Organizational Evolution at the Washington Free Health Clinic

“Health care should not be a commodity,” insists Bill MacKaye, a former board member and volunteer at the Washington Free Health Clinic, which operated from approximately 1970 to 2000. This principle guided many of the Clinic’s policies and practices as well as representing a personal commitment by Bill and many others associated with the Clinic.

For the last two of those three decades, the non-profit clinic was housed at St. Stephen and the Incarnation Episcopal Church in Columbia Heights, DC. The clinic remodeled a space it rented from the Church, which had a longtime commitment to social justice, equality and inclusion. During those 20 years, the Clinic expanded its mission to include a variety of health services and underwent organizational transformation itself.

As Bill explained to me in a retrospective account of the Clinic on August 7, 2020, the organization was first established in about 1970 at the Georgetown Lutheran Church by members of the Georgetown Clergy Association and a group of nurses from the wider community. The Clinic’s mission at that time was largely to service young people in the community and the emphasis was on diagnosis and treatment of sexually transmitted diseases.

In the late 1970s, in an agreement with St. Stephen, the Clinic was supported as part of the Church’s broader social ministry. In the beginning of the Clinic’s second incarnation, there was a loose structure, with volunteers and paid staff; the emphasis was on relative equality between members who were paid (never more than three positions) and volunteers. As Bill describes the organization around 1980, it sought to operate as a collective. However, an organizational crisis occurred due to a lack of managerial skills by the administration and a budget that went into the red. The Clinic had to close completely for 18 months in 1980 and 1981.

There was clearly a need for a somewhat more formal structure, especially for fiscal management and the pursuit of both foundation grants and monies from federal agencies and programs. So, the board hired a new executive director with personal pledges by the board members to provide six months of salary. The urgent task was to create a revenue stream, which the new director accomplished. The clinic expanded its services to four-five evenings a week, took on HIV, prenatal care, and offered free deliveries to mothers. The directors for HIV and maternal care were among the paid staff during part of this period.

The Clinic maintained a comparatively “flat” structure where equality of membership meant that volunteers as well as paid staff had relatively equal authority. This also meant that volunteers, including those in roles as screeners, could readily voice opinions about individual patient care and about policies of the organization. One of the most significant lessons about patient care, according to Bill, was that every individual who came to the clinic was seen by four or five members of the Clinic: an initial screener, sometimes a second screener, a nurse practitioner, a physician, and an exit interviewer. This enhanced quality control as well as enriching care.

At the end of every evening’s office hours, available members gathered for about 30 minutes to discuss experiences and lessons from that day. This created an important feedback loop for information sharing and organizational self-assessment. In one discussion, Bill recounted, the lay screener was correct in inferences about a patient’s illness by pursuing a line of questions about the individual’s experience that a physician had overlooked. The physician praised the lay screener for the insight. This is a great example of how the Clinic balanced the often-found tension between equality and expertise through open and effective communication.

Many of the volunteer caregivers were physicians in residence in area medical schools and hospitals. Interestingly, as Bill observed, many of them valued their work at the Clinic over other parts of their practice. At the Clinic their time with patients “was not driven by the clock” but by what these professionals saw as the time needed to help the people they were seeing.

Funding for the Clinic came from a combination of grants and donations. Importantly, as Bill told me, every patient was asked for a donation as he or she departed after assessment and treatment. The Clinic regularly received as much money from patient donations as did other clinics that charged fees with sliding scales.

Although the Clinic itself dissolved in about 2000, it helped to create two other clinics that are still operating: The Whitman-Walker Clinic in downtown Washington and the Clinica del Pueblo in the Columbia Heights neighborhood of D.C. These spin-offs remind us of how organizations like the Washington Free Clinic have influence beyond their own walls.

I was of course curious from the start of my conversation with Bill about how the Clinic ultimately closed down. Bill described two important factors, which were to some degree interrelated. The Clinic’s board was not effective in raising funds, even after the organization faced earlier phases of financial crisis. At the same time, The Primary Care Association of the District of Columbia determined that, from their perspective, there were too many no-cost or low-cost clinics, including in Columbia Heights. The view was that it was “more respectful to provide patients with insurance so they could pay for care rather than to treat them for free.” The Clinic responded with the importance of their role in providing free care. Throughout its life it refused insurance payments (and insurance rules) and, again, stressed that health care should not be considered a commodity.

Of the important lessons from the experience of the Washington Free Clinic, Bill highlights shared governance in an atmosphere of equality. He also stresses the need for healthy checks-and-balances between the members (in this case paid and volunteer staff) and the board. Volunteers should be given significant responsibilities, Bill argues, and they will rise to meet high standards of service. The board should be heavily engaged in the enterprise, Bill maintains, and it should include sympathetic critics who serve the organization and its clientele by exploring better ways to do things.

Bill MacKaye’s own experience with the Free Clinic helped propel him into a second career in consulting about effective board governance in theological organizations. Ultimately, Bill would like to see a health care system in the US that is similar to the British National Health Service in removing health care entirely from the insurance context, where substantial time and money are spent determining that patients are ineligible for care. The “de-commodification” of health care is ultimately the path to resolving care and cost issues, according everyone the assurance and dignity they deserve.

Header image by Department of Foreign Affairs and Trade. CC-BY 2.0