What is the role of free clinics in the safety net?

BACKGROUND: Free clinics play an important role in the safety net but little is known about what factors drive their existence within a given community. The anecdotal literature suggests that they exist due to growing numbers of uninsured and a lack of affordable care.
OBJECTIVE: To determine whether unmet needs explain the existence of free clinics.
MATERIALS AND METHODS: The relationship between demographics, Medicaid policy, and ambulatory safety-net care on the geographical distribution of all known free clinics (n=1007) across all metropolitan statistical areas (n=361) in the United States is investigated cross sectionally. Drawing from numerous secondary data sources and an original dataset of all known free clinics, a negative binomial model is used to examine whether free clinic prevalence is higher in communities with larger proportions of uninsured patients, poor adults, and African Americans and is lower in communities with greater availability of federally qualified health centers (FQHCs), FQHC look-alikes, and health departments, and more generous Medicaid eligibility for working parents and Medicaid beneficiary/provider payment levels. RESULTS AND DISCUSSION: None of the demographic variables has a positive, statistically significant relationship to the number of free clinics in a metropolitan statistical area. However, the number of FQHC grantees per 10,000 uninsured individuals [incidence rate ratios (IRR)=0.69, P<0.05], the number of FQHC look-alike sites per 10,000 uninsured individuals (IRR=0.46, P<0.05), Medicaid beneficiary payments (IRR=0.9998, P<0.05), and Medicaid eligibility levels (IRR=0.998, P<0.10) are negatively associated with the number of free clinics. Thus, free clinics seem to respond to particular gaps left by safety-net providers and Medicaid but do not seem to respond to direct need.