A massive shift is on the horizon for Virginia’s health care landscape as the state prepares to expand its Medicaid program in January, broadening the eligibility and welcoming an estimated 400,000 people into its ranks.

But more than 300,000 uninsured Virginians will likely remain, many relying on the state’s free clinics. And as each of those clinics prepare for the big changes, it’s not entirely clear where they’ll be once the dust settles.

“It’s wonderful that we have been able to expand eligibility for the Medicaid program,” said Deborah D. Oswalt, executive director of the Virginia Health Care Foundation. “It is going to make a huge difference in the lives of so many uninsured Virginians. It’s fabulous, but we cannot just think, ‘O.K., problem solved.’”

There are about 718,000 uninsured Virginians in the state right now, according to the Virginia Health Care Foundation, which uses research from the Urban Institute Health Policy Center to develop its data.

About 395,000 Virginians will qualify for Medicaid under the new eligibility rules, which opens the program up to anyone who makes up to 138 percent of the federal poverty level, or about $33,948 for a family of four.

That will leave 323,000 Virginians without insurance who will still rely on free clinics or emergency departments for their care.

But Medicaid expansion brings with it a lot of uncertainties for many free clinics, who will see their patient populations drastically change. Some are estimating that as many as 70 or 80 percent of their patients will qualify once the new eligibility rules set in.

Most free clinics in the state serve those whose income is below 200 percent of the federal poverty level, or $50,200 for a family of four. The Virginia Health Care Foundation estimates that about 100,000 people make between 139 and 200 percent of the federal poverty level, meaning they will still qualify for a free clinic’s care even after Medicaid expansion.

“Experience in states that expanded Medicaid several years ago has shown us that people automatically think that there are no more uninsured people,” Oswalt said. “That is incorrect – the needs for the health safety net in those areas still exist, just as it will here.”

In the months leading up to expansion, the state’s free clinics are trying to determine how to best react to the changes, depending on what their communities need.

“And that’s really why these clinics started, to fill a gap,” said Linda Wilkinson, executive director of the Virginia Association of Free and Charitable Clinics. “But the gap is different in each community.”

Every free clinic in the state is different, and some might try to boost other services if they lose their medical populations. Medicaid only covers emergency dental care, leaving many free clinics to pick up the slack for those patients who have no other preventative dental options.

Some are considering whether or not there are enough Medicaid providers in their areas now, Wilkinson said. If there aren’t, they might try to become a hybrid provider, meaning they treat uninsured patients while simultaneously accepting Medicaid.

Others will try to change their strategies entirely to reach out to those 323,000 Virginians who will remain uninsured.

Right now, the state’s 60 free clinics see about 60,000 patients a year, according to the Association of Free and Charitable Clinics. That’s only a fraction of the state’s uninsured.

Medicaid expansion, Oswalt and Wilkinson said, might free the clinics up to reach out to those they haven’t treated before.

That’s Charlottesville Free Clinic’s approach. Executive Director Colleen Keller said there are about 12,000 uninsured people in Charlottesville and Albemarle County. An estimated 5,000 will qualify for Medicaid.

That still leaves 7,000 people who will need care, she said.

About 30 or 40 percent of the free clinic’s patients will likely qualify for Medicaid after expansion, she said. So the free clinic might stop operating at capacity and find room to change up how they reach out to patients. That could mean going into the community to directly engage with potential patients and encourage them to start seeking primary care.

Medicaid expansion is progress, Keller said, “but it will not completely mitigate the need for a safety net.”

But a lot of what Charlottesville Free Clinic does will depend on how Medicaid expansion occurs: if all of those 400,000 people sign up and how work requirements play out. That’s what many free clinics are wondering, and most are simply waiting to see what will happen in the next few years before significantly altering their programs.

Donna Proctor, executive director of the Free Clinic of Franklin County, said that her clinic is considering all its options, but she suspects some patients might not sign up for Medicaid out of their own refusal to accept government assistance.

She’s also concerned about the work requirement, which the General Assembly passed when it finally agreed to expand Medicaid in May. The work requirement likely will not come into effect until well after the Jan. 1 expansion, and the details around it have yet to be hammered out.

“We have a huge group of people who are self-employed – they’re mechanics or they’re dairy assistants, they do lumbering, those kinds of things,” Proctor said. “Because of the way they do their work, they’re not going to be able to meet the work requirement even though they do work.”

Oswalt also pointed to the Medicaid phenomenon known as “the churn.” Some people don’t make an income that consistently qualifies them for Medicaid. Their salary might send them above 138 percent of the federal poverty level during some months, making them ineligible for Medicaid coverage. When that happens, many will turn to the state’s free clinics.

“It is going to be a long time before the health safety net isn’t needed in Virginia,” Oswalt said. “I wish the time would be now, I wish we could just move onto some other problems. But that is not the case.”