Free clinics are often overlooked as a part of the US health

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1 ORIGINAL ARTICLE The Perceived Impct of the Ptient Protection nd Affordble Cre Act on North Crolin s Free Clinics Greg A. Swn, Kristie L. Foley bckground The Ptient Protection nd Affordble Cre Act of 2010 (ACA) my drmticlly ffect the demogrphics of the uninsured popultion nd the funding prospects for free helth clinics. methods We conducted cross-sectionl survey of 64 of 80 free clinics (80.0% response rte) in North Crolin to ssess free clinic directors knowledge of the ACA nd their perceptions of how the ACA would ffect clinic opertions. results Free clinic directors were knowledgeble bout well publicized spects of the ACA (eg, lck of Medicid expnsion in North Crolin), but they were less knowledgeble bout provisions such s the Federl Tort Clims Act nd high-risk pools, which my hve direct nd indirect effects on free clinics. Directors expressed concern over the unintended consequences of the ACA, such s reduced funding nd reduced volunteerism. Anticipted clinic chnges s result of the ACA include initition of electronic medicl records nd, to lesser extent, move to become hybrid clinics (federlly qulified helth center look-likes). limittions This study is focused on North Crolin free clinics tht re members of the North Crolin Assocition of Free Clinics (NCAFC). Findings cnnot be generlized to non-ncafc free clinics or to free clinic networks outside the stte. conclusions Despite its effort to expnd helth insurnce coverge, the ACA my hve unintended consequences to low-cost free clinics tht serve uninsured popultions. Free clinics re often overlooked s prt of the US helth cre sfety net becuse they do not ccept government reimbursement for their services, re operted predomintely by volunteers, nd lmost exclusively serve uninsured individuls [1-3]. They cn generlly be described s privte, 501(c)(3) tx-exempt nonprofit orgniztions tht provide medicl, dentl, mentl helth, nd/or phrmcy services directly to ptients t little or no cost. They re distinct from federlly qulified helth centers (FQHCs), which receive federl funds, provide billed services to Medicre nd Medicid ptients, nd offer sliding-scle fees to their uninsured clients. Two independent studies in 2010 identified pproximtely 1,200 free clinics in the United Sttes tht served over 1.8 million ptients, ccounting for more thn 3 million medicl visits [1, 2]. Published dt on free clinics re rre nd re often limited to informtion bout single clinic; however, recent studies hve shown tht free clinics reduce utiliztion nd costs of hospitl services [4-6]. The Ptient Protection nd Affordble Cre Act of 2010 (ACA) ws predicted to hve brod impcts on the Americn helth cre system, including significnt reduction in the number of uninsured individuls the popultion served by free clinics. The ACA s primry strtegy to reduce the number nd proportion of uninsured individuls ws to expnd Medicid to 133% of the federl poverty limit (FPL). (The expnsion is effectively 138% of FPL due to the wy it is clculted, which is why both numbers re often quoted in the medi nd scientific literture.) As of October 3, 2014, totl of 27 sttes nd Wshington, DC hd implemented Medicid expnsion; North Crolin opted not to expnd Medicid t this time [7]. Additionlly, under the ACA, ech stte ws required to hve helth insurnce exchnge (HIE) by fll of HIEs re competitive, orgnized mrketplces intended to encourge uninsured people with incomes between 100% nd 400% FPL to purchse subsidized helth insurnce. The Congressionl Budget Office estimtes tht, by 2016, under current implementtion, only 9% of the popultion (24.75 million people) will be uninsured versus 20% without the ACA s implementtion [7, 8]. The demogrphics of the uninsured popultion re expected to shift s result of the ACA, with disproportionte number of uninsured individuls being younger nd/or undocumented persons [8, 9]. Additionlly, newly enrolled Medicid ptients my lck ccess to cre due to provider shortges, mking them functionlly uninsured [10]. The ACA could lso led to misperception tht ll uninsured individuls re now insured nd thus indvertently reduce volunteerism nd dontions to free clinics [11]. Volunteerism by physicins nd mid-level providers is generlly declining nd my be excerbted by declining insurnce reimbursements nd rising operting costs in doctors Electroniclly published Jnury 13, Address correspondence to Dr. Kristie L. Foley, Wke Forest University School of Medicine, Medicl Center Blvd, Winston Slem, NC (kfoley@wkehelth.edu). N C Med J. 2016:77(1): by the North Crolin Institute of Medicine nd The Duke Endowment. All rights reserved /2016/

2 privte prctices [12, 13]. Declining volunteerism, coupled with misperception tht volunteerism is not needed, could be devstting loss to free clinics. Indeed, new clinics often emerge in those communities where volunteer nd hospitl resources re sufficient to support the clinics, rther thn in communities where the highest proportion of uninsured people in need of sfety-net cre re locted [14]. North Crolin is model stte to study how the ACA ffects free clinics. North Crolin hs the lrgest number of free clinics of ny stte, nd it hs sttewide ssocition to serve nd lobby for their interests [15]. North Crolin hs chosen not to expnd Medicid coverge nd hs deferred to the federl government to set up the stte s HIE [7]. According to 2012 nnul outcomes report from the North Crolin Assocition of Free Clinics (NCAFC), North Crolin free clinics provided over $200 million in free helth cre services to 95,000 ptients in 2011, with n verge of $6.14 in helth cre provided for every dollr used to operte clinics [16]. To dte, there is no informtion on free clinic directors knowledge nd perceptions of the ACA or clinics nticipted response to the ACA. We filled this gp by surveying NCAFC s clinic directors on their knowledge nd perceptions of the ACA s they pertin to their clinic. Methods Humn Subjects The reserch protocol ws pproved by the humn subjects institutionl review bord of Dvidson College. Smple The NCAFC grnted permission for the reserch tem to ttch questions to its nnul outcomes survey; these extr questions relted to the impct of the ACA on free clinic opertions. Clinics were sked to hve only clinic executive directors complete the section relted to the ACA. Dt collection ws conducted vi web-bsed survey during Februry Of the estimted 150 free helth clinics in North Crolin, 80 clinics were members of the NCAFC t the time of dt collection. Mesurement Survey items relted to the ACA were developed by reviewing the ACA legisltion tht specificlly pertins to free clinics (eg, high-risk pool, expnsion of Medicid); survey items included both knowledge nd perception questions. These questions were developed in prtnership with NCAFC stff members, who fielded questions nd concerns from executive directors regrding the ACA s impct on free clinics, nd questions were reviewed by NCAFC bord member nd free clinic executive director to ensure they reflected understnding nd common misperceptions of the ACA. Knowledge of the ACA There were 7 true-or-flse questions regrding chnges implemented by the ACA; for exmple, questions sked bout the following sttements: Sttes hve the option to opt in or out of the expnsion of Medicid nd North Crolin hs high-risk pool. Survey respondents hd the option of nswering true, flse, or I don t know. The questions focused on cts of the ACA tht directly relte to free clinics. Correct responses were coded s 1, while incorrect responses or I don t know responses were coded s 0. Scores on individul items were used to crete n index of knowledge relted to the ACA (possible scores of 0 7, with 7 being the best score). Survey respondents were lso sked to rte how informed they, their stff members, volunteers, nd donors were bout the ACA; they were given the options of Well informed, Somewht informed, nd Not informed. The ACA nd Perceived Impct on Clinic Opertions Respondents were sked questions regrding how their clinic opertes for exmple, Does your clinic use electronic medicl records (EMRs)? nd Does your clinic see Medicid ptients? nd they were sked whether they were considering mking chnges to their clinic s opertions for exmple, Is your clinic considering obtining n EMR? nd Is your clinic plnning on strting to see Medicid ptients? If executive directors indicted tht they were considering chnging their opertions, they were sked whether tht specific chnge ws due to the ACA. Clinics hd the option to respond Yes, No, or In prt. Respondents were lso sked questions regrding the perceived effects of the ACA on their opertions for exmple, Do you think tht the Affordble Cre Act will ffect the number of dontions you receive? nd Approximtely wht percentge of your ptients do you believe will be eligible for Medicid t 133% of the federl poverty limit? Generl Clinic Chrcteristics Chrcteristics of the clinics (size, expenditures, nd ptient demogrphic chrcteristics) were obtined from the nnul outcomes survey nd were merged with the ACA items for descriptive purposes. The physicl ddress of ech clinic ws mnully entered into the US Deprtment of Helth & Humn Services, Helth Resources nd Service Administrtion s Find Shortge Ares tool in order to determine whether clinics were locted in mediclly underserved re (MUA) or whether they served mediclly underserved popultion (MUP). Anlysis Responses were strtified bsed on whether the clinic provided medicl services (with or without phrmcy) or phrmcy-only services. Clinics tht operte only s phrmcy my be less ffected by the ACA thn medicl clinics nd therefore my hve different plns nd perceptions. Descriptive sttistics (mens nd frequencies) were computed for ll items in the survey. 24

3 Results Chrcteristics of Free Medicl Clinics nd Phrmcy-Only Clinics Of the 80 NCAFC member clinics tht were sent the 2012 outcomes survey, 64 clinics responded to our optionl survey bout the ACA (80.0% response rte). A comprison of respondents nd nonrespondents reveled no differences in terms of clinic loction or size. The dt presented here include only the 64 clinics tht completed the ACA survey; there were totl of 57 medicl clinics nd 7 phrmcy-only clinics. Responding medicl clinics cred for n verge of 1,185 unduplicted ptients in 2012, with men of 2,910 ptient visits. Although the men expenditure of these medicl clinics ws $369,979.81, there ws wide vrition in expenditures, rnging from $8,075 to $1,496,869 [15]. Clinic directors were sked to indicte their ctul csh expenditures for the yer nd to exclude in-kind dontions from the clcultion. Medicl clinics in our smple dispensed n verge of 13,927 medictions in 2012 through onsite phrmcies, physicin-dispensed smples, nd ptient ssistnce progrms. The verge clinic expenditure per ptient (bsed on the verge clinic expenditure divided by the number of ctive ptients) ws $ All clinics were sked if they were ffilited with hospitls or religious orgniztions. Most clinics (n = 60; 93.8%) were freestnding fcilities unffilited with hospitls (n = 50; 78.1%) or religious orgniztions (n = 54; 84.4%). None of the clinics chrged fee for services, nd only 20 clinics (31.3%) sked for dontion from ptients. Few medicl clinics ccepted Medicre ptients (n = 11; 19.3%) or Medicid ptients (n = 9; 15.8%). The vst mjority of medicl clinic directors reported n increse in their number of ptients during the pst 3 yers (n = 41 clinics; 71.9%), nd mny clinics hd expnded services (n = 37; 64.9%). While nerly ll medicl clinics offer their services to ptients residing in n MUA or serve people in res with n identified MUP (n = 53; 93.0%), only hlf of the clinics were potentilly eligible to become FQHC or FQHC look-like (ie, physiclly locted in n MUA or serving MUP). On verge, phrmcy clinics were 3 times lrger thn medicl clinics in terms of expenditures, with the verge tble 1. Chrcteristics of Free Medicl nd Phrmcy-Only Clinics Affilited With the North Crolin Assocition of Free Clinics Medicl clinics Phrmcy-only (n = 57) clinics (n = 7) Averge number of ptients 1,185 2,061 Rce/ethnicity of ptients White 587 (49.5%) 869 (42.2%) Africn Americn 305 (25.7%) 869 (42.2%) Hispnic 245 (20.7%) 250 (12.1%) Other (eg, Americn Indin, Asin) 48 (4.1%) 73 (3.5%) Number of femle ptients 716 (60.4%) 1,285 (62.3%) Age of free clinic popultion Younger thn 18 yers 44 (3.7%) 17 (0.8%) yers 1,104 (93.2%) 1,783 (86.5%) 65 yers nd older 37 (3.1%) 260 (12.6%) Averge number of medicl ptient visits 2,910 Averge number of prescriptions dispensed 13,927 48,388 Number of clinics serving Medicre ptients 11 (19.6%) 5 (71.4%) Number of clinics serving Medicid ptients 9 (16.1%) 1 (14.3%) Number of hybrid clinics 4 (7.0%) Number of federlly qulified helth centers (FQHCs) nd FQHC look-likes 2 (3.6%) Ptient numbers in the pst 3 yers Clinics services in the pst 3 yers b One medicl clinic director did not respond (n = 56). b Two medicl clinic directors did not respond (n = 55). Incresed 41 (73.2%) 4 (57.1%) Decresed 4 (7.1%) 2 (28.6%) No chnge 11 (19.6%) 1 (14.3%) Expnded 37 (67.3%) 3 (42.9%) Contrcted 4 (7.3%) 1 (14.3%) No chnge 14 (25.5%) 3 (42.9%) 25

4 expenditure being $903,747. Phrmcy clinics lso mnged 72% more ptients on verge thn medicl clinics (2,061 versus 1,185). They provided n verge of 23.5 prescriptions per ptient, which is pproximtely 2 prescriptions per ptient per month for n entire yer. Most phrmcy-only clinics served Medicre ptients (n = 5; 71.4%), but only 1 clinic served Medicid ptients. Free Clinics Knowledge of the ACA Clinic directors were sked 7 true-or-flse questions bout the ACA. On verge, respondents nswered 4.8 questions correctly (stndrd devition [SD] = 1.6; rnge 1 7; see Tble 2). Approximtely hlf of the medicl clinic directors responded correctly tht the ACA expnded medicl mlprctice insurnce coverge under the Federl Tort Clims Act (FTCA) to include nonmedicl personl (n = 30; 52.6%). Clinic directors were less knowledgeble bout the implementtion of the ACA in North Crolin. Nerly hlf of medicl clinic directors were unwre tht North Crolin hs high-risk pool (n = 33; 57.9%) or tht North Crolin decided to let the federl government implement nd control the stte s HIE (n = 33; 57.9%). Directors of phrmcyonly clinics ppered to be s knowledgeble bout the ACA s were medicl clinic directors. When sked whether stkeholders were well informed bout the ACA, respondents of medicl clinics nd phrmcy-only clinics reported tht few stkeholders were well informed; this included 22.6% of executive directors, 4.8% of stff, 3.2% of donors, nd 1.6% of volunteers. Perceived Impct of the ACA The most significnt chnge tht clinic stff pln to mke is implementtion of n EMR system (n = 25; 43.9% of ll clinics; 78.1% of clinics tht do not hve n EMR), nd nerly one-third of these clinics were doing so in response to the ACA (n = 8; 32.0%; see Tble 3). More thn 10% of clinics were considering serving Medicre ptients, nd over one-qurter of clinics were considering ccepting Medicid ptients. Most clinic directors who were considering expnding services to Medicre nd/or Medicid ptients were doing so becuse of the ACA. Ten of the 57 medicl clinic executive directors who responded to the survey were considering trnsitioning their free clinic to hybrid clinic, with 9 clinics considering becoming FQHCs. The mjority of clinic directors indicted tht their considertion to trnsform their clinic ws in response to the ACA. Over hlf of medicl clinic directors indicted tht clinic stff intended to help ptients nvigte the stte s HIE, nd one-third of clinics pln to or hve produced informtionl mteril for ptients bout the ACA. Nerly ll clinic directors hve or pln to discuss the ACA nd its possible effects with their bords of directors. Two-thirds of clinics pln to contct donors to educte them bout the ACA nd its effect (or lck thereof) on free clinics. Only one-qurter of clinic directors thought tht the ACA would decrese volunteerism; however, most directors thought tht the ACA would negtively ffect privte dontions, public funding, nd/or privte funding, with 50% of clinic directors reporting tht it would hurt ll 3 types of funding. A mjority of medicl clinic directors (n = 45; 83.3%) nd ll phrmcy-only clinic directors thought tht fewer thn 25% of their ptients would utilize the stte s HIE, with 12 medicl clinic directors (22.2%) nd 1 phrmcy-only clinic director (14.3%) reporting tht none of their ptients would utilize the exchnge (see Tble 4). If North Crolin were to expnd Medicid, free clinics could be gretly ffected. Over hlf of medicl clinic directors (53.7%) nd tble 2. North Crolin Free Clinic Directors Knowledge of the Ptient Protection nd Affordble Cre Act Correct responses Correct responses from from medicl clinic phrmcy-only clinic directors (n = 57) directors (n = 7) The Affordble Cre Act originlly expnded Medicid coverge to 133% of the FPL. (TRUE) 43 (75.4%) 7 (100.0%) Sttes hve the option to opt in or out of the expnsion of Medicid. (TRUE) 54 (94.7%) 6 (85.7%) The Affordble Cre Act brought greter funding for rurl helth centers, community helth 27 (47.4%) 5 (71.4%) centers, nd rurl hospitls. (TRUE) The Affordble Cre Act expnded the coverge of the Federl Tort Clims Act (FTCA) to include protections for officers, governing bord members, employees, nd contrctors from medicl 30 (52.6%) 1 (14.3%) mlprctice suits. (TRUE) North Crolin hs high-risk pool. (TRUE) 33 (57.9%) 5 (71.4%) The Affordble Cre Act provides tiered subsidies to help low-income US citizens ( % FPL) 50 (87.7%) 6 (85.7%) purchse helth insurnce. (TRUE) North Crolin hs greed to design nd implement stte-controlled helth insurnce exchnge. 36 (63.2%) 4 (57.1%) (FALSE) Knowledge Index Score (out of 7) (verge ± SD) 4.8 ± ± 1.4 Rnge Note. FPL, federl poverty level; SD, stndrd devition. The federl poverty level (FPL) cn vry for different groups. Most people responded to this question correctly, even though the 133% FPL option ws given. 26

5 tble 3. Potentil Impct of the Ptient Protection nd Affordble Cre Act on Clinic Opertions Medicl clinics Phrmcy-only (n = 57) clinics (n = 7) Plnning on chnging clinic eligibility requirements b 12 (21.1%) 1 (14.3%) Due to the ACA 12 (100.0%) 1 (100.0%) Plnning to get n electronic medicl record system (n = 32 medicl clinics; n = 7 phrmcy-only clinics) 25 (78.1%) 2 (28.6%) Due to the ACA 8 (32.0%) 1 (50.0%) Considering serving Medicre ptients (n = 45 medicl clinics) b 7 (15.5%) 0 (0.0%) Due to the ACA 5 (71.4%) 0 Considering serving Medicid ptients (n = 48 medicl clinics; n = 6 phrmcy-only clinics) 15 (31.3%) 1 (16.7%) Due to the ACA 14 (93.3%) 1 (100.0%) Considering becoming hybrid clinic (n = 53 medicl clinics) 10 (18.9%) Due to the ACA 9 (90.0%) Considering becoming federlly qulified helth center (FQHC) or FQHC look-like (n = 54 medicl clinics) 9 (16.7%) Due to the ACA 6 (66.7%) Hve mde or re plnning to mke chnges to bord policies b 15 (26.8%) Due to the ACA 7 (46.7%) Pln on iding ptients in nvigting the helth insurnce exchnges (n = 54) 31 (57.4%) 4 (57.1%) Pln to contct privte donors with informtion bout the ACA nd how it my ffect the clinic b 37 (66.1%) 5 (71.4%) Hve or pln to increse trnsltor services b 19 (33.9%) 1 (14.3%) Hve discussed or pln to discuss with their bord of directors the ACA nd its possible effects b 51 (91.1%) 6 (85.7%) Plnning to produce informtionl mteril for ptients bout the ACA b Note. ACA, Affordble Cre Act. Clinics lredy responding ffirmtively to the question re removed from the denomintor. b One medicl clinic director did not respond to this question (n = 56). 37 (66.1%) 5 (71.4%) nerly hlf of phrmcy-only clinic directors (42.8%) indicted tht t lest 50% of their ptients would become eligible for Medicid with the expnsion. Further, 18 medicl clinic directors (33.3%) nd 1 phrmcy-only clinic director (14.3%) reported tht 75% or more of their ptients would become eligible for Medicid if the progrm were expnded in North Crolin (see Tble 4). Generl Perceptions of the ACA The ACA ims to improve the Americn helth cre sfety net by decresing the number of uninsured individuls nd by expnding funding to some prts of the sfety net tht cre for uninsured popultions. However, the executive directors of North Crolin free clinics, s whole, hve mixed feelings bout the ACA. Directors from 11 of the 50 clinics who responded to this question wished tht the ACA would be repeled completely, nd 18 of 50 directors wished tht prts of the ACA would be repeled; the reserchers did not inquire s to why the respondents felt this wy. When sked whether the ACA would benefit their clinic, 18 of the 53 medicl clinics directors who responded to this question (34.0%) believed tht the ACA will not benefit their clinics, with hlf of clinic directors (n = 29; 54.7%) responding tht it is too soon to tell. These responses were mirrored by the directors of phrmcy-only clinics. Discussion While the ACA will expnd insurnce coverge by n estimted 30 million people in the United Sttes, it will still fll short of providing universl coverge [8, 9]. With North Crolin s current decision not to expnd Medicid, its decision to defult to the federl HIE, nd its high proportion of undocumented immigrnts, the stte will still hve lrge number of uninsured individuls fter full ACA implementtion [17]. An expected 319,000 people who would hve been Medicid-eligible hd North Crolin expnded Medicid will fll into the coverge gp [17]. It hs been predicted tht 1.1 million North Crolinins would gin coverge, out of 1.7 million currently uninsured persons, ssuming the stte expnded Medicid to 560,000 individuls by 2019 [18, 19]. We expect free clinics will continue to ply very importnt role in the provision of sfety-net cre for uninsured individuls in North Crolin nd tht the clinics nticiption of nd preprtion for full implementtion of the ACA will impct their dy-to-dy opertions nd survivl. Knowledge of the ACA is relevnt to free clinics, not only 27

6 due to the ACA s expnsion of helth insurnce to more people nd its potentil to ffect volunteerism nd funding, but lso due to lesser-known provisions, such s the expnsion of the FTCA Medicl Mlprctice Progrm. For clinic directors who complete the ppliction process, the FTCA progrm is intended to increse chritble helth cre volunteering mong licensed professionls by reducing perceived libility risk through free mlprctice insurnce. This hs importnt implictions for free clinics tht depend on volunteers, mny of whom re retired nd my not hve mlprctice coverge from their primry employer. The ACA lso expnded FTCA tble 4. Potentil Impct of the Ptient Protection nd Affordble Cre Act on Volunteerism, Funding, nd Ptients How will the ACA ffect volunteer prticiption t the clinic? How will the ACA ffect the number of privte dontions the clinic receives? How will the ACA ffect the clinic s public funding? How will the ACA ffect privte funding? Perceived percentge of ptients who will utilize the North Crolin helth insurnce exchnge in 2014 (n = 54 medicl clinics) Perceived percentge of ptients who would be eligible for the Medicid expnsion (n = 54 medicl clinics) Medicl clinics Phrmcy-only (n = 55) clinics (n = 7) Increse 1 (1.8%) 0 (0.0%) Decrese 15 (27.3%) 0 (0.0%) Hve no effect 38 (69.1%) 7 (100.0%) Increse 1 (1.8%) 0 (0.0%) Decrese 29 (52.7%) 5 (71.4%) Hve no effect 25 (45.5%) 2 (28.6%) Increse 3 (5.5%) 1 (14.3%) Decrese 32 (58.2%) 4 (57.1%) Hve no effect 20 (36.4%) 2 (28.6%) Increse 1 (1.8%) 0 (0.0%) Decrese 32 (58.2%) 4 (57.1%) Hve no effect 22 (40.0%) 3 (42.9%) 0% 12 (22.2%) 1 (14.3%) 10% 20 (37.0%) 3 (42.9%) 25% 13 (24.1%) 3 (42.9%) 50% 7 (13.0%) 75% or greter 2 (3.7%) 0% 5 (9.3%) 10% 10 (18.5%) 2 (28.6%) 25% 10 (18.5%) 2 (28.6%) 50% 11 (20.4%) 2 (28.6%) 75% or greter 18 (33.3%) 1 (14.3%) Note. ACA, Affordble Cre Act. Two medicl clinic directors did not respond to ny of these questions (n = 55). coverge to clinic bord members, stff, contrctors, nd nonmedicl volunteers, which will provide incresed protection from litigtion for these individuls. Free clinic executive directors were generlly knowledgeble bout the highly publicized spects of the ACA, including sttes utonomy in opting in or out of Medicid expnsion, the tiered subsidies to purchse insurnce on the HIEs, nd the originl expnsion of Medicid coverge. A free clinic s bility to operte is tied directly to volunteerism, especilly of physicins (which is lredy declining), nd the potentil lck of knowledge bout the ACA mong volunteers nd donors my hve significnt negtive consequences for free clinics [12]. Donors who lck n understnding of the ACA nd its limittions my erroneously ssume tht free clinics no longer need privte finncil resources in order to provide helth cre for the uninsured popultion. This possibility, compounded by possible decrese in privte nd public funding, is perceived concern by the mjority of clinic directors in this study, s it my leve clinics with insufficient funds to continue their current level of opertion. While free clinic directors re more optimistic bout volunteer prticiption thn they re bout funding, lmost 28% think tht volunteerism in their clinics will decline. While we currently do not know whether ny of these unintended consequences of the ACA hve hppened or will hppen, the possibility hs proven sufficient to shift opertionl ctivities in free clinics; for exmple, some clinics hve begun providing services to Medicid nd/or Medicre ptients, s hs been reported in the medi [11]. Free clinic directors re prepring to ddress the unintended consequences of the ACA nd the lck of knowledge bout the ACA mong their stkeholders. Most directors hve discussed or pln to discuss the impct of the ACA with their bords of directors, nd the NCAFC hs mde ACA eduction priority t its nnul meetings. Two-thirds of clinic directors nticipte providing informtion bout the ACA to their ptients, nd modest mjority of medicl clinics re plnning to help ptients nvigte the HIEs. One potentil positive impct of the ACA is the doption of EMRs. Twenty-seven of the medicl nd phrmcy-only clinics surveyed re plnning to implement EMRs, nd 9 of the 27 re doing so s result of the ACA. EMRs hve the dvntge of llowing for udit nd feedbck within clinicl setting, which cn improve qulity control nd mngement. Moreover, funders re incresingly interested in ptient outcomes, nd EMRs provide distinct dvntge over pper records for dt collection nd nlysis, thus llowing free clinics to better leverge scrce resources. This study evluted knowledge nd perceptions of the potentil impct of the ACA on free clinics, criticl prt of the sfety-net cre system. Our study focused exclusively on NCAFC member clinics, which limits its generlizbility. Moreover, we hd no wy to control for executive directors experience or prior knowledge bout the ACA, nor re we certin tht our survey cptured ll of the foreseeble 28

7 chnges ffecting free clinics tht my result from the ACA. Despite these limittions, this study revels tht free clinics re indeed prepring for the ACA nd tht they believe its effects my be rdicl enough to chnge the lndscpe of cre for the uninsured popultion. The sfety-net system in North Crolin my look different in the coming yers, s n incresing number of clinics enter the relm of government-supported sfety nets, nd the remining free clinics shift their eligibility requirements, spend time helping ptients understnd nd utilize newly vilble insurnce options, expnd service to undocumented immigrnts (who re ineligible for Medicid or prticiption in the HIE), nd incresingly rely on EMRs. We believe this study provides preliminry evlution of the ACA, nd, with more thn 1,200 free nd chritble clinics in the United Sttes, there is n opportunity to expnd this study to other sttes tht my hve opted to expnd Medicid nd/or operte stte-run HIE. Free clinics provide medicl, phrmcy, dentl, nd/or behviorl helth cre services to uninsured individuls t remrkbly low cost nd high return on investment [1, 2, 12, 15, 16, 20-23]. They re lso medicl homes for mny uninsured people nd hve been shown to reduce non-emergent visits to emergency deprtments [24-26]. While free clinics were likely never considered s the ACA ws drfted, this ct hs lredy begun to impct their plns; therefore, sttes should nticipte meningful nd unnticipted consequences to the sfety-net system for the uninsured popultion s whole. Greg A. Swn, BS grdute student, Deprtment of Immunology, Duke University School of Medicine, Durhm, North Crolin. Kristie L. Foley, PhD professor, Deprtment of Socil Sciences nd Helth Policy, Division of Public Helth Sciences, Wke Forest School of Medicine, Winston Slem, North Crolin. Acknowledgments The uthors thnk Rory Crwford, formerly of HelthRech Community Clinic, nd the North Crolin Assocition of Free Clinic tem for their ssistnce in developing the survey. Study nd mnuscript preprtion occurred while uthors were ffilited with Dvidson College in Dvidson, North Crolin. Potentil conflicts of interest. G.A.S. nd K.L.F. hve no relevnt conflicts of interest. References 1. Geller S, Tylor BM, Scott HD. Free clinics helping to ptch the sfety net. J Helth Cre Poor Underserved. 2004;15(1): Drnell JS. Free clinics in the United Sttes: ntionwide survey. Arch Intern Med. 2010; 170(11): Allen TJ. Addressing Resource Gps in the US Helth Cre Sfety Net: An Assessment of the Free Clinic Network. Stmford, CT: AmeriCres; Crump WJ, Fricker RS, Crump AM, Jmes TE. Outcomes nd cost svings of free clinic cre. J Ky Med Assoc. 2006;104(8): Oriol NE, Cote PJ, Vvsis AP, et l. Clculting the return on investment of mobile helthcre. BMC Med. 2009;7: Fertig AR, Corso PS, Blsubrmnim D. 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Free clinics nd volunteer physicin referrl networks in the United Sttes. Helth Aff (Millwood). 2007;26(3): Hdley J, Crvens M, Coughlin T. Federl Spending on the Helth Cre Sfety Net from : Hs Spending Kept Pce With the Growth in the Uninsured? Wshington, DC: The Henry J. Kiser Fmily Foundtion; Drnell J. Wht is the role of free clinics in the sfety net? Med Cre. 2011;49(11): North Crolin Assocition of Free Clinics Annul Outcomes Report. Winston Slem, NC: North Crolin Assocition of Free Clinics; North Crolin Assocition of Free Clinics Annul Outcomes Report. Winston Slem, NC: North Crolin Assocition of Free Clinics; The Henry J. Kiser Fmily Foundtion. How will the uninsured in North Crolin fre under the Affordble Cre Act? The Henry J. Kiser Fmily Foundtion website. ct-sheet/stte-profiles-uninsured-under-c-north-crolin/. Published Jnury 6, Accessed October 3, Silbermn P, Cnsler LM, Goodwin W, Yorkery B, Alexnder-Brtcher K, Schiro S. Implementtion of the Affordble Cre Act in North Crolin. 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