State of the Safety Net 2014

Download the full State of the safety net 2014 here

The Affordable Care Act (ACA) is a sea change in the U.S. healthcare system. In the context of that change, the critical role of nonprofit safety-net healthcare providers warrants particular attention. Providing care to more than 24 million people, these health centers and clinics are on the front lines of treating those who are most in need, without insurance, and living in poverty. This report, as in past reports, aims to provide a current overview of these providers. In this edition we have also added a snapshot of their perspectives on the ACA.

Interviews were conducted over the past year with an array of providers—large and small facilities, free clinics and Federally Qualified Health Centers, providers in rural and urban environments, in states that have expanded Medicaid and states that have opted out. The goal was to understand the pending impact of one of the most sweeping laws our nation has seen on the providers that are, in many ways, most important to reaching disadvantaged communities. Perhaps, not surprisingly, there is a wide range of views and feelings among safety net health providers.   I anticipate that we will be seeing a large increase in the number of folks who will come to see us, which presents us with challenges.” — Dan Ahearn, CEO, Community Health Alliance, Reno, NV
As the report details, the perspectives of these providers on the implications and outcomes of the ACA have much to do with where they exist, what type of facility they are, and what sort of population they serve. The environments range dramatically – from states that have moved forward with Medicaid expansion compared with states that have not, some of which already have significantly greater disease burdens and risks than others. Facilities range widely from larger and more established health centers with staff that have extensive experience assisting with insurance enrollment, as compared to smaller, volunteer run free clinics with minimally comparable background. Still, though their environments may differ, their purpose does not: ensuring that everyone, regardless of their ability to pay or their personal background, have access to safe, high-quality healthcare.

Direct Relief is the sole nonprofit licensed to distribute prescription medicines in all 50 states and runs the largest U.S. charitable medicines program through a network of more than 1,200 of these providers in all 50 states. A unique perspective is afforded from our close, daily interaction to understand these providers’ circumstances, needs, interests, and concerns and, in turn, mobilize and deliver charitable resources efficiently.

Through the course of Direct Relief’s daily work, safety net providers continuously demonstrate that the most informed and thoughtful views are not always delivered in the loudest voice or even heard at all over the din of vigorous debate. These leaders’ voices, experienced and reflective of the breadth of circumstances that exist on the frontlines of the healthcare safety net, describe the strong influence of place and the differences in circumstances that exist. For the millions of people that depend on America’s nonprofit healthcare safety net, we hope these voices will be heard much more in the years to come.

1. At the highest level, all providers, regardless of location, size, or facility type, underscored that for the foreseeable future the need for charitable health care will remain. The need for charitable care is perhaps most obvious in the states that Have chosen not to expand Medicaid, which will under any immediate scenario continue to have higher levels of people who are uninsured than in the expansion states. Beyond this very obvious need there will continue to be gaps in coverage for immigrants (undocumented and otherwise) and those who will otherwise fall through the cracks.
2. As safety net providers have long known, having insurance is not the same as having access to a high quality health care provider. Great unease exists throughout the safety net about demand for services among the newly insured dramatically outpaces the supply of health facilities and health professionals.
3. Geography matters – one cannot talk about the Affordable Care Act without taking about differences of place. Vast unevenness exists in the law’s application, most obviously again in the split between Medicaid expansion and non-expansion states. But that geographic unevenness is amplified by unevenness in the functionality of the new insurance exchanges (federal and state), in the public health and economic conditions of different areas of the country, and even in
   the differential risk of natural disasters in places where the law’s outcomes are as yet unknown.
4. Safety net providers consistently pointed out that we are only at the very beginning stages of the momentous changes yet to come. Change of this scale cannot happen overnight. The shifting landscape of insurance coverage and health providers that treat low income patients is creating a more complex safety net; the provision of charitable care must rise to meet the challenge of that additional complexity. As people receive coverage they in some cases had never had before in their lives, it is a new experience for them and will take time to adjust. While the ACA is a national law, the practice of US health care, particularly for the most vulnerable parts of our population, is changing on a community by community basis.

Safety Net Voices & the Affordable Care Act

An interview with Nicole Lamoureux, Executive Director, National Association of Free and Charitable Clinics

Can you provide some background into your association and free clinics?

NICOLE LAMOUREUX: The National Association of Free and Charitable Clinics is the only national organization that is organized and developed to work with free clinics in the communities they serve. Our mission is to broaden access to affordable health care for the medically underserved by increasing public awareness, promoting volunteerism, and supporting and advocating for the nation’s Free and Charitable Clinics as we work together to build a healthy America, one
patient at a time. Many people do not realize that there are approximately 1,200 free or charitable clinics throughout the nation, who, since the 1960s, have been filling in the gap for those who fall through the cracks in our current healthcare
system.

Our clinics believe in giving a hand up, not a hand out. We activate at the grass roots level, not at the government level. What sets us apart from our other counterparts in the safety net arena is that we receive little to no state or federal funding and we are not considered Federally Qualified Health Centers. Our clinics rely very heavily on the generosity of individual donors, foundations, and grants as funding sources, and we utilize a staff and volunteer model to provide health care
to those in our communities who need it the most.

As the legislation has begun to roll out, how do you see the initial impact affecting free clinics?

NICOLE LAMOUREUX: The first thing that I stress when I’m speaking to people is one of the most common misconceptions about how the United States will look after the full implementation of the ACA is that there will no longer be a need for free or charitable clinics any longer.

The Affordable Care Act was never designed to be a universal healthcare option, a public option – an option where every single person in America was given an insurance card. Rather, it was to lower the barriers of health affordability for many
people in the country. We know that this is not a public option, so that means that everyone is not going to have access. So as we’re looking at where the ACA is going to go in the future, free clinics are dealing with a couple of different issues when it comes to our patients.

There are clinics who are located in states who have not expanded the Medicaid program. There are about 26 of those states across the country. Those states may or may not decide to have a model that is a different way to expand Medicaid than the one that was outlined in the bill. But currently in the states where there is no expansion of Medicaid, the patients will not have access to any of the subsidies or any of the programs that those living in expansion states do.

As we’re looking at patients across the country, first and foremost, there is important education going on. If you think about it, having health insurance is confusing for those of us who have had health insurance our entire lives, never knowing what form to fill out, or whether your doctor is in-network or not in-network, if you are self-insured or your employer offers your healthcare plans. This is confusing for people who have had health insurance, imagine being someone who has never had health insurance before and you have no idea how to fill out what forms are needed for you or where you can go to the doctor. And then, even more so, imagine if you are a person who is eligible for the health insurance plans, but you have a job that doesn’t allow you to go to the doctor between 9:00 and 5:00. One of the things that Free and Charitable Clinics can offer as part of the safety net is sometimes our hours are different. They are the non-traditional hours that allow people to go to the clinics to get the care that they need and continue to be working.

Is there a difference for free clinics in the states that will expand?

NICOLE LAMOUREUX: Clinics in states that are not expanding their Medicaid programs are definitely going to continue working in the same way that they have in the last couple of years, with an eye towards the future and what other clinics are doing in other locations. The reality of not expanding Medicaid means that you have a very similar patient base to what you have today, as opposed to those states that have expanded their Medicaid programs and their patient demographics may look a little different moving forward.

However, I think what you are finding more clinics doing is looking at how to best serve the needs of their community. And what we are finding is we can look  at clinics who have decided that it is the best interest of their community and their patient base to transition into a Federally Qualified Health Center role, where they will still serve the uninsured, but be able to take some funding from the federal government. Then we look at some of our clinics who have decided to take more of a charitable clinic role where, at this point in time, they are asking patients for a $5 payment towards their services, instead of free.

We also then have clinics in states, regardless of whether Medicaid is expanding, who have said, “You know what? We need to be a hybrid clinic. We need to have an entire free clinic side of things, but we also need to start accepting some Medicaid patients as well.” Then I think you’re also looking at clinics who have said, “For right now, where we are in our communities and what we’re doing, we’re just going to remain free clinics.” That’s probably one of the most beautiful things about Free and Charitable Clinics is that we truly can be community built and grassroots built. We’re finding that clinics are looking at how to best serve their community and does the business model need to change, and how does that impact the mission of my organization all at one time? It’s a real growth and opportunity time for us, along with a challenge.

What are some of the opportunities or challenges the ACA presents  free  clinics?

NICOLE LAMOUREUX: Well, I think definitely the opportunity that we see, and that we are hoping by telling the story of our clinics across the country and the amazing work that they do on a daily basis, we’re hoping to highlight how critical we are to the nation’s safety net. We are an essential piece to the safety net and that’s an opportunity, to tell the story of who’s left behind when it comes to the Affordable Care Act, the stories of the patients that are not going to receive coverage.

Some of the challenges that we are addressing are not just for our clinics, but also for our patients: Whether or not people understand what the Affordable Care Act is, if someone gets an insurance card in their pocket, will there be a flooded healthcare system? Will there be a doctor to accept their health insurance? What about the hours of operation, as I talked about before? What about citizenship? Affordability of these programs that are there, especially in those states that did not expand their Medicaid programs? Transportation, how people are going to get to and from the doctor? Sometimes it’s great to have an insurance card in your pocket, but if you don’t have the $20.00 to go round trip to your doctor that becomes a challenge for you to get that health care.

Will charitable healthcare remain a relevant model?

NICOLE LAMOUREUX: Again, one of the most common misconceptions about how the U.S. will look after the full implementation of the ACA, is that there will no longer be a need for our clinics to continue to provide charity care as a member of the safety net. People are surprised to hear that according to the Congressional Budget Office – there may be as many as 29 million people, including documented, undocumented, and those who are eligible for Medicaid, but reside in states that are not going  to expand this program, who are still without access to health insurance. So we feel at the national level in the upcoming months and years, doctors and hospitals, navigators, states, and our clinics, as well as other members of the safety net, will be addressing the needs of the underserved with respect to affordability and accessibility of primary, specialty, dental care, and medication access. There will continue to be a need for charity care in the United States after the full implementation of the Affordable Care Act.

The following provides an overview of demographic information from 2013 for the almost 22 million people treated annually at the nation’s Federally Qualified Health Centers (FQHCs).

• 21.7 million total patients served
• 7.6 million patients (34.9%) lacked health insurance
• Of individuals for whom income level was known, the vast majority (71.9%) were living at 100% or below of the Federal Poverty Level (FPL) – in 2013, that amounted to $11,490 for an individual and $23,550 for a family of four.

The following charts show demographic information on patients at FQHCs in 2013, and what has changed compared to previous years.

For the last five years the percent of individuals with incomes at or below 100% of the FPL seeking care at FQHCs has hardly varied (71.4-71.9%).

While the percentage remained fairly stable, this is actually an aggregate increase from 10.1 million to 11.7 million individuals.

From 2012 to 2013 not only did the uninsured percentage of patients seen at FQHCs decrease, but the aggregate number did as well, from 7.59 million to 7.57 million.* 2013 also saw an increase in patients using Medicaid, a continuation of the change seen in 2010 when Medicaid patients first exceeded uninsured patients. * The only other insurance category that decreased in both percentage and number was Other Public Insurance (non- Medicaid or Medicare).

Those aged 60-74 years were the fastest growing group as a proportion of the whole. This is a continued age increase from 2010 when the fastest growing group was those aged 50-64 years.

By gender, the five most common ages of patients seen at FQHCS were:

• Males 0-9 yrs (2,142,889)
• Females 20-29 yrs (2,128,691)
• Females 0-9 yrs (2,057,539)
• Females 30-39 yrs (1,887,387)
• Females 10-19 yrs (1,775,540)

Safety-net health facilities, such as the Federally Qualified Health Centers, play a critical role in providing care for at least 1 in 13 Americans. As part of a health network caring for under- and uninsured working class poor that do not otherwise have access to health care it is important that not only do the services exist, but that they are of the highest standards. Indeed, a 2011 study conducted by Randall Stafford, MD, PhD of Stanford University found that despite treating significantly more “medically and socially complex patients” than those seen by private providers, community health centers actually provide “better care than do private practices.”

There’s a significant portion of our population that probably has not ever been insured in their adult life.” — Rhonda Stuart, Enabling Services Manager, Northern Health Centers, Lakewood, WI In 2011 the Health Resources and Services Administration changed the way in which diagnoses at Federally Qualified Health Centers were tracked to include all diagnoses at a visit, regardless of primacy. Previously only the primary diagnosis was used to estimate percent of patients with a condition or for tracking number of visits. The change, however, took into account that primary diagnosis alone likely underestimates the morbidity and burden of certain conditions for the patients and for the health centers. This hypothesis is carried out when comparing the data on total visits by diagnosis from 2011, for which the data showed 12.3% of visits were related to hypertension, diabetes, heart disease and asthma, and 2013, for which the new calculation gives 22.8% for the same four conditions.

The new data collection parameters already show a greater number of patients than previously estimated for all tracked diagnoses, giving a more accurate portrayal of the burden on FQHCs for service provision. Particularly with chronic conditions, which account for a large percentage of total services provided, there is an even greater stress placed on clinics due to these conditions requiring services over a longer period of time. It is thus up to FQHCs to provide high quality care to a growing population of patients with increasing needs.

From 2010-2013 FQHCs saw the percentage of adults aged 18 and older with a hypertension diagnosis increase by 11.0%. In fact, hypertension as a primary or related diagnosis accounted for more visits in 2013 than any other condition, a total of 9,472,375. While the rate of FQHC patients with hypertension is increasing, the patient population at these safety-net facilities tend to actually have a lower rate than for the state population.

States colored in blue have a lower rate of diagnosed hypertension at FQHCs than the rate for that respective state. States in red scale have a greater rate of diagnosed hypertension at FQHCs.

Despite the increasing burden of hypertension, FQHCs have shown to provide the utmost in quality of care for patients. Stafford’s study identified blood pressure screening as one of six measures that FQHCs and FQHC Look-Alikes performed better on than private primary care practices. As well, almost all state FQHC populations have met the United States’ Healthy People 2020  Target of 61.2% of adults with a hypertension diagnosis considered controlled. Fifteen states have not yet met the Target, but even the state with the lowest percentage of controlled hypertension, Arkansas, is only 5.3 percentage points away, with five years remaining.

Healthy People 2020 lists controlled hypertension as a Leading Health Indicator. The Target is  61.2% of adults with a hypertension diagnosis considered controlled. Thirty-five states have met the Target within the FQHC population.

A condition that has a similar weight on safety net resources is diabetes. Of note is that diabetes is over represented amongst FQHC patients compared to the rest of the US population. The rate of diagnosed diabetes among adults aged 18 and older is higher in the FQHC population in all but one state. As many FQHCs continue to see an increase in the proportion of patients with

controlled diabetes, they are also thus faced with a greater demand for services and medication. No state has yet met the Healthy People 2020 Target of 83.9% of adults with a diabetes diagnosis considered controlled. The over burden of diabetes exemplifies the need for support and resources to enable safety-net facilities to provide and expand quality care for all their patients.

These quality of care measures for chronic diseases are important as if these intermediate outcomes are improved, then later poor health outcomes will be far less likely. Direct Relief USA works with more than 1,200 clinic partners across the country, more than half of which are Federally Qualified Health Centers like the ones studied. The report from Stanford and the collected FQHC data confirm that the patients Direct Relief’s clinic partners serve can access quality care from what many acknowledge is an already- strained network caring for a disproportionate share of socially vulnerable and chronically ill patients.

States colored in blue have a lower rate of physician diagnosed diabetes at FQHCs than the rate for that respective state. States in red scale have a greater rate of diagnosed diabetes at FQHCs.

Healthy People 2020 lists controlled diabetes (Hb A1c <9%) as a Leading Health Indicator. The Target is 83.9% of adults with a diabetes diagnosis considered controlled. No state has yet met the Target within the FQHC population.

The preeminent issue for understanding the impact of the ACA upon uninsured people across the country remains the status of their state relative to the Medicaid expansion portion of the law. According to a study published in Health Affairs1 along with related studies published by RAND and the Kaiser Family Foundation, there are likely an estimated 8 million individuals living  in the 25 states which are not expanding Medicaid who would be newly insured this year had their states opted in to the Medicaid expansion provisions of the ACA. Almost all of these individuals will remain uninsured, given that their incomes will likely remain too low to qualify for the health insurance exchange subsidies, yet not low enough to fall within prior Medicaid qualifications. Subsidy amounts were set at a minimum of 138 percent of the Federal Poverty Level (FPL) for a family of three, under the assumption that Medicaid expansion would take care of coverage for those households and individuals between 100 percent and 138 percent of FPL.

Among those nearly 8 million uninsured individuals exist hundreds of thousands of cases of depression, diabetes, and other chronic illnesses which will likely require some form of charitable mechanism to address. The most incisive study to date on the possible impact of the uneven Medicaid expansion landscape on the health of people without insurance was published by JAMA in April 20144. According to the authors’ interpretation of health data collected from a national pool of roughly 19,000 persons living under the 138% FPL threshold, chronic conditions such as hypertension, cancer, stroke, and respiratory diseases were significantly more prevalent among those living in non-expansion states. In other words, poor residents of non-expansion states will not only be unlikely to receive additional assistance from the ACA with improved access to healthcare payments, but are also already in poorer health than their counterparts in Medicaid expansion states. Granted, health insurance in itself does not guarantee access to quality healthcare. Yet the best evidence available indicates that where you live in the future may play an even greater role in the health outcomes than it has so far.

Local, just as much as national, landscapes of care are shaped by the conditions of place. Cities like Las Vegas, NV and New Orleans, LA face very similar challenges in the post-ACA world. The populations of these cities are of similar population size and income distributions. Both have dealt with significant challenges over the past several years: Las Vegas through the crisis in the housing market and the pressures of economic recession, New Orleans with the aftershocks of Hurricane Katrina and their own recessionary trends since 2008. Mapping the census blocks of each city according to the ACA’s new Medicaid eligibility levels (138% FPL) in relation to the locations of safety net facilities reveals high densities of proximate neighborhoods with high likelihood of significant numbers of newly insured people. Yet, of course, these landscapes mean very different things in 2014 based upon differences in approach at the state level to the ACA. In Las Vegas, given that Nevada is participating in the Medicaid expansion, census blocks with median income levels of 138% FPL and below will be likely to put pressure on the safety net through increases in new Medicaid patients. In New Orleans, however, given Louisiana’s opposition to the Medicaid expansion, this very same landscape is one which indicates persistent uninsured levels and sizeable ongoing gaps in the ability to pay for healthcare services. In each case, safety net institutions face significant pressures, but the nature of those pressures differs markedly depending on where they occur and how their states have chosen to approach the implementation of the ACA.

Community Health & Medicaid Expansion

Community health centers are experiencing in 2014 an overall increase nationwide in people seeking care at their facilities, but a decrease in people who are uninsured. This finding accords with a number of other recent indicators showing that the ACA does appear to be reducing uninsured rates nationally. However, Direct Relief’s poll also shows that the impact of the ACA is highly variable based upon geography.

Respondents in states which are not expanding the Medicaid program overwhelmingly reported that their uninsured rates have actually been increasing, whereas the opposite was true in states which have undertaken Medicaid expansion. Respondents from states that have adopted expanded Medicaid eligibility authorized under the Affordable Care Act also indicated that they hold a substantially more favorable view of the law’s impact than those in non-expansion states.

These findings come from a poll of nearly 100 community health centers conducted by Direct Relief in August 2014 at the annual conference of the National Association of Community Health Centers. Survey respondents collectively serve more than 1.5 million people and operate clinical sites in 27 U.S. states.

• Affordable Care Act  (ACA) – requires health insurance for most citizens and legal residents of the U.S., and provides for the creation of state-based American Health Benefit Exchanges through which individuals can purchase coverage, with premium and cost sharing credits available to individuals/families with income between 133-400% of the Federal Poverty Level. The ACA creates separate Exchanges through which small businesses can purchase coverage. . Requires employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers. Impose new regulations on health plans in the Exchanges and in the individual and small group markets. Expands Medicaid to 133% of the Federal Poverty Level.
• Community Clinic – a nonprofit provider agency that treats anyone regardless of ability to pay, but generally charges patients on a sliding fee scale. Federally Qualified Health Center (FQHC) – public and private nonprofit healthcare providers located in medically underserved areas that treat anyone regardless of ability to pay, and meet certain federal criteria under the Health Center Consolidation Act (Section 330 of the Public Health Service Act). There are 1,202 FQHCs operating over 8,000 sites in 2013 that treated 21.7 million people across the United States, of whom 7.6 million lacked health insurance.
• Direct Relief Partner – a community clinic, Federally Qualified Health Center, or free or charitable clinic that was vetted and approved to be part of the Direct Relief Partner
• Direct Relief Partner Network – the network of more than 1,200 community clinics, Federally Qualified Health Centers, and free or charitable clinics that Direct Relief currently supports with donations of free medicine and medical supplies.Network.
• Federal Poverty Level (FPL) – the set minimum amount of gross income that a family needs for food, clothing, transportation, shelter, and other necessities as determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines.
• Free Clinic – a nonprofit, usually volunteer-based provider facility that treats anyone regardless of ability to pay, typically free of charge or with a nominal donation for services. An estimated 1,200 free clinic operate across the United States.
• Look-Alike – an organization that meets the eligibility requirements of Section 330 of the Public Health Service Act, but does not receive federal grant funding. Look-Alikes receive many of the same benefits as FQHCs, including enhanced Medicare and Medicaid reimbursement, and eligibility to purchase prescription and non-prescription medications at a reduced rate. There were 100 Look-Alikes in 2013 that treated 1.0 million people across the United States, of Whom 329,000 lacked health insurance.
• Medicaid – a U.S. government program—financed by federal, state, and local funds—that provides health coverage for lower-income people, families and children, the elderly, and people with disabilities.
• Safety Net – the network of nonprofit provider agencies that deliver health services to vulnerable populations experiencing financial, cultural, linguistic, geographic, or other obstacles to accessing adequate health care. The nation’s healthcare safety net includes more than 10,000 clinical sites providing comprehensive, culturally-competent health services to more than 24 million people regardless of their ability to pay.

HEALTH RESOURCES AND SERVICES ADMINISTRATION – Uniform Data System: The information presented here applies to those entities from which the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) collects data through the Uniform Data System (UDS). These are grantees of the following HRSA primary care programs: Community Health Centers, Health Care for the Homeless, and Public Housing Primary Care providers. Grantees can be found in all 50 states, the District of Columbia, and U.S. territories. The reported data should not be
extrapolated to any other population as it is representative only of those individuals who utilize services of FQHC grantees. Please note that rates of diagnoses, insurance levels, demographics, etc. are descriptive measurements to provide context and are not intended for the sake of population-level analysis or comparison with institutions that are not nonprofit safety-net health centers and clinics. For example, a particular health center might show that a high percentage of its patient population consists of homeless individuals. This does not necessarily mean that the area in which it operates has an exceptionally high rate of homelessness. Rather, the health center may have specific programs and outreach aimed at bringing health care to homeless individuals. Such a program therefore would skew the facility’s patient population numbers not only away from the norm of its service area, but also from levels seen at FQHCs without such programs. Likewise, disease diagnosis rates recorded at these institutions should not be mistaken for disease prevalence rates among the area’s general population. It should also be noted, however, that all FQHCs are located by law in areas that are deemed by the federal government to be medically underserved.

COMMUNITY HEALTH INSTITUTE AND EXPO FLASH POLL: During the 2014 Community Health Institute and Expo hosted by the National Association of Community Health Centers, Direct Relief surveyed attendees regarding their perceptions related to health centers, their patient population, and the Affordable Care Act. The survey was a total of six questions and each respondent represented an individual from a health center. Fifty-six responses were garnered from this population from August 23-24, 2014.

VOICES OF THE SAFETY NET: Interviews took place with nonprofit safety-net clinic and health center staff, as well as national associations from August 2013 – March 2014. Quotes from the following interviews are included in this report:

• Dan Ahearn, CEO, Community Health Alliance, Reno, NV
• Jane Calhoun, VP Medical Affairs & Clinical Director, Delta Health Alliance, Stonesville, MS Shane Chen, Chief Operations Officer, Asian American Health Coalition Clinic, Houston, TX Pam Cross-Cupit,
• Executive Director, Health Alliance for the Uninsured, Oklahoma City, OK Alieta Eck, Founder, Zarepath Health Center, Somerset, NJ
• Richard Gibbs, President and Co-Founder, San Francisco Free Clinic, San Francisco, CA Sean Granahan, President/General Counsel, The Floating Hospital, Long Island City, NY Jim Harris, CEO, Health
• Access Incorporated, Clarksburg, WV
• Beth Houghton, Executive Director, St. Petersburg Free Clinic, St. Petersburg, FL
• Florence Jameson, Founder and CEO, Volunteers in Medicine of Southern Nevada, Las Vegas, NV Judy Jones, Executive Director, Bethel Free Health Clinic Inc., Biloxi, MS
• Rhonda Stuart, Enabling Services Manager, Northern Health Centers, Lakewood, WI
• Ana Taras, Chief of Strategic Initiatives, William F. Ryan Community Health Center, New York, NY Tom Tocher, Chief Clinical Officer, Community Health Center of Snohomish County, Everett, WA Barb
• Tylenda, Executive Director, Health Care Network, Racine, WI
• Shondra Williams, CEO, Jefferson Community Health Care Centers, Marrero, LA
• Nicole Lamoureux, Executive Director National Association of Free and Charitable Clinics, Alexandria, VA

Since 1948, Direct Relief has provided humanitarian assistance to improve the health and quality of life of people affected by poverty and disasters throughout the world by providing essential material resources—medicine, medical supplies, and basic equipment. Direct Relief is the nation’s leading nonprofit provider of donated medicines to community clinics, free clinics, and community health centers for low-income patients without health insurance. It operates the largest charitable medicines program of its kind, and is the only nonprofit that is certified by the National Association of Boards of Pharmacy to distribute prescription medicine in all 50 states. Since 2004, Direct Relief has delivered more than $440 million (wholesale) in medical resources to more than 1,200 nonprofit clinic and health centers.

Direct Relief is recognized for its fiscal strength, accountability and efficiency, and consistently achieves top rankings from Forbes, Charity Navigator (including “Top Charity” and “4-Stars”), the Better Business Bureau, and Consumers Digest. In 2011, Forbes rated Direct Relief “100% efficient” and “[Among the] 20 most efficient large U.S. charities.”