PUTNEY -- The plan from the start was to only offer a free walk-in medical clinic in Putney until the state or federal government improved access to medical care for everyone.
Even back in 1991, when Richard Fletcher started the clinic in the Putney Medical Office, then-candidate Bill Clinton was campaigning on the promise of improving the health care system.
Two years later his wife, Hillary, would issue her more-than 1,000 page health care report, which ultimately was defeated.
So Fletcher's work continued.
Fletcher opened the clinic in collaboration with Putney Family Services at a time when skyrocketing insurance premiums, bloated malpractice insurance plans, and a shortage of rural primary care doctors were all leading to a crisis in the medical field.
For almost 23 years Fletcher and a small group of volunteer doctors, nurses and assistants served anyone who walked in to the Putney office on a Thursday afternoon.
But now, as Vermont and the nation move ahead with the Affordable Care Act and more people are signing up to health care plans, organizers who run the Putney Walk-in clinic say there is less of a call for their services.
Last Thursday the clinic closed its doors for the final time.
Changes in Vermont's health care system have led to a significant drop in the number of patients who are using the clinic, former clinic Director Leon Cooper said.
And at the same time, Cooper said, by remaining open the clinic was, in a way, preventing people who should be signing on to the state's new health insurance from doing so.
"Our intention from the beginning was to see ourselves out the door and hope that eventually the country or Vermont would get its act together on health care," Cooper said. "We didn't want to become a permanent finger in the dike."
Over the past year, as Vermont has tried to aggressively get people to sign up with the state's new health insurance plans, the number of people coming in to the clinic has dropped.
A few years ago, on average, five or six people would come in during the hour-and-a-half the clinic was open, and on some nights a dozen or more patients might come in.
During the last few months the average has dropped to two or three, and on some nights no one would show up.
"Vermont has always done a good job of making sure people were covered, but once the Affordable Care Act passed our numbers dropped even more," Copper said. "The hand writing was on the wall."
Amy Hamlin is executive director of Volunteers in Medicine, a national non-profit organization based in Burlington that helps communities open free medical clinics by offering technical and business planning assistance.
Hamlin said Volunteers in Medicine is as busy as ever in other parts of the country where state plans and the Affordable Care Act are either nonexistent or just getting off the ground.
But she said she was not surprised to hear about the Putney Walk-in clinic's story.
"Vermont is way ahead of the game compared to other states," Hamlin said. "The reality is that unlike so many other states, Vermont has a pretty good track record of taking care of people who are outside the system."
Across the country, according to Hamlin, it is going to be important to continue supporting and opening free clinics even as the Affordable Care Act moves forward.
An estimated 31 million people will be uninsured, even when the Affordable Care Act is fully implemented in 2024 she said, and even low income individuals who have a plan may not seek medical care to avoid paying a premium.
In Vermont though, she said, the state's drive to get more people insured will probably lead to additional free clinics closing.
"Given what we know about Vermont, which has had a very enlightened policy around health insurance, we don't think there is a need to expand clinics here," she said. "The last thing free clinics want to do is duplicate services"
Cooper said when the clinic was open it thrived due to the wide ranging support it received.
Hotel Pharmacy for years donated all of the medicine, and even when it started charging the clinic it only billed them at cost.
Doctors and nurses who worked an eight to 10 hour day spent an extra two to three hours at the clinic.
And there were always local donations coming in through Putney Family Services specifically earmarked to the clinic to help cover the approximately $42,000 it took to keep the doors open.
Cooper, as a Putney Family Services employee, has been clinic director for 16 years.
As clinic director it was Cooper's job to staff the clinic, which was open Thursday afternoons from 6:30 to 8 p.m.
He said it has been increasingly hard to find volunteers.
And with the impacts from the Affordable Care Act so evident, Cooper said it was harder for him to continue asking the busy doctors and nurses to work when their services were less needed.
Cooper also said Putney Family Services board members and staff thought that by keeping the clinic open they were giving patients a reason not to enroll in the statewide system.
"It got to the point where we realized that the people we were seeing should be enrolled," he said. "Everyone has a story about why they won't enroll, but it was hard to ask these doctors and nurses to volunteer time to see people who were taking advantage of the system. We were enabling people to not do what they ought to have been doing. It was clear we needed to come up with a different model."
Putney Family Services is a designated navigator for Vermont Health Connect and Cooper will continue working with uninsured and underinsured Vermonters who are trying to figure out how to enroll in the new health care system.
And while he understands that the clinic's closing was inevitable, and in many ways marks an improvement in the health care system, there was still some regret in closing the doors last Thursday night.
"It's bittersweet. Being around those volunteers was inspiring," Cooper said. "And it was nice being able to help those people every week. You can really do something in a short period of time that makes a huge difference for someone, and I will miss that."
Howard Weiss-Tisman can be reached at firstname.lastname@example.org or 802-254-2311, ext. 279.