What do you do when something everyone needs is so expensive, so out of reach for many people, that you have to deny it to some of the poorest, sickest and most desperate?
For Lisa Smolski, Judith Koegler, and their colleagues at the Rhode Island Free Clinic, that’s not a theoretical question – it’s a daily dilemma. They have a tiny space, limited hours and a commitment to their existing patients. Yet the demand for their services seems endless.
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It’s simple math: 1,500 registered patients, but well over 90,000 uninsured adults in Rhode Island – more than 100,000, actually, by Smolski’s estimates. Even if you assume some of those adults can pay out-of-pocket, R.I. Department of Health figures show the poor are far likelier to lack coverage: 24.9 percent of those under the federal poverty line were uninsured in 2001, compared with 12 percent at 200 to 299 percent of poverty, and 3.7 percent at more than 400 percent.
The statistics come to life at the clinic in the shape of middle-aged women with diabetes, depression and signs of domestic abuse, breadwinners disabled by back problems, men struggling with high cholesterol and hypertension.
They make emotional pleas: “Think of me as your mother!” one woman recently begged Koegler, the clinic’s nursing director. For most, it’s this or no medical care at all.
So what do you do? At a forum hosted by Brown Medical School and the Ocean State Ethics Network on Sept. 22, clinic staff and volunteers presented their dilemma to a group of doctors and others in the health care community, seeking advice and support.
What they got was a mix of sympathy, criticism and outrage that health care is beyond the reach of so many people.
“Usually when we talk about scarcity in health care, we’re talking about high-tech resources, we’re talking about an (intensive-care unit) bed, a new liver,” said Dr. Jay Baruch, director of the ethics network. “But here we’re talking about basic primary care.”
The network routinely hosts discussions about ethical dilemmas in medicine: end-of-life issues, ICU admissions for patients with do-not-resuscitate orders, flu vaccine rationing.
Many are based on hypothetical questions; in this case, it was who should take priority if a clinic volunteer had a diabetic relative in need of care and an agency with ties to the clinic had a friend with dizziness and high blood pressure, but only one of them could get a slot.
Such situations arise constantly at the clinic, said Koegler and Smolski, the executive director. The conflicts are handled on a case-by-case basis, they said, with volunteers tending to get priority but some being resolved at random – such as by who returns a call first.
Few in the audience wanted to tackle that problem, but several took issue with the way the clinic runs its “walk-in” days, when most new patients are admitted: Every first Thursday, from 4 to 4:30 p.m., people can go in and get a raffle ticket. At 4:30, there’s a drawing, and 10 to 15 get appointments, while the rest – 15 to 30, Smolski said – are sent home.
As cold as that may seem, Smolski said, it’s the best solution the clinic has come up with.
When they first started, it was first-come, first-served, she said, and it got to a point where people were lining up at 7 and 8 a.m. to get in at 6 p.m. Diabetics would skip lunch to avoid losing their place in line. Fights almost broke out in the parking lot.
Still, Smolski said, “it pains me” to have a lottery. “I don’t think anybody should be getting health care this way.”
Several in the audience asked why the clinic didn’t triage the patients instead, and accept only the sickest. But others countered that the clinic’s mission is to provide primary care – to prevent major illness. Plus, as another woman noted, wouldn’t it be unethical to turn someone away, time and again, until he was truly sick from lack of basic care?
Koegler also noted that some patients will claim to have “a gazillion conditions” just to get into the clinic. And Smolski said a more in-depth triage system is beyond the clinic’s means right now – it has neither the space nor the resources, though if plans for an expansion work out, that will be put in.
Koegler said the clinic does make referrals to health centers, but some patients say they can’t afford to make even small payments. Smolski also noted that health centers – like most doctors’ practices and the Free Clinic itself – can’t take everyone themselves.
Asked what doctors and other medical providers could do to help, Smolski said the clinic currently has enough volunteers, but it could use referral slots for primary and specialty care (the clinic has a whole network of specialists, imaging services, etc.), supplies – such as generic drugs from a pharmacy, to supplement the brand-name samples provided by drug companies – and help with fund raising and advocacy.
“Rhode Island has the fastest-growing level of adult uninsured in New England,” Smolski said. “I’m surprised by the lack of knowledge and lack of support for this issue in Rhode Island.”
To find out more about the Rhode Island Free Clinic, go to www.rifreeclinic.org.
