for those clinics to serve everybody who walked through the door, even those without insurance. Today the clinics confront, on the one hand, more uninsured patients, and, on the other hand, lower Medicaid revenues. (Governors have controlled spending by cutting the "fat" from Medicaid, which meant cutting the "fat" from hospitals and clinics.) While nonprofit clinics accept the uninsured, they risk insolvency when they do it too zealously.
So adults who are working, earning enough to pay the rent and buy groceries, navigate between Scylla and Charybdis. If they have a chronic disease, like asthma, diabetes, or arthritis, they need health care. If they buy that care, they won’t be able to pay the rent. But if they neglect their health, they will be too sick to work – and won’t be able to pay for rent and groceries.
The clinics help them.
All the clinics rely on volunteer physicians, nurses, nurse-practitioners, and dentists (some clinics offer dental care). Although a clinic with a large caseload may pay the salary of a physician-director (as in Chester, Pennsylvania), most clinicians donate their time.
Many clinics receive a subsidy (services, staff, and/or money) from local hospitals. That hospital linkage insures continuity of care. In Rhode Island, Rhode Island Hospital does preliminary diagnostic work; and Women & Infants runs a monthly women’s health clinic. Lifespan pays for the clinic’s administrator and nurse practitioner. Hospitals of course gain (the Paoli, Pennsylvania, hospital helped start the Chester clinic to reduce unnecessary emergency room admissions). But it is also possible that hospitals are harking back to their long-ago mission-driven past, when all were non-profit, and all professed to serve their communities, not their shareholders.
Some clinics receive state or local funds. The State of Vermont, for instance, contributes toward a network of free clinics. A local public health department may contribute. Again, public health departments may be going back to the future, when public health departments ran free clinics.
Philanthropy, however, deserves a mega-bow. Foundations and wealthy donors undergird these clinics. The four year-old Chester clinic had an operating budget of $350,000 in 1999, a $900,000 budget in 2001 – money that came from donations. Without that generosity, the clinics would not happen.
Admittedly, the clinics are not a solution. Most are open only a few days a week, with limited (if any) specialty services. Few have 24-hour on-call staff. Some act primarily as referral stations, helping patients get onto established insurance programs.
To a cynic, the clinics mark the failure of American health care policy: In a perfectly just world, every person would have insurance. But in an avowedly imperfect world, these clinics testify to the imaginative responsiveness – and generosity – of philanthropists. The spirit that amazed de Tocqueville persists.
