Stevie and Lisa, a middle-aged couple, dealt with complex, chronic illnesses, lack of health insurance and no access to professional care. A hospital emergency room had been their only source of treatment, and this had worsened their persistent debts. A social worker wrote, "urgent needs from head to toe," on the referral note that she gave to the couple. They set out by bus, rested for a few hours at a motel, before joining hundreds of impoverished people who waited throughout the night for admission to a free health clinic. They were assigned numbers 461 and 462.

Reporter Eli Saslow, writing in The Washington Post on June 22, describes the heart-wrenching scene at the Cleveland, Tennessee, high school that would serve as a temporary medical clinic for the next two days. Remote Area Medical (RAM), a nonprofit organization, organized the clinic. Since its founding in 1985, RAM has provided free medical care for hundreds of thousands of people, coordinating the services of thousands of volunteer providers — nurses, dentists, physicians, lab and X-ray technicians, and counselors.

Once the doors of the clinic opened, the first 100 patients were ushered in. The high school had been organized into dental clinic, lab, X-ray facility and exam spaces. Stevie and Lisa entered when their numbers were called. Stevie needed attention to dental abscesses. Lisa's evaluation disclosed a dangerous situation, beyond the capabilities of the mobile clinic. An ambulance was summoned, and she was transported to a nearby emergency room. Following IV fluids and oral medications, she returned to the RAM clinic. The ER visit would add an estimated $3,000 to her medical debts.

The clinic had patched up Stevie and Lisa. They would return to their home in an unchanged predicament with no private transportation, no access to on-going health care for their multiple problems, and mounting debt.

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Clif Cleaveland

Following its services in Cleveland, the RAM clinic's next stops would be in Hazard, Kentucky, and Weatherford, Oklahoma. On many weekends, RAM will operate mobile clinics in two or three sites.

RAM provides invaluable services to many patients during its two-day clinics. The problem is lack of follow-up. What happens to a person with newly diagnosed diabetes, high blood pressure, or kidney disease if he returns to a county where there is no one to monitor his health or to provide medication and counseling? What happens to an opioid-addicted person or to an individual with mental health challenges? He is fortunate if he lives in an urban area where he may be able to find care in public or volunteer-manned clinics. This is not an option for residents of many Tennessee counties.

Too often, hospital emergency rooms become the health provider of last resort for urban and rural residents who lack health insurance. Unpaid bills accrue interest. Hospitals may utilize bill-collectors who, in turn, garnish wages. A nonprofit hospital system in Memphis recently earned condemnation in national and international media for its collection agency that relentlessly sued poor people, including hospital employees, for payment of medical debt. Imagine, if you are barely staying afloat financially and have a chunk of each paycheck garnished.

Tennessee's General Assembly is either unaware or does not care about the plight of poor, sick people who reside in our state. Legislators declined expansion of TennCare, which then-Gov. Bill Haslam advocated. Had the legislature acted, more than 200,000 non-elderly residents would have gained coverage. The federal government, under the Affordable Care Act, would have covered all of the expenses associated with the expansion for five years, and then covered 90% of costs thereafter. Expansion of TennCare would have relieved financial pressures on rural hospitals which struggle to stay open.

Read Eli Saslow's fine, investigative report. It presents a challenge for all of us.

Contact Clif Cleaveland at