Making Health Care and Legal Services Accessible to Those Who Need Them Most

    • March 20, 2015

In 2012, the Robert Wood Johnson Foundation (RWJF) named Amy Johnson, JD, an RWJF Community Health Leader in recognition of her leadership in establishing Harmony Health Clinic in Little Rock, Ark. The free clinic serves the working poor—people who don’t qualify for Medicaid or Medicare and do not make enough money to afford health insurance.

Johnson developed the clinic as a volunteer. In her paid position as executive director of the Arkansas Access to Justice Commission, Johnson also works to help low-income Arkansans overcome legal barriers that perpetuate poverty. In that role, she has helped raise more than $2.1 million to support the provision of free legal aid to low-income people.

The problem...and progress. In 2012, Arkansas ranked near the bottom in the country on many health indicators, and more than 20 percent of its residents were uninsured. In a short time, the number of uninsured in Arkansas had been cut nearly in half—from 22.5 percent in 2013 to 12.4 percent midway through 2014, thanks in large part to a state-federal partnership under the Affordable Care Act (ACA) that uses federal Medicaid money to subsidize private coverage for people newly eligible for Medicaid under the Act.

While the progress is good news, gaps remain. Lack of access to basic dental care continues to be an enormous public health issue in Arkansas. Medicaid covers only basic dental service, Johnson says, and there is a shortage of dentists in Arkansas, and even fewer that accept Medicaid.

“The waiting times are often so long that we’ve had people who come into the clinic who have pulled their own teeth.”—Amy Johnson

Volunteer dentists working at Harmony Health told Johnson that the condition of people’s mouths was similar to what they had seen in third-world countries.

Lack of access = lack of health. Johnson grew up in Northwest Arkansas and during her first job after college got her first glimpse of what lack of access to basic services can do to a person. As a caseworker at a residential facility for adults with developmental disabilities in Little Rock, she realized that many of her middle-aged clients had lived at home most of their lives and had never had access to community support services.

“They ended up at the facility,” she says, “when they became too much for their parents to handle, or their parents became elderly or sick. That led me to see ... how lack of access to services, specifically mental health supportive services and legal help, can result in really negative consequences for people.”

One of Johnson’s roles as caseworker was to identify people who could serve as guardians to advocate for her clients. Sitting in court hearings piqued her interest in the legal profession. “Those people simply needed a voice,” she says.

Johnson went on to law school at the University of Arkansas, Little Rock, and after graduating in 2002 was hired by a private law firm that did primarily health care regulatory work. “I enjoyed practicing law,” she says, “but I was working for corporations, hospitals, and nursing homes, which was all worthy and important, but I didn’t feel like it was enough.”

In 2005, Johnson reconnected with Matt House, a classmate from Hendrix College in Conway, Ark., where she had gotten her undergraduate degree in psychology. “He wanted to start a health clinic and that was something that immediately appealed to me,” she says. “I felt that I could use my training and my background to do something that would actually make a direct and positive impact on people.”

More than just meeting health care needs. Neither Johnson nor House knew anything about setting up a health clinic, so they held dozens of meetings with leaders in the community, as well as those in other states who had created charitable clinics. “Sometimes it would be just Matt and I to show up at these meetings,” Johnson says. “We were told over and over again, ‘Well, good luck with that!’ I suppose this could have just as easily ended up falling on its face. But that is a risk you have to be willing to take.”

Three years later, in 2008, Harmony Health Clinic opened its doors. A small paid staff and volunteers provide all of the direct services. About one-third of the clinic’s funding comes through contracts and grants, one-third through special community fundraising events, and another one-third from private donations.

From the beginning, how patients felt when they walked through the door was as important as the health care they received. “Our staff and volunteers really work hard to make sure everyone feels welcome,” Johnson says. “They are not just patients, they are our neighbors.”

“The clinic is a place you can come not just to get your meds or get treatment for an illness. It is a place to come and feel accepted and loved. We are doing more than just meeting health care needs.”—Amy Johnson

By 2012, the clinic had 2,000 patients, the vast majority of whom suffered from chronic conditions such as diabetes, heart disease, high blood pressure, and obesity. Dealing with these conditions early can help avoid bigger health problems later. Johnson says the care provided that year translated into approximately 1,000 fewer emergency room visits. And many families were saved from the financial ruin that often follows an uninsured hospital stay.

“We have been able to be a step along the way for people to become more self sufficient,” Johnson says “and to avoid being in a situation where they would have much more catastrophic health issues and associated catastrophic costs.”

Filling the gaps in teeth...and in dental coverage with her Community Health Leader award. After Arkansas’s ACA-authorized private option health exchange was implemented, the number of patients visiting Harmony Health Clinic for general medical care was reduced by half. But demand for dental care remains “overwhelming,” Johnson says. “We have about 1,000 dental patients and could double that number quickly if we had additional staff and volunteer capacity.”

Approximately 15 percent of adult patients seen by Harmony have never been to a dentist, so awareness of good oral hygiene practices is often lacking. Complicating this is the prevalence of lower health literacy among patients seen at Harmony.

To address this need, in 2012, Johnson used the $105,000 project portion of her $125,000 Community Health Leader award to create Healthy Smiles, a comprehensive hygiene education program within Harmony Health Clinic designed to break the cycle of poor oral health. Some 100 patients enrolled in the program, and as of the end of 2014, 65 patients had received examinations, treatments, and oral hygiene and nutrition education. Nearly half of the participating patients had other chronic medical conditions, such as high blood pressure or diabetes.

One of the patients who participated was Walt (not his real name), a 52-year old former methamphetamine addict who has been in recovery for six years. Many of Walt’s teeth were ravaged by decay and erosion caused by his previous meth use. As a result of the Healthy Smiles program, Walt received a full lower denture and partial upper denture, along with care for his salvageable teeth. And he learned through the hygiene instruction portion of the program the steps for maintaining his improved oral health.

“Here is a guy who had messed up and was trying to do better for himself,” says Johnson, noting that Harmony Health is the only free clinic in Arkansas that provides free dentures. “Getting new teeth was the last step of what he needed to be able to get a job and do the things he needed to do to improve his life.”

Opening up access to legal services. Through her work with the Arkansas Access to Justice Commission, Johnson is also tackling another uphill battle: opening up access to legal services. “The United States ranks among third-world countries with regard to the accessibility and affordability of civil legal services," she says. "More than 90 percent of Arkansans with critical legal issues involving children, loss of housing, and domestic violence are left to represent themselves in court. We have to rethink the way the legal market and court system work to ensure that the amount of justice you get doesn't depend on the size of your bank account.”

The health care field provides a model, Johnson notes. “There are communities in Arkansas, which is a rural state, where there are no doctors,” she says. “The advanced practice nurses who provide the care are essential. It can be the same for the legal field. You need an attorney for really complicated matters, but for things that are more routine, you can have someone who is trained, but not necessarily a lawyer.”

Opening up access to legal services and information in Arkansas will be a tough sell, Johnson says. But she has no intention of giving up. “Right now people can’t afford to pay an attorney,” she says. “My dream is to make that possible.”

RWJF Community Health Leader perspective. Johnson says the Community Health Leader award has given her increased credibility with policymakers and organizations in Arkansas that are working to advance health care reforms. Johnson currently is a consumer representative on a payment reform initiative in Arkansas and serves on the board of the state’s Quality Improvement Organization. “The Community Health Leader award has been a significant influence in opening up some opportunities for me to get involved in shaping health care policy,” she says.

Johnson also has found among her fellow leaders a community of likeminded people unlike any other she had experienced in her professional life.

“Doing this kind of work can make you feel alone sometimes. You’re out there working in the trenches, without a lot support. So to be in a room with people who have experienced those same things...they understand you. And you have some of the smartest people doing this work. There is consensus on some basic things in terms of policy that need to happen.”—Amy Johnson

RWJF perspective. The Foundation recognized the first 10 RWJF Community Health Leaders in 1993—unsung and inspiring individuals who work in their communities, often among the most disenfranchised populations, to address some of the nation’s most intractable health care problems.

The formal recognition of these Robert Wood Johnson Foundation Community Health Leaders and their programs has often launched them to greater levels of influence and extended their reach to serve more vulnerable populations. For more information on the program see the Program Results Report.

“Community Health Leaders have been characterized by three specific traits—they are courageous, they are creative, and they are committed,” says National Program Director Janice Ford Griffin.

“Through the program, we at the Foundation have had the opportunity to recognize innovative and courageous local leaders behind ground-breaking efforts in communities across the United States,” says Sallie George, MPH, program officer at RWJF. “These individuals remind us that one person can have a powerful impact on health and health care within their communities.”

The last round of leaders was chosen in the fall of 2012. The program closed at the end of 2014.