1998 Winner
Buncombe County, NC
Innovations in American Government Awards
Innovations in American Government Awards
North Carolina

Due to the skyrocketing cost of heath care, providing practical health services to citizens of low to moderate income is a challenge for most communities in the United States. With an income that is both too high to qualify for the traditional state-sponsored support, and too low to enable them to purchase health care on their own, the lower middle class often finds themselves "squeezed out" of appropriate care. The health care they do receive is often delayed and episodic, more likely experienced in the emergency room than in the doctor's office. As emergency care is significantly more expensive than prevention and early intervention, the cost of care for the uninsured often reaches beyond their means to become the taxpayer's burden.

In Buncombe County, North Carolina, the county government has chosen to broaden the character of their department of Public Health beyond the traditional role of food and water inspection, epidemic tracking, etc. The new role now includes health care for the uninsured. Building on a long-history of free care for the indigent, county officials have created a program called Buncombe County Medical Society (BCMS) Project Access, which solicits, manages, and distributes voluntary free care from local medical professionals for its uninsured citizens.

The key to the program is the management of specific appointments that are offered free by participating health care professionals. Most Project Access clients enter the program either through referral from the local clinic when it is discovered that they don't have insurance. If the patient needs a referral, the referring doctor will consult a database, produced by Project Access, to find an appointment. When the patient goes to the appointment, she presents a membership card, which is treated in a very similar way to an insurance card. This creates a sense of privacy protecting the client from the stigma of public assistance. 

The project is innovatively funded by an appropriation of the County's indigent care fund. The funds that typically went to subsidize area hospitals for unreimbursed indigent care now contribute to emergency prevention. The participating physicians are asked to volunteer their services to the program. Specifically, each member of the Buncombe County Medical Society is asked to make a pledge to see a specified number of Project Access patients in one year, free of charge. The local pharmacies pledge to provide medication to participants at cost, for which the government reimburses the participant through county funds. Even all three local hospitals pledge free services to the participants. The incentives for making this pledge are significant: membership in the BCMS is highly respected in the county, the members are acknowledged yearly in the local papers, a "Good Samaritan" law protects them from liability for free services rendered, and the services represent a tangible contribution from the medical community to the welfare of local citizenry. Perhaps more importantly though, those physicians who do not participate are subtly stigmatized, and often passed over by primary physicians when referring their insured clients.

The impact of the program is significant; Buncombe County has effectively ensured that every citizen has access to health insurance of some kind. Specifically, over 500 local health professionals participate in the program, providing comprehensive care to 13,000 of the County's uninsured residents. Usually taken at the regional or national level, other efforts at health care reform have met with mixed results at best. Commonly based on discounts of the traditional fee-for-service model, these reforms neglect to take advantage of the huge potential for savings offered by a simple shift in focus, from cure to prevention. In Buncombe County, they have created a community-based solution that considers prevention as an important aspect of health care and health care as an important aspect of public health.

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