Removing Barriers to Health Care for Uninsured Patients

In North Carolina and South Carolina, two free clinics provided medical care and information for the uninsured. Staffed by volunteers, the events also helped connect people to health care networks.

To improve access to more comprehensive health care services in North Carolina and South Carolina, The Duke Endowment is part of a public/private partnership working to integrate health providers serving the uninsured into community-based, collaborative networks.

Challenge

In North Carolina and South Carolina, more than one-sixth of the population is uninsured. In North Carolina, more than 1.5 million people — 17 percent of the state's population — lack health insurance coverage. In South Carolina, nearly one in six people have no health care coverage.

Increasing Numbers of People Without Health Insurance

What's more, in recent years North Carolina and South Carolina experienced larger increases in the number of uninsured people, and larger decreases in employer-based insurance coverage than most of the country.

Who are the uninsured? In South Carolina, 103,000 uninsured South Carolinians are under 18. Many of their parents work for small employers or are self-employed and can't afford health insurance premiums.

In the Carolinas, a majority of uninsured people are full-time workers or in a family with full-time workers. In a statewide survey in North Carolina, more than half of the uninsured said they could not afford insurance coverage because of cost.

Impact on Health and Beyond

In the Carolinas and elsewhere, studies show that lack of insurance has a negative impact on health — which, in turn, adversely affect worker productivity and school performance. Even families who have health insurance coverage are affected by the growing number of uninsured. In South Carolina, for example, 20 percent of people without coverage rely on hospital emergency rooms for general or routine health care. Patients face longer waits as a result, and resources designed for emergency care are diverted.

Although good safety net providers exist — including community health centers, free clinics and medication assistance programs — they can't meet all the health care needs of the uninsured in a coordinated way.

Response

James B. Duke, the founder of The Duke Endowment, was committed to removing barriers to quality health care. In his 1924 Indenture of Trust, he established a program designed to help provide hospital care for patients who weren't able to pay for it. In his words, his Endowment would pay a sum "not exceeding One Dollar" for each "free bed per day for each and every day that said free bed may have been occupied during the period covered by such payment free of charge by patients unable to pay as the amount available for this purpose hereunder will pay on a pro rata basis."

In later years, the Endowment called this its Free Days of Care program, which allowed all eligible hospitals to apply for an assistance award. The Endowment reviewed and slightly modified the program in 1970, and again in 1992 and 2002.

Adopting a Comprehensive Approach

At Alliance Medical Ministrynear downtown Raleigh, N.C., Dr. Susan Weaver talks to Bertha Mercado, a certified nursing assistant. Alliance is part of the CapitalCare Collaborative, a network in Wake County working to improve the health of the region's medically uninsured.

In 2006, Trustees elected to discontinue the program and aim for a redesign that would make it more comprehensive. Endowment staff began meeting with health care leaders in North Carolina and South Carolina and with other major funders.

The groups focused on establishing collaborative networks for low-income, uninsured people in North Carolina and South Carolina. Instead of reacting to patient needs when patients are already sick, this model would integrate health services on the front end. Helping low-income, uninsured patients have access to primary care and preventative care would help them stay healthier in the long run.

In June 2007, an initial grant from The Duke Endowment went to the North Carolina Hospital Association and South Carolina Hospital Association to establish statewide partnerships to oversee the development of resources for these collaborative networks.

The partnership in North Carolina includes the N.C. Institute of Medicine, the N.C. Hospital Association, the N.C. Office of Rural Health, the N.C. Department of Public Health, the N.C. Association of Free Clinics, the N.C. Medical Society, the and the N.C. Foundation for Advance Health Programs.

In South Carolina, partners include the S.C. Hospital Association, Welvista, the S.C. Office of Rural Health, the Primary Care Association, the Department of Health and Human Services, the United Way Association of S.C and the Free Clinic Association.

In June 2008, Endowment Trustees approved an initial $2.1 million grant to the South Carolina Hospital Association and an initial $1.8 million grant to the North Carolina Hospital Association to expand provider capacity and develop integrated networks in nine S.C. counties and 12 N.C. counties.

The Endowment has continued its support and in 2011, 43 networks in 80 counties are providing medical homes for more than 122,000 low-income, uninsured residents and providing an estimated $265 million in primary care services annually.

Participating Sites

North Carolina

• Care Share Health Alliance, Raleigh

South Carolina

• AccessHealth SC, Columbia

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Vice President
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