[dropcap]T[/dropcap]here is an organization that has not been affected by any of the national health care debate or federal legislation in the last few years. Remote Area Medical (RAM) clinics have provided health care services to people who live in areas where such services are not available, or if they are available, are inaccessible. RAM provides dental care, vision care and medical care to patients, for free, no questions asked, and has been doing so since 1985.
RAM was founded by Stan Brock, who has led a full, colorful life that sounds like a movie script. He has worked as a cowboy, was a host on Mutual of Omaha’s Wild Kingdom and has dedicated years to the philanthropic endeavor that is RAM. Brock was injured as a young man while living in Guyana. When he was hurt, he was in a remote part of the country. It was a 26-day journey to the nearest doctor, and there was doubt as to whether or not he would survive. The experience inspired him to get his pilot’s license and begin flying medical personnel to similarly remote places to provide care.
Although originally RAM provided services in places such as Guyana, the organization soon found there was a great need in the United States. Today 90% of the work RAM does is in the US, though they still operate clinics in Guyana and provide disaster relief throughout the world.
Even in the early days of holding US clinics, RAM faced a problem. The state of Tennessee, at that time, did not allow medical volunteers from out of state to provide care to residents. Brock himself led the movement to change the law, and in 1997, Tennessee passed legislation recognizing medical licenses from other states for volunteers to provide free medical care to the indigent population.
Today, 38 states still do not allow volunteers to provide medical care if they are not licensed within the state where the care will be provided. For example, if a physician from Ohio agrees to volunteer with RAM, and wants to attend a clinic being held in Texas, unless the physician goes through the process to become licensed in Texas, it is illegal to provide care there. Although there are some federal standards for medical education, each state operates a medical board which oversees licensure, and the requirements are wildly different state-to-state.
The Affordable Care Act (ACA) has not impacted RAM clinics, because the majority of people who attend the clinics are coming for dental and vision care, and the ACA largely does not address those needs. Brock says that none of the recent legislation in the national spotlight is likely to affect the people who come to RAM clinics. However, the state laws related to medical licensure represent a significant barrier to providing free services to a segment of the population that has few, if any, other options for care.
[dropcap]T[/dropcap]here are several reasons state medical boards may consider more leniency when it comes to licensure. In the aftermath of Hurricane Katrina, it became clear that states needed to have exceptions for emergency situations.
The authors of a 2014 article, “Liability Reforms Needed to Provide Timely Care to Disaster Victims,” published in the Bulletin of the American College of Surgeons, describe some of the difficulties that volunteers faced in trying to help victims of the disaster. They say that more than 33,000 volunteer health professionals either responded to requests for assistance or arrived to help.
“However, legal issues, such as licensing and credentialing, civil liability, and reparations for harm to volunteers, delayed or prevented these volunteers from providing care,” say Naveen Sangji, MD, and the co-authors of the article.
Many states have since enacted good samaritan laws or other legislation relevant to disasters or emergency situations.
Attorney Denise Bloch of Sandberg Phoenix & von Gontard in St. Louis, Missouri, says that emergency situations and the services that RAM provides through their clinics are different issues. When there are emergencies such as Katrina, or the tornadoes in Joplin, Missouri in 2011, volunteers must be mobilized and nearly all states have some sort of legal provision for those situations.
“Then you have the other issue,” she says, “and that is when the population is so rural, so poor and so underserved. That’s a totally different circumstance, and that’s where not all states are allowing volunteers, and there’s no other access—that’s the key—there’s no other access to care, no matter how you look at it.”
Telemedicine is another area that is bringing the need for more streamlined licensing procedures to the forefront. The promise of telemedicine—that patients can get care even if the clinician is not physically accessible—is less exciting when state lines effectively represent walls that limit access to care.
Yet, although telemedicine may help bring care to those who otherwise don’t have access, it does not address the same issues that RAM does. In order to benefit from telemedicine, patients still need some sort of health insurance coverage or to pay out of pocket, and physicians are providing the service as part of their regular practice with the expectation of remuneration. Patients at RAM clinics do not pay, and all care providers are volunteers.
The medical board in the state of North Carolina has streamlined the process of expedited licensure for applicants who have maintained a clean license in another jurisdiction and wish to become licensed in North Carolina. However, volunteers still must be licensed within the state.
Jean Fisher Brinkley, the communications director for the North Carolina Medical Board says it comes down to a thorny ethical question: “Is potentially poor care better than no care?” She adds that there have been cases where the North Carolina board declined licenses when other jurisdictions had granted them. The regulatory body exists, after all, to make sure that all licensees meet quality standards.
Brinkley says that all patients, regardless of their economic status, should not have to worry about whether or not the person providing health care services is qualified to do so.
“The board understands the need and demand for issuing licenses more quickly, but a critical point is that the board is only willing to streamline the process hand-in-hand with ensuring our standards of quality are met,” she says.
West Virginia recently passed legislation allowing physicians licensed in other states to volunteer to provide care to the indigent population. In 2016, during devastating floods in the state, RAM provided disaster relief. Now, the organization will be able to more easily hold clinics there.
Vicki Gregg, the clinic manager at RAM, says, “Dealing with a closed state or a state that won’t allow out-of-state providers, we are limited to trying to recruit from within and cannot call on the groups who are our staple providers.”
In addition to the complications posed by state medical board licensing regulations, RAM organizers must also address the regulations imposed by dental boards, nursing boards, and optometry boards, because professionals from all of the those fields volunteer at the clinics. Because 85% of the attendees at the clinics are there for dental care, recruiting dental care professionals is particularly important.
Disaster situations do not often require dentists or hygienists, and dental care cannot be delivered via telemedicine, so the forces that are driving change in medical licensure are not also shaping the course of dental licensure.
Gregg says that the community hosts she works with tell her it is often difficult to recruit volunteers among local dentists because the perception seems to be that the clinics take business from them. However, given the level of poverty and lack of dental insurance among many RAM patients, that seems unlikely. Legislation such as that passed in West Virginia offers one solution.
[dropcap]R[/dropcap]ecently, the United States Public Health Service (USPHS) signed a memorandum of understanding (MOU) with RAM. Although the commissioned corps officers are able to work in any state, the MOU will not change where clinics are held, or how RAM and the community that hosts it works with recruit volunteers. The MOU formalizes the relationship, allowing the USPHS to more widely advertise opportunities to volunteer with RAM within its ranks. RAM benefits from the additional volunteers.
Regardless of the outcome of the ubiquitous national debate about health care and health insurance, no pending outcome is likely to address the dental needs of the people who attend RAM clinics.
Whether the barriers to providing that care are overcome through changes to state law, cooperation among the various entities involved or through some other mechanism, many more people who have few other choices could receive care they desperately need.
