1. Bouvier, Sonia MPH


Abstract: In the absence of universal coverage, there is a need to develop solutions at a local and state level to the dramatic rise in the uninsured. This article summarizes a local county-wide effort to address this issue in a rural area. Key ingredients for success include both hospital leadership (they have significant resources at their disposal), extensive community involvement (to maintain momentum for the program), and local physician leadership (physicians are, in essence, forgoing income in return for a formalization of who is eligible for the free care program).


ON ANY DAY, in emergency rooms across the United States low-income, uninsured people are seeking treatment because they have no other options for care. These patients often leave with prescriptions for medication and referrals to doctors that they cannot afford. Many may be eligible to receive Medicaid, financial assistance, or free medication from drug companies, but they do not know how to apply for these benefits. These and other problems were highlighted in a recent national study by the Access Project, "Paying for Health Care When You're Uninsured: How Much Support Does the Safety Net Offer?" (Andrulis et al., 2003). The study found that the majority of uninsured patients in hospitals or other ambulatory care settings are never made aware of available assistance. When the report was presented at a press conference in January 2003, Hampshire HealthConnect (HHC), a program at Cooley Dickinson Hospital in western Massachusetts, was highlighted as a model for its commitment to link uninsured people with financial and health care assistance programs.


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From a policy perspective, the increasing numbers of uninsured have "forced" some communities and health care providers to take matters into their own hands. While not a practice that can be counted on in a systematic manner, some physicians and other health care providers throughout the country have offered discounted or even free care for outpatient services (O'Toole et al., 2001). In states and counties with a high percentage of uninsured, other providers have attempted to fashion a managed care plan that focuses on the needs of the uninsured (Kaufman et al., 2000). Such efforts at coordinating and, as in this case, decreasing the overall cost of care have been particularly useful for hospital-based providers that may be required by law to accept all patients, including the uninsured. Not infrequently, the motivation to provide health services to the uninsured emanates from individuals with a religious background (Ashton & Laird, 1994). This article describes a hospital-based program providing care to the uninsured that began with efforts on the part of community activists to meet an unmet need.



HHC is a program based at Cooley Dickinson Hospital in Northampton, Massachusetts, with a history established on helping low-income, uninsured area residents access available health coverage and health care services. HHC was founded by a group of community activists who have promoted access to health care for the last decade. In the mid-1990s, the group worked to secure agreements from local physicians to provide services at reduced cost to local uninsured people who did not qualify for other types of health care assistance. At the time, universal health coverage was being pursued by the Clinton administration, and their hope was that once universal coverage was in-place, there would be no need to continue the program.


Years later, universal health coverage was clearly not imminent, and the needs of the uninsured were still pressing. HHC approached Cooley Dickinson Hospital-representatives from the hospital had been active in the group since its inception-and expressed an interest in expanding the program to provide more direct assistance to help uninsured people access to new state and federal health care initiatives. Cooley Dickinson agreed and, in partnership with the local advocacy group, was awarded funding from the Blue Cross/Blue Shield Foundation of Massachusetts. The hospital also contributed funding, and HHC began serving local residents at the hospital in the spring of 2002.


Since then, the HHC has helped people access a range of health coverage and health care services, including vision, mental health, and prescription assistance programs. Services include eligibility screening for Medicaid and other state and local assistance programs, help in completing applications, and case management, as needed. HHC employees use advocacy, education, and ongoing follow-up to help ensure access to all available programs and services.


Community members find out about HHC's services through many avenues. HHC staff members assist all uninsured patients seeking emergency care and other ambulatory services who are referred to the program. Local doctors and human service providers also encourage people to contact HHC. Since its program offices are based in the hospital, HHC can respond quickly to people in need.


Often, the people who contact HHC need help accessing multiple services. If a client is not eligible for health insurance, HHC staffs members will help them to access primary care from a local physician at a reduced cost. If they have prescription needs, HHC personnel will help them to complete applications for free or discounted prescription-assistance programs. Finally, if the client has hospital bills, HHC staff members will help qualifying patients apply for free care provided by the Massachusetts Uncompensated Care Pool, a state-funded program through which their hospital bills can be reduced or forgiven. HHC case manager advocates with employers, Social Security, or Medicaid to get necessary documentation or to expedite approvals for clients.


Since its inception, HHC has worked with more than 1,300 uninsured individuals. More than 250 people have been enrolled in Medicaid or other state-funded health insurance programs, and 300 people were approved for the state's Uncompensated Care Pool to help with their hospital bills. In addition, more than 700 people received help in accessing prescription-assistance programs. Local primary care physicians participate in the program by accepting HHC patients into their practice; these providers are assured that those patients are receiving all available resources for which they are entitled. Many clients of the program have said that they did not know about the services available to them, and others have said they could not have completed all the necessary applications or accessed the services they needed without this support. The end result is better access to care, better reimbursement for hospitals and physicians, decreased use of the emergency department for care that could be given in a physician office, and client peace of mind.



Andrulis, D., Duchon, L., Pryor, C., & Goodman, N. (2003). Paying for health care when you're uninsured: How much support does the safety net offer? Boston: The Access Project. [Context Link]


Ashton, M.M., & Laird, S.W. (1994). Inner-city clinics enable a ministry to continue: A Minnesota congregation expands its acute care ministry in order to serve the poor. Health Progress, 75(4):36-7, 57. [Context Link]


Kaufman, A., Derksen, D., McKernan, S., Galbraith, P., Sava, S., Wills, J., & Fingado, E. (2000, April). Managed care for uninsured patients at an academic health center: A case study. Academic Medicine, 75(4), 323-330. [Context Link]


O'Toole, T.P., Simms, P.M., & Dixon, B.W. (2001, October). Primary care office policies regarding care of uninsured adult patients. J Gen Intern Med, 16(10), 693-696. [Context Link]