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OCR for page 47
ThQ COrQ SOIQTY NQ! And the
SOfQtY NQ! SYSIQm
The concept of a health care safety net conjures up the image of a
tightly woven fabric of federal, state, and local programs stretched across
the nation ready to catch those who slip through the health insurance
system. As has already been cited in the opening chapter of this study,
America's safety net is neither secure nor uniform. Rather, it varies greatly
from state to state and from community to community, depending on the
number of uninsured people, the local health care market, the breadth
and depth of Medicaid and other programs directed at the poor and
uninsured populations, as well as the general political and economic envi-
ronment (Baxter and Mechanic, 1997~. These variations notwithstanding,
most communities can identify a set of hospitals and clinics that by man-
date or mission care for a proportionately greater share of poor and
uninsured people. Even within the new environment of choice and com-
petition, these core safety net providers continue to be relied upon to play
a critical role in providing access to health care for those who fall outside
the market, primarily members of the nation's poorest and most dis-
advantaged groups.
A precise measure of the total share of care to the poor and uninsured
populations delivered by safety net providers is difficult to come by,
given the safety net's variability across communities, the lack of adequate
and comparable data, as well as the lack of a consistent definition of the
"health care safety net." Estimates show, however, that although core
safety net providers such as community health centers (CHCs) and public
hospitals provide a relatively small share of care to the poor and un-
47
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48 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
insured, that share is disproportionate to that provided by other health
care providers. For example, 41 percent of federally qualified health center
(FQHC) patients are uninsured, 33 percent are on Medicaid, 86 percent
are low income, and 64 percent are people of color (Bureau of Primary
Health Care, 1998~. For outpatient clinics that are members of the National
Association of Public Hospitals and Health Systems (NAPH),~ 42 percent
of care is to self-paying patients or patients requesting charity care and 30
percent is to Medicaid patients (National Association of Public Hospitals
and Health Systems, 1999~. From 1990 to 1998, FQHCs saw a 60 percent
increase in the number of uninsured patients that they treated (Bureau of
Primary Health Care, 1990, 1998~.2
As part of their unique role and mission, core safety net providers
offer a combination of comprehensive medical and enabling or "wrap-
around" services (e.g., language interpretation, transportation, outreach,
and nutrition and social support services) specifically targeted to the needs
of the vulnerable populations. These services rarely generate sufficient
revenues to cover their costs and are thus less likely to be provided by
others in the community at large. Together with their commitment to the
care for the poor and uninsured, core safety net hospitals and health
systems offer critical highly specialized services such as trauma care, burn
care, and neonatal care to anyone in their communities. For example, in
1997, NAPH members represented 17 percent of hospital beds in the
markets but provided more than 25 percent of neonatal intensive care
beds, 66 percent of burn care beds, 33 percent of pediatric intensive care
beds, 45 percent of Level 1 trauma centers, and 24 percent of emergency
department visits (National Association of Public Hospitals and Health
Systems, 1999~.
In addition, major public teaching hospitals train large numbers of
physicians and other health professionals. In 1997, for example, NAPH
member hospitals trained almost 16,000 residents (National Association
of Public Hospitals and Health Systems, 1999~.
Another major characteristic of core safety net providers is their neg-
ligible ability to shift costs, given their payer and patient mix. Cost shift-
ing has, until recently, been a primary vehicle used by non-core safety net
providers as a means of subsidizing care for the uninsured population
(Cunningham et al., 1999; Davis et al., 1999~. However, core safety net
providers tend to have a small privately insured patient population, and
GRAPH represents over 100 safely net hospitals and health systems in metropolitan areas
around the country. Most members are major [caching hospitals or academic health science
centers.
2The 60 percent increase from 1990 to 1998 also reflects the expansion of the CHC pro-
gram to include homeless and public housing programs, adding 400,000 to 500,000 users,
most of whom are uninsured (Bonnie Lefkowitz, personal communication, February 2000~.
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
49
unlike their non-core safety net counterparts, these providers must rely
primarily on federal, state, and local grant funds and other forms of direct-
subsidy payments to provide care for the poor (e.g., charitable contribu-
tions and donations) (Davis et al., 1999; Rosenbaum, 1999~.
This inability to shift costs for uncompensated care onto private insur-
ance revenues has become an even more significant problem as revenues
from Medicaid, the primary source of third-party financing for the core
safety net providers, are restricted. Medicaid is a central rather than mar-
ginal third-party payer for the core safety net (Rosenbaum, 1999~. As a
result, if future Medicaid revenues decline (whether because of a drop in
the rate of coverage among the patient population or a drop in payment
levels for the patient population), core safety net providers must effec-
tively absorb this loss through the use of revenues and services intended
to provide care for those without the ability to pay. Moreover, unlike
private practitioners, core safety net providers cannot pass on their rev-
enue shortfalls in the form of patient cost sharing. Not only do the patients
of core safety net providers have little or no ability to pay, but the legal or
mission-based obligations of the safety net providers prevent this reallo-
cation of financial responsibilities.
Two Medicaid compensation systems the disproportionate share
hospital (DSH) payment program in the case of hospitals, and the FQHC
program in the case of federally funded health centers and certain other
entities have in the past yielded Medicaid compensation levels for the
core safety net that help avoid shifting costs by use of grants and subsi-
dies intended to provide care for the uninsured population. For example,
in the case of health centers, the FQHC payment structure has contributed
to closer parity between health centers' Medicaid patients and their Med-
icaid revenues (Figure 2.1~. To the extent that these payment arrange-
ments are eliminated or reduced, core safety net providers necessarily
will confront the implications of their eroding canacitv to treat uninsured
individuals (Felt-Lisk et al., 1997~.
Against this background, this chapter provides a description of the
core safety net providers and other providers in the safety net system
including their patient and payer profiles, their unique structural charac-
teristics, missions, and core competencies, and how the structures and
organizations of safety net systems vary across the country.
THE HEALTH CARE SAFETY NET
Characteristics of Populations Served by the Core Safety Net
Poor people who are uninsured, are of minority and immigrant status,
live in geographically or economically disadvantaged communities, or
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50 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
~ Other ~ Uninsured
· Medicare ~ Medicaid
100 1
14%
75 -
Cal
50-
25 -
O
~ Other ~ Medicare
· Self-Pay/ ~ Federal Grants
Patient
Collections ~ Medicaid
18%
20%
1985 1 997
Patients
5% _
_
1
1
6%-
27%
1985 1 997
Revenues
FIGURE 2.1 Changes in health center Medicaid and uninsured patients by
revenue source, 1985-1997. SOURCE: The Kaiser Commission on Medicaid and
the Uninsured (2000~. Data from Center for Health Services Research and Policy
analysis of 1997 Uniform Data System and estimates by the National Association
of Community Health Centers using 1985 Bureau of Common Reporting Require-
ments data. Reprinted with permission of The Kaiser Commission on Medicaid
and the Uninsured.
have a broad range of social, demographic, and poverty-related health
problems must rely disproportionately on the core safety net for their
health care (Box 2.1~. For some, the primary barrier is a lack of insurance
coverage. In recent years the number of uninsured individuals has grown
because the cost of employment-based health insurance has become
unaffordable for many low-income people and because fewer people are
enrolled in Medicaid (Kronick and Gilmer, 1999~. Many low-income indi-
viduals (especially Medicaid beneficiaries and low-income workers with
unstable employment) move on and off of insurance. Almost two-thirds
of new Medicaid enrollees lose their coverage with a year and many go on
to prolonged spells without insurance (Carrasquillo et al., 1998~.
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
5
For those enrolled in Medicaid, traditionally low levels of payments
to providers of health care resulted in limited and skewed provider par-
ticipation, forcing many low-income patients to seek episodic care from
emergency departments and hospital clinics. Medicaid coverage is often
severely limited for some services such as pharmaceuticals, mental health
treatment, and substance abuse treatment.
Still other populations have special needs or circumstances that can
create impediments to care, such as homelessness or complex health prob-
lems, like mental illness or human immunodeficiency virus (HIV) infec-
tion/AIDS (see Chapter 6 for an expanded discussion of populations with
special needs). Insurance coverage alone is often inadequate to ensure
access for these populations who may require outreach and access to
specialists or other support programs to meet their special needs.
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52 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
Core safety net providers offer these populations a combination of
essential health and social services that go beyond those provided in the
commercial insurance model. Many core safety net providers have tai-
lored their services to meet the needs of such medically underserved
populations as minority communities and non-English-speaking indi-
viduals, groups that are more likely to lack insurance coverage.
Using data from the 1997 Current Population Survey and controlling
for poverty and employment status, a study by The Commonwealth Fund
indicated that adult minorities ages 18-64 are more likely than their white
counterparts to be uninsured, suggesting that reliance on the private
health insurance market may not result in substantial improvements in
coverage rates for minorities (Hall et al., 1999~. This means that there will
continue to be a disproportionate number of minority individuals who
depend on the safety net for care. A study that compared urban safety net
hospitals and non-safety net hospitals in the same market areas showed
dramatic concentrations of African-American and Hispanic patients at
safety net hospitals relative to the concentrations at non-safety net hospi-
tals in the market area (Gaskin, 1996) (Figure 2.2~. Among public hospitals
in New York City, minority patients accounted for 90 percent of outpa-
tient visits and 88 percent of admissions in 1995 (Siegel, 1996~. Similarly,
nearly two-thirds of all FQHC patients in 1998 were minorities, more than
85 percent had incomes less than 200 percent of the federal poverty level
and 41 percent were uninsured (Figure 2.3~. More than 18 percent of the
30,
25 -
~ 20 -
8
15 -
10 -
5 -
O -
24.6
4.3 3.4
a.
9.3
13.3
Asian African
American American
Group
23.0 ~ Urban Safety
Net Hospitals
Other Urban
Hospitals
10.5
Native Hispanic
FIGURE 2.2 Ethnic and racial composition of urban safety net hospital market
areas, 1994. SOURCE: Gaskin and Hadley (1999~. Reprinted with permission of
the Institute of Health Care Research and Policy.
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
Medicare,
7%
Other
Third Party,
19%
Uninsurea,
41%
By Payor Source
_ Medicaid,
1 00%-200%
of Federal
Poverty Level,
20%
White,
36%
Al,
4%
200% of Federal
Poverty Level,
142 -
By Income
53
African American,
26%
Hispanic,
34%
By Race/Ethnicity
Below Federal
Poverty Level,
66%
FIGURE 2.3 Payor source, income, and racial characteristics of FQHC patients,
1997. Data are based on 8.3 million users in 1997. SOURCE: 1997 Bureau of
Primary Health Care Uniform Data System.
8.3 million FQHC users in 1997 required translation services; 556 of the
671 FQHCs provided translation services either directly or through a ven-
dor (Lefkowitz, 1999~. Local health departments also serve large numbers
of uninsured patients, many of whom are seeking specialized services
such as treatment for HIV infection/AIDS, sexually transmitted diseases
(STDs), or substance abuse. Among 504 local health departments queried
in a national survey conducted in March 1999, health officers estimated
that one-half of urban health department clients and one-third of clients
at health departments serving smaller jurisdictions were uninsured in
1998 (Shields et al., 1999~. Nearly half of urban health departments and
about a third of smaller health departments reported an increase in the
number of uninsured clients served between January 1998 and January
1999, with the greatest increases seen among women and children.
In addition, more than 71 million Americans live in medically
underserved areas (MUAs) of the country, primarily inner-city and rural
areas with minimal or no economic base and very limited access to pro-
viders. According to Darnell and colleagues (1995), more than half of
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54 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
these people are located in urban areas and a disproportionate number
are poor African-American and Hispanic individuals. In contrast, people
in rural communities tend to be white but are also disproportionately
poor and are underserved due to the double jeopardy created by poverty
and sparse population (Kindig, 1994; Rosenbaum et al., 1998~. Although
these groups are highly dependent on core safety net providers, the public
hospitals that serve rural communities frequently are located in distant
metropolitan areas. CHCs are not evenly distributed in rural communi-
ties. Thus, vulnerable people in rural settings rely more heavily on the
commitment of local providers, such as private physician practices, to
maintain an open-door policy regardless of the patient's ability to pay
(Ricketts et al., 1998~.
Core Safety Net Providers
Core safety net providers are often referred to as "essential commu-
nity providers" or "providers of last resort." As part of President Bill
Clinton's health care reform initiative, the U.S. Congress in 1993 defined
essential community providers as providers of health services located in
federally designated MUAs or in designated health professional shortage
areas or providers that are serving medically underserved populations.
Such designated providers were legally obligated to provide services to
the poor or were, by law, located in areas with high levels of need for
health care services. Other providers who were located in underserved
areas for reasons unrelated to a legal obligation (e.g., a mission to serve
the poor) were not entitled to automatic designation as essential commu-
nity providers. Thus, the definition made a major distinction between
voluntary uncompensated care and care provided as part of a legal obli-
gation. The Institute of Medicine's (IOM) committee's definitions of the
core safety net and the safety net system have incorporated those mission-
driven providers that do not meet the definition of essential community
provider but that nonetheless care for a substantial share of the poor and
uninsured population.
The individuals who use core safety net providers have complex
needs that require both medical and enabling services, the funding for
which comes from numerous sources. Over the years, Medicaid has
become an increasingly important revenue source for these providers,
accounting for about a third of revenues. In fact, in 1997 payments from
Medicaid accounted for 33 percent of revenues for NAPH member public
hospitals and 35 percent of revenues for FQHCs, whereas commercial
insurers were only 10 and 9 percent, respectively (Health Resources and
Services Administration, 1999; National Association of Public Hospitals
and Health Systems, 1999~. Thus, core safety net providers also must
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
55
piece together a number of small grants from a range of federal, state, and
local public and private sources to help support their missions. To high-
light the patchwork quilt of safety net financing, Boxes 2.2 and 2.3 illus-
trate the complex funding streams for a major urban safety net provider
(Denver Health, Denver, Colorado) and a rural safety-net system (Rural
Health Group, Inc., Jackson, North Carolina).
Public Hospitals
There are an estimated 1,300 public hospitals in the United States
(Legnini et al., 1999~. Public hospitals' tradition of providing free or un-
compensated care goes back more than 200 years to the early public and
nonprofit charity hospitals that cared for the poorest individuals at a time
when most wealthier individuals were cared for in their homes. Many
functioned as charity hospitals in the nation's urban areas. These charity
hospitals were outgrowths of what were once the old almshouses for the
poor and provided the vulnerable citizens of cities and nearby commu-
nities with outpatient clinics, emergency services, hospitalization, and,
often, dental care (Gage, 1998~. Until the creation of Medicare and Medic-
aid in 1965, these public hospitals represented virtually the only treat-
ment alternative available to most low-income patients.
Today, large public hospitals tend to be located in urban centers and
primarily serve Medicaid beneficiaries and uninsured patients. Initially,
public hospitals were owned and operated by state or local governments
or public authorities. In recent years many public hospitals have closed or
changed their governance to gain greater autonomy and flexibility. Some
have been acquired by for-profit and not-for-profit hospital systems that
may alter the roles public hospitals have been playing (see Chapter 3~.
In an examination of the sources of revenue for public versus private
hospitals (Table 2.1), Rosenbaum (1999) notes several key differences:
· The proportion of self-paying patients at public hospitals is far
higher than that of private hospitals.
· Medicaid is a relatively marginal payer for private hospitals and a
major payer for public hospitals.
· The amount of commercial coverage at public hospitals is marginal
compared with that at private hospitals.
· The higher numbers of uninsured likely translates into a patient
population with poorer health status compared to that of the patient popu-
lation at private hospitals.
Not only is the proportion of self-paying patients much higher at
public hospitals than at private hospitals but also there appears to be a big
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56 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
57
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70 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
and Native Americans and Alaska Natives, many of whom might other-
wise add to the demand on the core safety net.
The original mission of the VHA was to provide hospital care for
veterans with service-connected disabilities. Over the years this mission
has expanded to include both inpatient and outpatient care for veterans
with service-connected disabilities and for veterans with non-service-
connected disabilities (National Health Policy Forum, 1998~.
Veterans Affairs (VA) hospitals and ambulatory care services are often
an unrecognized but significant source of safety net services. In fact, the
VA medical center system is one of the nation's largest health care sys-
tems, with 173 hospitals, 600 outpatient clinics, 133 nursing homes, 40
domiciliaries, 206 counseling centers, and 185,000 employees. Each year
these facilities serve approximately 10 percent of the total veteran popula-
tion, providing comprehensive services to approximately 2.5 million vet-
erans annually. Only about 12 percent of those treated at a VA facility are
treated for a service-connected disability. The majority are poor; 70 per-
cent have annual incomes less than $21,610 (National Health Policy
Forum, 1998~.
IHS works in conjunction with 547 federally recognized tribes to
deliver health care to Native Americans and Alaska Natives throughout
the country. IHS is the primary, and often the sole, provider of health
services for many Native Americans and Alaska Natives. IHS has a staff
of 14,500 that operates with approximately $2.2 billion in federal appro-
priations and that serves 1.4 million beneficiaries in 500 direct care centers.
In addition, IHS operates the Contract Health Services program with non-
IHS providers, which currently accounts for 18 percent of all expendi-
tures. Although direct and contracted patient care is a large component of
IHS, it also provides environmental and educational services. Hospital
and ambulatory care, preventive services, and alcohol treatment account
for most of the IHS expenditures on direct services. IHS provides services
through a broad range of facilities and personnel: 37 IHS hospitals, includ-
ing 3 major medical centers; 64 health centers; 5 school-based health
centers; 50 health stations; and an array of physicians, dentists, nurses,
pharmacists, and other health care professionals (Indian Health Service,
1997~.
THE SPECIAL VALUE OF CORE SAFETY NET PROVIDERS
As health care continues its transformation toward a more market-
oriented, performance-based system, special treatment for designated
classes of providers even those providers with important social mis-
sions will be highly dependent on their proven ability to add value and
operate efficiently. Despite their laudable track record for caring for dis-
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
71
proportionate numbers of this nation's poorest and sickest population
groups, core safety net providers are often viewed as operating in a less
efficient manner than other groups of providers and with less ability to
document their unique contributions to health outcomes for their patient
populations (Harrington et al., 1998; Thorpe and Brecher, 1987~. In addi-
tion, the committee heard and read evidence that safety net hospitals and
clinics operated by state, municipal, or other government subdivisions
may be at a disadvantage in their ability to make timely business deci-
sions, form strategic partnerships, or succeed in a more competitive envi-
ronment given the hiring, procurement, and other rules with which such
publicly owned entities have to comply (Bovbjerg and Marsteller, 1998;
Siegel, 1996; West, 1999~. Evaluations of safety net providers in some of
the states that have received 1115 waivers found that many of these pro-
viders have weak existing business and administrative functions largely
because the bulk of their business has been limited to the Medicaid, Medi-
care, and uninsured populations, none of which required strong business
skills (Hoag et al., 1999~. In a system of surplus capacity and downsizing,
the ability to measure and demonstrate competitive financial and quality
performance is becoming a critical requirement for future survival, for
both private and traditionally publicly sponsored health care providers.
Although concerns about inefficiencies are occasionally cited, the
committee found very limited evidence with which to assess the relative
efficiency of safety net providers. The majority of articles devoted to this
issue point to safety net providers' more complex patient population and
the broader array of services that they have to offer. These "product"
differences make assessments of comparative efficiency more difficult
(Landon and Epstein, 1999; Lipson, 1997; Savela et al., 1998; Schauffler
and Wolin, 1996~.
The move to a more market-based system has called renewed atten-
tion on issues of efficiency and effectiveness in health care. The phaseout
of cost-based reimbursement for FQHCs in the 1997 BBA was propelled
in part by a perception in the U.S. Congress and among state governors
that such cost-based reimbursement provides few incentives for efficient
behavior. A 1998 study with data from 328 health centers assessed the
impact of cost-based reimbursement for FQHCs on revenue and utiliza-
tion. Although the sample was not perfectly representative of all CHCs, the
study demonstrated that the shift to cost-based reimbursement increased
the total number of users and Medicaid beneficiaries who receive care at
CHCs but that there was no direct link to overall increases in medical
encounters per user. The focus on volume is important because states are
already allowed to apply caps and productivity screens to the per visit
rate (Lewis-Idema et al., 1998~.
However, some policy makers contend that despite the potential for
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72 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
internal controls, the cost-related payment system of FQHC is not consis-
tent with an emphasis on managed care. Therefore, a number of bills were
introduced in the 106th U.S. Congress to develop some type of prospective
payment system for FQHCs to replace the current cost-based reimburse-
ment system. Lack of agreement on a new method led to the BBA Refine-
ments Act of 1999, which tempered the cost reimbursement phaseout as
outlined in the 1997 BBA and called for a study to assess alternative
payment strategies.
Unresolved payment issues aside, studies have demonstrated that
these providers can be uniquely effective in addressing the special needs
of certain vulnerable populations (Andrulis and Goodman, 1999;
Rosenbaum et al., 2000~. For example, New York City's Health and Hospi-
tal Corporation, the country's largest public hospital system, serves about
55 percent of the city's patients with AIDS, 48 percent of its patients with
tuberculosis, and about 36 percent of its patients who need inpatient
psychiatric treatment (LaRay Brown, Health and Hospital Corporation,
personal communication, March 2000~. A study to assess whether the
presence of a public hospital in a community increased access to care
among the poor found that the presence of such a hospital not only
increased the volume of care provided to the medically indigent popula-
tion, but also reduced the uncompensated care burden for private hos-
pitals (Thorpe and Brecher, 1987~. The study also found that public hos-
pitals in cities with a substantial level of graduate medical education
delivered proportionately more uncompensated care than nonteaching
public hospitals. A 1990 study by Bindman and colleagues found that the
closing of a public hospital in a semirural area of northern California had
a significant effect on access to health care and was associated with a
decline in the self-reported health status of patients previously served by
the closed hospital (Bindman et al., 1990~.
A number of comprehensive literature reviews of CHCs and the
Medicaid program have documented that the effectiveness and cost-
effectiveness of CHCs in improving access to ambulatory care, reducing
inappropriate hospitalizations, and delivering quality care, was compa-
rable to that of other types of providers (Davis and Schoen, 1977; Dievler
and Giovannini, 1998; Hawkins and Rosenbaum, 1998~. A study that
looked at the impact on access to health care after the introduction of
CHCs in five low-income areas across the country found that the avail-
ability of CHCs not only increased access to medical and dental care but
also resulted in a major shift in care from hospital clinics to CHCs and a
significant reduction in hospital inpatient use (Okada and Wan, 1980~.
The new CHCs also attracted people with no previous source of care. The
study found, however, that although Medicaid and the presence of CHCs
greatly facilitated the use of health services, disparity in the utilization of
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
73
health and dental care remained between the study areas and the aver-
ages for the nation. The impact of health centers on outcomes was demon-
strated by a national analysis of county data using multivariate tech-
niques which attributed 12 percent of the decline in black infant mortality
from 1970 to 1977 to the presence of CHCs (Goldman and Grossman,
1988).
A seminal study by a team of researchers at the Johns Hopkins School
of Hygiene and Public Health that looked at the relationship between
efficiency in the use of resources and quality of care in different primary
care settings targeted mainly to Medicaid beneficiaries found that, irre-
spective of costs, the quality of medium-cost health centers met or ex-
ceeded the quality of other providers (Starfield et al., 1994~. Another study
by a Johns Hopkins-based team compared Medicaid utilization and ex-
penditures for users of health centers and other providers and found that,
after adjusting for case mix, health center users had costs and inpatient
admissions similar to those for patients who used private physicians for
their primary care and less than those who used hospital clinics (Stuart
and Steinwachs, 1993~. A more recent but related study on income, in-
equality, primary care, and health indicators, also conducted by researchers
at Johns Hopkins, found that availability of primary care may in part help
overcome the severe adverse impact of income inequalities on health (Shi
et al., 1999~.
Other recent analyses found that Medicaid users of CHCs experience
a 22 percent lower rate of hospitalization for ambulatory care sensitive
conditions than Medicaid beneficiaries who receive medical services from
other primary care providers (Falik et al., 1998~. A nationally representa-
tive survey of health center patients conducted by Mathematica Policy
Research, Inc. in 1995 for the Bureau of Primary Health Care found that
female health center patients are more likely to obtain mammographies,
clinical breast exams, and Pap smear tests than a comparison group drawn
from the National Health Interview Survey (Regan et al. 1999~. Moreover,
both this study and a survey for the Picker-Commonwealth Fund based
on a representative sample of health center patients reported high levels
of satisfaction, respectful treatment, increased access over other providers,
convenient hours, and availability of translation/interpretation into their
own language (Regan et al., 1999; Zuvekas et al., 1999~.
A longitudinal study on the impact of pediatric visits to hospital emer-
gency departments after the establishment of a neighborhood health center
found that inappropriate emergency department visits declined signifi-
cantly with the establishment of the center in a poor Rochester, New
York, neighborhood (Hochheiser et al., 1971~. No such decline was
observed among residents of a control community that remained without
a CHC. The study suggests, however, that the proximity of underserved
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74 AMERICA'S HEALTH CARE SAFETY NET: INTACT BUT ENDANGERED
populations to health services is an important but not an overriding
inducement to use. Access and provision of quality care for poverty resi-
dents, the study shows, must be associated with aggressive outreach,
cultural considerations, and effective communications.
A study that looked at the effects of Florida's Medicaid eligibility
expansions for pregnant women found that access and birth outcomes
improved for low-income women who did not have private insurance
(Long and Marquis, 1998~. These improvements in access and outcome
were linked to the availability of county health department services. Study
results showed the importance of linking expanded insurance coverage
for low-income women with a delivery system that can accommodate
their special needs. However, a study by researchers at the Agency for
Health Care Policy and Research and the University of California chal-
lenged these findings and showed that Medicaid-eligible women who
obtained multidisciplinary prenatal care at private physician's offices that
were reimbursed by Medicaid for enhanced care had equal or better out-
comes than women served by local health departments (Simpson et al.,
1997~.
A more recent study from California sheds additional light on this
issue. Using telephone surveys of residents in urban California com-
munities, Grumbach and colleagues found that physician supply alone
may not guarantee effective access to care for disadvantaged populations
(Grumbach et al., 1997~. The study suggests that in poor communities
physician supply may need to be linked with organizational structures
that address the multiple sociodemographic factors that can impede access
to care.
SAFETY NET PROVIDERS IN A CHANGING
HEALTH CARE ENVIRONMENT
Today's environment of change and challenge will likely have impor-
tant policy and program implications for the nation's traditional safety
net providers. As the rolls of the uninsured continue to expand, other
major players in the delivery system are finding it more difficult to sus-
tain their past commitment to uncompensated care, placing more of the
burden on public hospitals and CHCs. Despite this reliance and the
acknowledged contributions of safety net providers, profound questions
are being raised today about how the future financing of health care and
health care for poor and uninsured individuals should be organized and
funded. Devolution and the market paradigm with its dynamics of com-
petition, consumerism, and choice have focused major interest in expand-
ing access to affordable insurance for low-income Americans as an alter-
native to continued government support for a designated set of providers.
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THE CORE SAFETY NET AND THE SAFETY NET SYSTEM
75
Whereas core safety net providers have always survived on a tenuous
patchwork of funding, the policy and political mindsets in many quarters
support the notion that these, as well as other providers, should be chal-
lenged to operate more effectively and efficiently even with more limited
resources and with patients with more complicated medical conditions
and socioeconomic challenges.
The committee concludes that the safety net system is a distinct deliv-
ery system, however imperfect, that addresses the needs of the nation's
most vulnerable populations. In the absence of total reform of the health
care system and while the new market paradigms are unfolding, it seems
likely that the nation will continue to rely on safety net providers to care
for its most vulnerable and disadvantaged populations. Chapter 3 pro-
vides a comprehensive analysis of the major factors that affect the health
care safety net.
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Representative terms from entire chapter:
core safety
