During the first five months of Medicaid expansion, nearly 285,000 Virginians have enrolled and gained a way to pay for their health care.

With fewer people needing to rely on free and charitable clinics, the safety-net clinics are adjusting their business models.

“There was talk that Medicaid expansion would put free clinics out of business. That’s the furthest thing from the truth. We’re not scared of that at all. The need for free and charitable clinics will continue,” said Teresa Tyson, executive director of the Health Wagon in Wise.

There is still a great need to serve those who earn slightly more than Medicaid’s cap but not enough to afford private insurance or the copays and deductibles to use it.

“We have one patient who works at McDonald’s and has a terrible skin rash going on. But when she applied, she found out she was $35 over, and she was ineligible. She was one of the people we thought Medicaid would help the best,” Tyson said. “Certainly Medicaid expansion was better than no expansion at all. But what we’re seeing is not all people are covered.”

Connie Little, the clinic’s Medicaid outreach coordinator, said she has helped more than 200 patients apply to the Department of Medical Assistance Services. For adults to qualify, their family income has to fall below 138% of the federal poverty level. For an individual, that’s $17,236 this year, and for a family of four it’s $35,535.

“There are a few patients who are just right above the income eligibility,” she said. But for those patients who do qualify, it’s like hitting the jackpot.

“I often joke and say I feel like Oprah on the mornings that I have a lot of approvals because I get to call patients. These are people I’ve sat in exam rooms with and they have given me their life stories. So many patients just cry when they find out they will be eligible,” Little said.

The coverage opens access to services that the clinic doesn’t offer and that patients couldn’t afford.

“A lot of our patients were getting the very, very basics because their financial situation didn’t allow for further testing and specialists. Medicaid expansion has really helped them,” Little said.

However, in Virginia’s coalfields, the shortage of health care providers, and of providers who accept Medicaid patients, has left some with insurance but still without a doctor.

Tyson said the Health Wagon has continued to treat them. While the Health Wagon accepts donations, it does not have a mechanism to bill insurers. It recently purchased a former dentist’s office in Coeburn that it is renovating with the expectation of seeing Medicaid patients.

Tyson said they have created a separate entity in order to bill Medicaid. The plan was to offer addiction treatment. Tyson said the Health Wagon won a grant and is working with University of Virginia telehealth to offer medication-assisted treatment, but she learned this month that they might not be able to get or afford professional liability insurance.

She said insurers don’t want to cover prescribers of Suboxone and other substances that help with addiction in an area where these drugs had been diverted to the street.

“My biggest concern is, are we going to open,” she said.

The Virginia Free and Charitable Clinics anticipated that its 60 member clinics across the state would evolve depending on how easily Medicaid patients could access care elsewhere.

“At this point, we’re only five months in, so it’s a little too early to make major calls on where we see things headed,” said Rebecca Butler, spokeswoman for the association. “Many of our free clinics are responding to the unique needs of their communities.”

Free clinics in comunities with federally qualified health centers that accept Medicaid patients are adapting to reach people Medicaid misses.

Bradley Free Clinic in Roanoke now accepts patients with higher wages and is continuing to offer specialty services for dental and behavioral health care that can supplement Medicaid.

Executive Director Janine Underwood said many of the clinic’s patients who are among the most chronically ill qualified for Medicaid and are able to access the care that they need. “For them to be able to continue receiving quality care in our community is extremely reassuring,” she said. “In the meantime, we are realizing there is a continued need for the safety net we provide. We see patients who make too much money to qualify for Medicaid, or live in a household as a dependent or caregiver and the household income is too high to qualify.”

She said there is also a shortage of medical and behavioral health providers who are accepting new patients, so they struggle to find a provider or are wait-listed.

“As long as this is the case, Bradley Free Clinic is committed to being a safety net to meet these patients’ health care needs,” she said.

Last year, Bradley revised its eligibility requirements so that it could reach people whose incomes are too high for Medicaid but too low to pay for medical care. Patients can earn up to 250% of the federal poverty level, which is $30,050 for an individual or $64,375 for a family of four.

Before Virginia expanded Medicaid, the only adults who qualified for the insurance were those in extreme poverty who were also elderly or disabled.

Last year, about 700,000 Virginians lacked insurance. The state estimated that about 400,000 of them would meet the new Medicaid guidelines. The other 300,000 fall into the gap of earning too much for Medicaid and too little to afford coverage on their own.

“We were strong advocates for expansion, and it will impact the state in a tremendous way,” Butler said.

However, putting policy into practice can be a difficult transition.

“We are working through some of the hiccups,” she said. “It’s been a constantly changing landscape.”

And one that could become more so if Virginia pursues the work requirement, which could lead to people churning on and off of Medicaid.

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Luanne Rife writes about the businesses, policies, discoveries and inventions that affect the health of people living in southwestern Virginia.

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