On a typical Thursday evening at the Free Clinic, Nurse Manager Dena Young cuts off admission at 5 p.m. By then, some 80 patients are packed in the Clinic's waiting room, squeezed into worn chairs close enough to fear each other's contagion. Many have come fresh from low-paying service industry jobs, still dressed in their uniforms, wearing the tired pallor of the working poor.
Young stands at the intake desk, vacillating between empathy and toughness: empathy for the distraught patients who whisper their symptoms in her ear and toughness for the latecomers who try to convince her to make an exception to the no-admission-after-5 o'clock rule. Just this once.
Had to get the kids from day care. Couldn't get off work early. Was just in the bathroom. Young's heard all the excuses. She understands the desperation in their voices, because she's been there. Twenty-nine years ago, Young was a big-dreaming young mother of four who couldn't afford a $12 physical.
"That physical almost kept me out of nursing school," she recalls. Then she found the Free Clinic, where a volunteer doctor did it for free. Off she went to Case Western Reserve University, without having to sacrifice her food budget.
Now a veteran of hospital emergency rooms from Baltimore to Kodiak, Alaska, Young is one of the Free Clinic's 45 paid staffers. She helps manage a volunteer corps of 600, all of whom want the same thing -- to deliver health care to everyone, regardless of ability to pay.
That's not going to happen tonight, however.
"You were supposed to be here at 5," she tells one young man at 5:15, trying to conceal the apology in her voice with resolve. "You'll have to come back tomorrow."
Thirty years ago, it wouldn't have occurred to Free Clinic workers to turn away patients in need. Like their clientele, the workers were mostly young, mostly white, and mostly trying to change the world. The Free Clinic was the one place in town that specialized in treating the health problems of the counterculture -- drug-related, sex-related, or both. A sign on the front door promised that Clinic staffers would stay on the job each night from "5:30 til we reach our limit," which often meant until the last patient was seen, well into the early morning hours.
But the Free Clinic was never supposed to serve more than a temporary need. When it opened in June 1970, its idealistic founders were already working toward its demise. The idea was to teach the medical establishment how to care for the neglected population of young drug users, fight the discrimination against them, then disappear once the Clinic rendered itself unnecessary.
Now, with the ideal of a reformed health care system guaranteeing universal coverage still unrealized, the need for the Free Clinic is greater than ever. Its expanded services and growing patient population has turned the former refuge for drug-using kids into a safety-net provider for the entire community.
To see who is unable to access health care in Cleveland, one need only take a look inside the Clinic's waiting room. For the most part, the recreational drug users and suburban white kids are gone. Patients have grown poorer, darker-skinned, and sicker, their inaccessibility to health care stemming not from prejudice against their lifestyle, but from an inability to pay. As the only provider besides hospital emergency rooms with an open-door policy, the Clinic has evolved into a mainstay of the city's troubled health care landscape.
Cleveland's Free Clinic has survived while so many others around the country have closed partly because of the growing community need and partly because of its own effectiveness. The Clinic's volunteer doctors -- both primary-care physicians and specialists -- now treat an entire spectrum of illness, from sore throats to hypertension to AIDS. In the past three years, they have gone from seeing 550 medical patients a month to more than 1,500. The amount of care the Clinic provides has increased to more than $10 million annually.
In these times of shrinking health care coverage, the growth spurt shows no signs of leveling off. The ranks of the uninsured keep growing. The government keeps slashing subsidies to hospitals for charity care. Some, such at Mt. Sinai, have closed as a result of such factors, driving high-cost patients to other health care providers, in particular the Free Clinic.
But even that safety net has its breaking point.
"We have had the luxury in the past of being able to see all patients," says Free Clinic Executive Director Martin Hiller. "We no longer have that luxury. As demand has exceeded our capacity, we have wrestled with the question of how to provide services to people who need us the most."
This represents a foundation-quaking cultural shift for an organization whose motto for 30 years has been "Health Care is a right, not a privilege." Stickers proclaiming as much still adhere to the walls next to posters advocating safe sex and proper nutrition. Unlike free love, the Free Clinic is truly free. There is no co-pay for drugs or services, no sliding scale, no insurance companies billed.
Hiller insists the Clinic will never require any sort of payment. "We don't want to be the "Almost Free Clinic,'" he says.
As the Clinic prepares to celebrate its 30th anniversary by unveiling a $7.5 million expansion and endowment fund-raising campaign -- a landmark event by any measure -- the larger health care picture continues to deteriorate. And the Free Clinic is struggling mightily to fill the gap without abandoning its philosophy and goals.
"It's great we're here, but we shouldn't have to be here," says Jane Loisdaughter, the Clinic's director of education and one of its longest-serving staffers. "In a way, we've enabled the local health care system not to serve the people they should be serving."
As it always has, the Clinic will adapt to meet the needs of the community. But Loisdaughter worries, "At what point do you sell your soul?"
The Unrealized Dream
In the mid-'60s, Jeanne Sonville knew something was happening here. She was nearing 40 when she opened the Well, an East Cleveland coffee shop that soon became a local hangout of future Free Clinic patients. High school and college kids would come in night after night, engaging in 20-minute "sound-offs," railing against the establishment.
The kids began to trust the self-declared "hippie mother," and Sonville was soon privy to more than their political beliefs. Though Sonville was a public health nurse, she had never seen anyone on LSD until some frightened kids took her to a woman in the throes of a bad acid trip. With instinctive skill, Sonville talked the woman down, neutralizing her fears and installing herself as a trusted figure in the youth drug underground.
Toward the end of the '60s, Sonville started a hotline with her own money in a church basement. It quickly became apparent that many young drug users were neglecting their health and suffering from drug-related problems. When they did end up in the hospital, Sonville was outraged by the mistreatment she perceived.
"Hospitals discriminated against kids on drugs," Sonville says. "It was a different ball game when someone came into the emergency room in a diabetic coma than when someone had overdosed."
The incarnation of the Free Clinic came about because of an unlikely conjunction of Sonville's alarming hotline statistics, a Hell's Angels trial, and a few supporters from "the establishment."
Lawyer Charles Clarke was one of them. While working on a Hell's Angels murder trial in the late '60s, Clarke needed someone to testify to the effects of LSD. He brought in the Haight Ashbury Free Medical Clinic's Dr. David Smith, an acquaintance of his daughter in San Francisco and a national expert on psychedelic drug users. That experience, along with an interesting proposition from The Cleveland Foundation, recruited him to the cause.
"It was at the Union Club, of all places," Clarke recalls, where Foundation officials asked him to incorporate the Free Clinic. As it turned out, Sonville's statistics, showing that middle-class suburban kids were getting swept up in the drug culture, had made a strong impression. But the nascent effort needed Clarke "to give the Free Clinic a patent of respectability," he says.
Clarke secured the first grant at that tony luncheon, and the Clinic opened on June 1, 1970, in an old house on Cornell Road that rented for $500 a month. The news spread quickly through word of mouth and the underground newspaper, the Great Swamp Erie da da Boom.
"We didn't know until 4 p.m. that we were going to open that night," recalls Sonville. "We didn't have drugs people needed. We didn't know if we were going to have any doctors show up. We told people to come between 6 p.m. and 10 p.m. We ended up staying until 2 a.m.
"We had many more clients and problems than we expected. We weren't ready for the number of unexpected pregnancies and requests for birth control . . . We weren't ready for the 16 heroin addicts who showed up that night."
It didn't take long for both the counterculture and Cleveland's medical community to embrace the Clinic, which attracted scores of volunteers and a starting budget of just under $98,000. In its first 12 weeks, 1,183 patients made 2,201 visits. Half were treated for drug-related problems, including heroin and barbiturate overdoses, cellulitis, and abscesses. Sixteen percent of them had some kind of sexually transmitted disease.
Donations large and small showed up at the converted house -- a half-gallon of milk, a 1965 VW Beetle, exam tables, bar stools -- and Executive Director Gordon Friedman wrote thank-you letters for all of them. The Clinic straddled the fence between the mainstream and the fringe, ensuring its patients first-class care by well-regarded physicians who volunteered their services. At the same time, its toxicologist wrote a "Bad Dope" column for the da da Boom. Rockers held benefit concerts to keep it going. Volunteers and staffers brought their dogs to work and lived in communal housing.
A radical idea in a turbulent time, the Free Clinic had its detractors. In the basement today, amid dusty archives, a framed letter reminds staffers of the resistance it once encountered. A single penny is taped to a typewritten page, dated August 22, 1970, in response to a funding plea that aired on a local television station.
"I am enclosing my contribution to your clinic," wrote Guy Richard of Wooster. "The amount is not large, but it is based on my idea of the value of your organization, judged by the speech made by your psychiatrist from Columbus, whose name escapes me. From his remarks, I fear he is going to try to replace God, if he can secure enough funds . . . On the same channel, we heard that a properly funded organization is going to erect a new clinic or hospital in Cleveland in the near future, which we presume will be properly financed, obviating the necessity of begging before they have justified their existence."
Only once did resistance to the Free Clinic nearly turn violent, Sonville says. Shortly after the Clinic opened in June, residents of nearby Little Italy made it clear they didn't want a facility for drug users operating in their backyard.
"We had just opened on Cornell when we got a call on the hotline telling us to evacuate the building," she recalls. "It was a bomb threat. I told everyone to clear the building, then I called Fred, an accountant who was also a Hell's Angel and a good friend. Ten minutes later, there were bikers in the middle of the street and residents of Little Italy walking down the street with clubs."
The incident was resolved peacefully. By August of that year, the Free Clinic was treating some of the protesters' kids.
To many staffers and volunteers, the health of their patients took precedence over almost everything -- the budget, their time constraints, even the law. Sonville recalls one Clinic volunteer setting up a lab in his home to analyze street drugs for patients. In the years before Roe vs. Wade, counselors would refer women who wanted abortions to a doctor in New York. Friends who worked at the Cleveland Clinic and University Hospitals also did covert favors for the Free Clinic.
"For years, those hospitals were doing our lab work for free without knowing it," Sonville says.
The Free Clinic, however, saw its relationship with the greater medical community as symbiotic. Hospital staffs welcomed the educational efforts of Clinic workers, from whom they learned how to recognize and treat drug users. It also kept many nonpaying patients out of their emergency rooms, much as it does today.
As the era of free love gave way to Reaganomics, free clinics everywhere suffered. The need was still there, but the funding was not. Nationwide, the number of free clinics dropped from 600 in the mid-'70s to about 200 in the mid-'80s, according to an article in The New Physician magazine. When Hiller, a psychologist and former infantry platoon sergeant in Vietnam, took over the Clinic in 1983, he didn't believe it would be among the survivors. The first day on the job, he discovered a file cabinet in his office, two drawers of which were crammed with unpaid invoices.
"We owed everybody," he recalls, "including the IRS. Nobody really knew the extent to which we were in this deep hole . . . We survived because nobody wanted to be the one carrying the onus of closing the Free Clinic."
At the time, the Clinic had already moved to its present location, a nondescript brick building on Euclid, just east of Cleveland's medical mecca in University Circle. Located on rapid and bus lines, the new location drew people from the nearby Hough and Glenville neighborhoods. The Clinic went with the flow, shifting its program focus from experimenting youth to the urban poor.
In 1991, the Clinic was named one of President George Bush's points of light (#581). One year later, Hiller accepted an invitation to meet Bush at Hopkins Airport, where he found the former President completely unreceptive to his pitch for health care reform.
The Bill Clinton years also proved to be greatly disappointing, says Hiller. During his two terms in office, public health advocates entertained serious hopes of national health care, only to have them shattered by the downward spiral of managed care.
The Clinic still offers a range of primary medical services for both teens and adults, mental health and substance abuse treatment, legal help, and a crisis hotline that fields about 400 calls a month. The newer programs include HIV treatment and prevention, and a Thursday women's clinic so busy that it frequently draws up to 60 patients. Other programs have come and gone in accordance with the fluctuating times and funding streams. Longtime staffers remember the runaway shelter and the full-scale dental clinic, in particular, with great sadness, because both programs are still needed today.
Despite the Free Clinic's unqualified success, when it threw a 25th anniversary gala five years ago, former Executive Director David Roth felt troubled. He had great pride in the organization he helped usher to excellence, but was saddened by the growing need for its services.
"We always felt we were just a drop in the ocean providing care," he says.
He never thought the ocean would start to go dry.
The New Crisis
A few years ago, Dr. Pete Cubberley, the Free Clinic's medical director and only paid doctor, saw a man suffering from full-blown AIDS and pneumonia. He sent him to the emergency room at a local hospital, where the patient was admitted to intensive care and treated with intravenous antibiotics. He returned to the Clinic just a few days later, because he couldn't afford his prescriptions. If the Clinic hadn't filled them for free, a relapse would have been imminent, Cubberley says.
Although the man's case stands out in his mind because of its severity, Cubberley listens to similar stories of inaccessible health care almost every day.
"I never cease to be appalled," he says. "It's really tough getting someone to take care of these people."
No issue has upset the bottom line at area hospitals more than caring for uninsured and underinsured patients. Over the past few weeks, the headlines have been dominated by reports of local charity care casualties. First Mt. Sinai Medical Center closed, citing insurmountable financial difficulties triggered by serving so many impoverished inner-city patients. Then County-run MetroHealth Medical Center announced its intention to stop treating patients who belong to Medicaid HMOs next year, because it can no longer afford the low reimbursements. St. Michael Hospital and Mt. Sinai Medical Center East, both owned by the private Primary Health Systems, were next in line for closure, though bankruptcy court and rescue efforts by local politicians may ultimately preserve some of their operations. The future of Deaconess Hospital, also owned by the bankrupt PHS, remains uncertain.
Since the Balanced Budget Act of 1997, hospitals big and small have suffered cutbacks in Medicare reimbursements -- in Northeast Ohio to the tune of $963 million. By 2003, local hospitals are expected to endure a reduction of $1.2 billion, according to Richard Fox, senior vice president and chief financial officer for the Center for Health Affairs. In addition, Ohio's pool of funding to help hospitals offset the cost of providing uncompensated care, the Hospital Care Assurance Program, has shrunk from $340 million in 1997 to $309 million in 2000.
Speculation that ailing hospitals will try to make up the shortfall by decreasing their services to the poor worries public health advocates. According to a 1998 study released by the Center for Studying Health System Change, Cleveland is already doing a dismal job in that regard. More than 40 percent of uninsured Clevelanders reported difficulty accessing health care -- tying Lansing, Michigan, as the highest of 12 cities surveyed. The Cuyahoga County commissioners are so concerned about the growing numbers of uninsured that they created the Access to Care initiative, a coalition trying to figure out how to rescue that population from health care limbo.
It's an ambitious undertaking, admits Sandra Chappelle, the commissioners' health policy and programs coordinator. According to the 1997-1998 Ohio Family Health Survey, 12.3 percent of Cuyahoga County residents were uninsured, higher than the state average of 11 percent. The same survey showed that 423,000 Ohioans had lost their health insurance in the prior 12 months. With so many people leaving the welfare rolls for low-paying jobs that offer few benefits, experts expect the number of uninsured to continue to swell.
"You can see what's going on by looking at the Free Clinic," she says, "with the numbers they're serving, with Mt. Sinai . . . This thing is a snowball effect. We've got to take in all of these issues and come up with a community response."
It's tempting to place blame on the region's two biggest hospital systems, the Cleveland Clinic and University Hospitals, for using their market dominance to squeeze smaller hospitals. But the health care giants say they're also faltering under the charity care burden.
In 1998, reported losses for University Hospitals and the Cleveland Clinic were $20 million and $111 million, respectively. Both institutions blame their current fiscal predicaments on the same factors that unhinged Mt. Sinai, MetroHealth, and St. Michael -- the growing number of uninsured; reduced reimbursements from Medicare, Medicaid, and managed care; and shrinking uncompensated care subsidies from the state.
"I think Mt. Sinai is the tip of the iceberg," Fox says. "I think there will be reduced services. I think people are going to wait longer for care. I think access is going to be slowed."
To workers at the Free Clinic, it seems as if that time has already arrived. They regularly see patients like 54-year-old Annie Smith, who had to stop working because of her illness and has no health insurance.
"[The Free Clinic] literally saved my life," says Smith, a regular visitor to its hypertension clinic. "I didn't know I was diabetic when I came here. I couldn't see. I was going to the bathroom a lot. I had high blood pressure. When I came here, I found out my blood sugar was up around 300 . . . I don't know where I would go if it wasn't for the Free Clinic."
Cubberley says the number of adult primary care patients seen regularly at the Clinic has doubled in the last two years, to 400. If the Clinic didn't turn people away, that number could easily reach 1,000. Despite the great need, the Clinic has been unable to find funding to treat more chronically ill adults, many of whom suffer from the triple whammy of diabetes, high cholesterol, and high blood pressure. Drugs to control those conditions can cost as much as $200 a month.
Unfortunately, a recent scare reminded Smith that the Free Clinic can't be her one-stop medical shop. A few weeks ago, she was admitted to a local emergency room for heart palpitations. Doctors used drugs to slow down her heart rate, conducted some tests, then released her.
"I didn't have health insurance," explains Smith. "They told me to go see a heart specialist."
Patients like Smith often end up at smaller community hospitals, such as Mt. Sinai before it closed, rather than at UH or the Cleveland Clinic. Experts suspect the size of those institutions are off-putting to low-income people with little experience maneuvering through the health system.
"They're not going to look to those bigger institutions to take care of them," says Fox. "They're going to go to where they feel there is more comfort."
For a growing number of people, that means the Free Clinic, which gets none of the state's Care Assurance money and little public funding for its medical programs. Long reliant on the generosity of local hospitals, the Clinic is also feeling the pain of their streamlining and closures. Mt. Sinai used to conduct free X rays for Clinic patients. Until June, UH did its lab work without charge.
The loss of that lab service -- valued at $150,000 a year -- has put a substantial strain on the Clinic's $2.1 million budget. "It will now be necessary to cut test ordering to the bone," Cubberley told his staff in a letter. The Clinic is paying UH a discounted rate for lab work while searching for a better deal. In the meantime, the Clinic is managing the crisis the way it has so many others: Whatever it can't pay for, it simply does without.
If the local health care crisis continues to escalate, that may one day include patients.
Holding the Line
At the moment, latecomers turned away from the Free Clinic can simply come back tomorrow. But it's not certain how long tomorrow will remain an option for everyone.
Until recently, the only questions the Clinic asked its patients were in reference to their health. Now the intake volunteers make them fill out surveys that ask about their income and insurance status. This is being done because the Clinic may eventually have to turn away all but the truly uninsured, leaving the underinsured, who can't afford co-pays for doctor visits or prescriptions, nowhere to go.
"We are fast approaching that point where some people won't be able to be treated because they have insurance," says Hiller.
Even if the Clinic succeeds in raising the full $7.5 million of its aptly named "Meeting the Challenge" campaign, that won't eliminate the dilemmas of rising health care costs and increasing patient load. As long as charity care keeps eroding, the Clinic will keep shouldering a disproportionate and growing health care burden.
The original goal of the Free Clinic hasn't changed -- supporters still wish it could go out of business. But until and unless the health care system is reformed, the staff will keep trying to serve as many people as possible.
Certainly the Clinic has survived tough challenges before. To keep it running at various points in its colorful history, Clinic workers have resorted to holding street fairs and sacrificing their own jobs and programs. Once they even guilted a roomful of irate bankers into giving them a loan, despite the Clinic's sorry credit record.
"The Clinic has demonstrated that we're going to survive," Cubberley says. "But while we're going to survive, we can't do it all ourselves."
As hospitals continue to close, and insurance coverage continues to shrink, all the Free Clinic can do is treat the newest victims of the health care crisis -- and keep hoping for a revolution.
Jacqueline Marino can be reached at