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Hmerico's EQUIP Cal sorely NET Intact but Endongorcd Committee on the Changing Market, Managed Care, and th Future Viability of Safety Net Providers Marion Ein Lewin and Stuart Altman, Editors INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. e

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Health Resources and Services Ad- ministration (Contract No. 240-97-0030~. The views presented in this report are those of the Institute of Medicine Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers and are not necessarily those of the funding agency. Library of Congress Cataloging-in-Publication Data America's health care safety net: intact but endangered / Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers; Marion Fin Lewin and Stuart Altman, editors. p. ; cm Includes bibliograpical references and index. ISBN 0-309-06497-X (hardcover) 1. Medical assistance United States. 2. Medical care Needs assessment United States. 3. Medically uninsured United States. 4. Poor- Medical care United States. I. Lewin, Marion Fin. II. Altman, Stuart H. III. Institute of Medicine (U.S.~. Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers. [DNLM: 1. Medical Assistance United States. 2. Delivery of Health Care United States. 3. Medically Uninsured United States. W 250 AA1 A512 2000] RA 395.A3 A5965 2000 362.1'0973 dc21 00-033231 Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's home page at www.nap.edu. The full text of this report is available at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2000 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"I(nowing is not enough; we invest apply. Willing is not enough; we midst do. " Goethe ......... .......... ....... .... . . . . ....... .... I NSTITUTE OF MEDICI N E Shaping the Future for Health

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National Acaclemy of Sciences National Acaclemy of Engineering Institute of Meclicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedi- cated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advis- ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal gov- ernment. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

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COMMITTEE ON THE CHANGING MARKET, MANAGED CARE, AND THE FUTURE VIABILITY OF SAFETY NET PROVIDERS STUART H. ALTMAN (Chair), Sol C. Chaikin Professor of National Health Policy, Helter Graduate School of Social Policy, Brandeis University JOHN G. BARTLETT, Chief, Division of Infectious Diseases, Johns Hopkins University School of Medicine RAYMOND I. BAXTER, Executive Vice President, The Lewin Group, Falls Church, Virginia JOHN BILLINGS, Associate Professor and Director of the Center for Health and Public Service Research, Robert F. Wagner School of Public Service, New York University PATRICIA A. GABOW, Chief Executive Officer and Medical Director, Denver Health MARY L. HENNRICH, Chief Executive Officer, CareOregon, Portland SANDRAL HULLETT, Executive Director, West Alabama Health Services, Inc., Eutaw THOMAS G. IRONS, Associate Vice Chancellor for Health Sciences, East Carolina University School of Medicine, and President, Health East, Greenville, North Carolina JOYCE C. LASHOF, Professor Emerita, School of Public Health, University of California at Berkeley PATRICK H. MATTINGLY, Senior Consultant, Picker Institute, Boston CAROLINA REYES, Associate Director, Division of Women's Health Policy and Research, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles CHERYL I. ROBERTS, Director of Managed Care, Virginia Department of Medical Assistance Services, Richmond STEPHEN A. SOMERS, President, Center for Health Care Strategies, Inc., Princeton, New Jersey ANN ZUVEKAS, Senior Fellow, Center for Health Services Research and Policy, School of Public Health and Health Services, The George Washington University Medical Center Staff MARION KIN LEWIN, Study Director JUSTINE LANG, Research Assistant (December 1997-October 1998) KARI MCFARLAN, Program Associate v

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Consultants ANDREA FISHMAN, Research Assistant, The Lewin Group, Falls Church, Virginia DARRELL I. GASKIN, Research Assistant Professor, Institute for Health Care Research and Policy, Georgetown University Medical Center JUDITH KRAUSS, Professor, Yale University School of Nursing THOMAS C. RICKETTS III, Director, North Carolina Rural Health Research Program, Cecil G. Sheps Center for Health Services Research, and Associate Professor, Department of Health Policy and Administration, School of Public Health, University of North Carolina at Chapel Hill LESLIE SCALLET, Vice President, The Lewin Group, Falls Church, Virginia ANDY SCHNEIDER, Principal, Health Policy Group, Washington, D.C. ALEXANDRA SHIELDS, Senior Research Associate, Institute for Health Care Research and Policy, Georgetown University Medical Center REBECCA T. SLIFKIN, Senior Research Fellow, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill MICHAEL SPIVEY, Principal, Health Policy Group, Washington, D.C. Al

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PrQfucc At a time of unprecedented prosperity and budget surpluses it seems almost out of style to focus on groups in our nation who fall outside the economic and medical mainstreams. These people include not only this country's 44 million uninsured individuals but also an almost equal num- ber of low-income underinsured individuals. Vulnerable populations ex- tend as well to poor and disadvantaged individuals living in inner cities and isolated rural communities, minority and immigrant families, people with special health care needs, and low-income groups who face a variety of other financial and nonfinancial barriers to stable health care coverage. To address at least the basic health care needs of these impoverished and disadvantaged populations, America has long relied on an institu- tional safety net system, a patchwork of hospitals, clinics, financing, and programs that vary dramatically across the country. The funding and organization of the safety net have always been tenuous and subject to the changing tides of politics, available resources, and public policies. De- spite their precarious and unstable infrastructure, these providers have proven to be resilient, resourceful, and adept at gaining support through the political process. Today, however, a more competitive health care marketplace and other forces of change are posing new and unprec- edented challenges to the long-term sustainability of safety net systems and hold the potential of having a serious negative impact on populations that most depend on them for their care. Our committee was asked to examine the impact of Medicaid man- aged care and other changes in health care coverage on the future integ- rity and viability of safety net providers, particularly core safety net pro- viders such as community health centers, public hospitals, and local health . . V11

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V111 PREFACE departments. To carry out its charge, the committee reviewed the evi- dence from the peer-reviewed literature, held a 2-day public hearing, and elicited a broad array of expert testimony. The committee also conducted a number of regional meetings and commissioned several papers to pro- vide further analyses on topics of special relevance to the study charge. In the course of our work, we were impressed by a number of excellent ongoing studies and surveys under way to determine how safety net providers and vulnerable populations are faring in the new environment. Much of this work is being sponsored by major health care foundations. At the same time, the committee was struck by the dearth of reliable and consistent data that can be used to accurately assess, measure, or compare the changing status of safety net systems across the country. Compound- ing the difficulty of accurate measurement is the ongoing evolution of Medicaid managed care and the turbulent health care environment. These limitations notwithstanding, the committee came away from its deliberations convinced that today's changing health care marketplace is placing core safety net providers in many communities at risk of not being able to continue their mission of caring for a growing number of uninsured at a time when other national, federal, state, and local initia- tives to expand coverage are still on the drawing board, in a fledgling state, or falling short of their promise. The growth of Medicaid managed care enrollment, the retrenchment or elimination of key direct and indi- rect subsidies that providers have relied upon to help finance uncompen- sated care, and growing demand for charity care are making it more difficult for many safety net providers to survive. Moreover, in many communities these adverse forces are affecting safety net providers all at once, placing already fragile underpinnings in even greater danger of falling apart. In the absence of agreement on broader health care reform and with growing demand for charity care, the committee came to feel strongly that our nation's core safety net provider system needs to be sustained and protected. At the same time, the committee realized the importance of encouraging safety net providers to actively embrace the positive as- pects of current change, including incentives to develop more integrated and accountable delivery systems and a greater emphasis on performance and customer service. Together with the committee's findings and recom- mendations, this report includes a synthesis of what the committee heard and learned over its 18 months of deliberations. We hope that our work will contribute in some small way to the dialogue on broadening the reach of access to health care for all Americans. Stuart Altman, Ph.D. Chair March 2000

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x ACKNOWLEDGMENTS of safety net organizations across the country. Valerie Lewis, Crystal Hayling, Brian Bites, and David Sandman deserve special praise for their help in developing these important meetings. Appreciation goes as well to lames Tallon and the United Hospital Fund for hosting a meeting in the early stages of the study. The committee wants to give special thanks to the dedicated and hardworking staff at the Institute of Medicine. We are particularly fortu- nate that Marion Ein Lewin agreed to take on the responsibilities of study director for the project. Marion brought to this effort a knowledge of the issues surrounding safety net providers and the individuals whose re- search activities and experience were most important for our evaluation. Above all, Marion's tireless energy, enthusiasm and commitment to ex- cellence pushed the committee to produce what we believe is a first rate report. Judith Krauss, the 1998-1999 Institute of Medicine/American Academy of Nursing/American Nurse Foundation's Senior Nurse Scholar, contributed in major ways not only to the content of the report but also to many of the other lofty and mundane tasks that this kind of effort involves. Kari McFarlan deserves major commendation for her mas- terful and proficient handling of communications with the committee, organizing the literature database, and carrying out a myriad of other critical administrative tasks with great professional aplomb. Justine Lang deserves thanks for her administrative help in the early stages of this report and organizing the committee's first site visit to Tampa, Florida. Project assistant Michael Conroy was also helpful to the committee's work. We thank Michael Hayes not only for his careful and professional editing but also for his interest in the project and thoughtful ongoing support. The committee also appreciated Richard Sorian's editing help from the perspective of his communications and health policy expertise. The committee owes countless thanks to Heather Binder, who "adopted" the study in its final months of gestation. Heather meticulously incorpo- rated all of the edits and checked and double-checked all of the refer- ences, charts, and figures. Her proficient and careful review of the draft was a major contribution to the quality of the final product. Claudia Carl and Mike Edington provided assistance during the report review and preparation stages. The committee wishes to express heartfelt appreciation to the authors of the commissioned papers. The well-researched and highly informative background papers enhanced the committee's understanding of the many dimensions of this complex issue. Alexandra Shields not only authored one of the commissioned papers but also conducted a national survey of local health departments with Magda Peck and contributed significantly to the research and writing of the report. Marlene Niefeld deserves thanks for her research assistance.

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ACKNOWLEDGMENTS Xl 1 The committee extends special thanks to all of the people who con- tributed to the substance, learning, and enjoyment of our site visits. The committee is especially thankful to Bob Master, km Hooley, km Bernstein, Bill Remmes, lane McCaleb, Patricia Bean, and Commissioner Thomas Scott for their help in planning and organizing these activities. The committee greatly appreciates the help and contributions of Christine Burch, Joel Cantor, Peter Cunningham, Lynn Fagnani, Marilyn Falik, Paul Fronstin, Darrel Gaskin, Brad Gray, Dan Hawkins, John Holohan, Robert Hurley, Lucy Johns, Ronda Kotelchuck, Leighton Ku, Debbie Lewis-Idema, lack Needleman, Stephen Norton, and Sara Rosenbaum. These respected experts were never too busy to answer our calls, respond to our inquiries, and give generously of their time and knowledge. Thanks go as well to Joe Anderson, Jack Ashby, Amy Bernstein, Maura Bluestone, Dennis Braddock, Carol Brown, Bruce Bullen, Thomas Chapman, Lisa Tremento Chimento, Anne Dievler, Susanne Felt- Lisk, Irene Fraser, Marsha Gold, Eric Holzberg, Pat lerominski, Neva Kaye, Peter Kralovec, Larry Lewin, Jack Meyer, John Murphy, Bill Sappenfeld, George Schieber, Bruce Siegel, Helen Smits, David Sundwall, Caroline Taplin, Pat Taylor, and Andrew Wallace for their thoughtful and informed perspectives. Finally, the committee would like to thank the chair, Stuart Altman, for his intellectual leadership and for his strong commitment to the pur- poses of this project. He, in turn, wishes to thank the excellent and hardworking committee members whose dedication and perseverance to this effort far exceeded any reasonable expectations.

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X11 ACKNOWLEDGEMENTS Judith Krauss, the 1998-1999 Institute of Medicine/American Academy of Nursing/American Nurse Foundation's Senior Nurse Scholar, contributed in major ways not only to the content of the report but also to many of the other lofty and mundane tasks that this kind of effort involves. Karl McFarIan deserves major commendation for her masterful and proficient handling of com- munications with the committee, organizing the literature database, and carrying out a myriad of other critical administrative tasks with great professional aplomb. Justine Lang deserves thanks for her administrative help in the early stages of this report and organizing the committee's first site visit to Tampa, Florida. Project assistant Michael Conroy was also helpful to the committee's work. We thank Michael Hayes not only for his careful and professional editing but also for his in- terest in the project and thoughtful ongoing support. The committee also appreciated Richard So- rian's editing help from the perspective of his communications and health policy expertise. The committee owes countless thanks to Heather Binder, who "adopted" the study in its final months of gestation. Heather meticulously incorporated all of the edits and checked and double-checked all of the references, charts, and figures. Her proficient and careful review of the draft was a major contribution to the quality of the final product. Claudia Car] and Mike Edington provided assistance during the report review and preparation stages. The committee wishes to express heartfelt appreciation to the authors of the commissioned papers. The well-researched and highly informative background papers enhanced the commit- tee's understanding of the many dimensions of this complex issue. Alexandra Shields not only authored one of the commissioned papers but also contributed significantly to the research and writing of the report. Marlene Niefled deserves thanks for her research assistance to Alexandra. The committee extends special thanks to all of the people who contributed to the substance, learning, and enjoyment of our site visits. The committee is especially thankful to Bob Master, Jim Hooley, Jim Bernstein, Bill Remmes, Jane McCaTeb, Patricia Bean, and Commissioner Thomas Scott for their help in planning and organizing these activities. The committee greatly appreciates the help and contributions of Christine Burch, Joel Cantor, Peter Cunningham, Lynn Fagnani, Marilyn FaTik, Darre] Gaskin, Brad Gray, Dan Hawkins, John Holohan, Robert Huriey, Lucy Johns, Ronda Kotelchuck, Leighton Ku, Debbie Lewis-TUema, Jack Needleman, Stephen Norton, Magda Peck, and Sara Rosenbaum. These respected experts were never too busy to answer our calls, respond to our inquiries, and give generously of their time and knowledge. Thanks go as well to Joe Anderson, Amy Bernstein, Maura Bluestone, Dennis Braddock, Thomas Chapman, Lisa Tremento Chimento, Anne DievIer, Susanne Felt- Lisk, Irene Frazier, Marsha Gold, Eric Ho~zberg, Pat Jerominski, LarTy Lewin, Jack Meyer, John Murphy, George Schieber, Helen Smits, David Sundwall, Carolyn Taplin, Pat Taylor, and An- drew Wallace for their thoughtful and informed perspectives. Finally, the committee would like to thank the chair, Stuart Altman, for his intellectual lead- ership and for his strong commitment to the purposes of this project. He, in turn, wishes to thank the excellent and hardworking committee members whose dedication and perseverance to this effort far exceeded any reasonable expectations.

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i7QviQwQrs The report was reviewed by individuals chosen for their diverse per- spectives and technical expertise in accordance with procedures approved by the National Research Council's Report Review Committee. The pur- pose of this independent review is to provide candid and critical com- ments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manu- script remain confidential to protect the integrity of the deliberative pro- cess. The committee wishes to thank the following individuals for their participation in the report review process: GERARD F. ANDERSON, Director and Professor, Center for Hospital Finance and Management, Johns Hopkins University JAMES BERNSTEIN, Director, North Carolina Office of Research, Demonstrations, and Rural Health Development, Raleigh JO IVEY BOUFFORD, Dean, Robert F. Wagner Graduate School of Public Service, New York University JAMES W. CURRAN, Dean and Professor of Epidemiology, The Rollins School of Public Health, Emory University MARSHA R. GOLD, Senior Fellow, Mathematica Policy Research, Inc., Washington, D.C. . . . x'''

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REVIEWERS KEVIN GRUMBACH, Chief, Family and Community Medicine, San Francisco General Hospital/Community Health Network and Vice- Chair, Department of Family and Community Medicine, University of California at San Francisco ROBERT HURLEY, Associate Professor, Department of Health Administration, Medical College of Virginia,Virginia Commonwealth University RONDA KOTELCHUCK, Executive Director, Primary Care Development Corporation, New York City JOSEPH P. NEWHOUSE, John D. MacArthur Professor of Health Policy and Management, Harvard University MARK V. PAULY, Chair, Health Care Systems Department, The Wharton School of Finance, University of Pennsylvania DAVID J. SANCHEZ, Jr., Commissioner, Health Commission, City and County of San Francisco While the individuals listed above provided many constructive com- ments and suggestions, responsibility for the final content of the report rests solely with the authoring committee and the Institute of Medicine.

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EXECUTIVE SUMMARY Contents 1 BACKGROUND AND OVERVIEW Background, 16 Approach to the Study, 18 Organization of the Report, 20 Key Definitions, Study Parameters, and Caveats, 21 Program and Policy Overview, 29 THE CORE SAFETY NET AND THE SAFETY NET SYSTEM The Health Care Safety Net, 49 The Special Value of Core Safety Net Providers, 70 Safety Net Providers in a Changing Health Care Environment, 74 3 FORCES AFFECTING SAFETY NET PROVIDERS IN A CHANGING HEALTH CARE ENVIRONMENT Increasing Demand for Care, 84 Uncertainties in Public Support, 98 Changing Structure and Environment of the Health Care Marketplace, 106 Conclusion, 126 xv 1 16 47 81

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xv! 4 HOW SAFETY NET PROVIDERS ARE ADAPTING TO THE NEW ENVIRONMENT The Changing Medicaid Managed Care Marketplace, 134 Safety Net Provider Participation in Managed Care, 136 New Federal Safety Net Initiative, 152 Importance of State and Local Policies, 153 5 THE IMPACT OF CHANGE ON VULNERABLE POPULATIONS Access, Quality, and Satisfaction, 162 Nonfinancial Barriers to Access to Health Care, 166 Improving the Scope and Content of Beneficiary Choice, 166 How Effective Are Current Enrollment and Choice Policies?, 169 Mainstreaming, 170 The Uninsured Population, 173 Innovative New Approaches to Care for the Uninsured Population, 174 Other Challenges, 175 6 SAFETY NET POPULATIONS WITH SPECIAL HEALTH AND ACCESS NEEDS People with Special Needs, 181 Lessons Learned, 198 Generalizations to the Larger Safety Net System, 200 7 FINDINGS AND RECOMMENDATIONS Findings, 206 Recommendations, 212 APPENDIXES Committee Biographies B Workshop Agenda C Workshop Participants D California Regional Meeting Agenda E California Regional Meeting Participants F New York Regional Meeting Agenda New York Regional Meeting Participants Rural Conference Call Participants Acronyms INDEX CONTENTS 132 159 180 205 221 227 234 243 244 249 253 258 260 263

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CONTENTS . . XVI! TABLES, FIGURES, AND BOXES Figures 2.1 Changes in health center Medicaid and uninsured patients by rev- enue source, 1985-1997, 50 2.2 Ethnic and racial composition of urban safety net hospital market areas, 1994, 52 2.3 Payor source, income, and racial characteristics of FQHC patients, 1997, 53 3.1 Forces affecting the health care safety net, 82 3.2 Number of uninsured nonelderly Americans (in millions), 1987 to 1998, 85 3.3 Employers offering health insurance and worker participation, 1987 to 1996, by wage of workers, 87 3.4 Trends in Medicaid coverage and a lack of health insurance cover- age, 1987 to 1998, 88 3.5 Variations in percentage of nonelderly uninsured among U.S. states and the District of Columbia, 1998, 90 3.6 Rate of growth in Medicaid enrollment by eligibility group, 1990 to 1997, 94 3.7 Percentage changes in selected states' Medicaid enrollment, 1995 to 1997, 96 3.8 Medicaid spending on DSH payments, 1990 to 1996, 99 3.9 Average net revenues from select sources at NAPH member hospi- tals, 1993 to 1997, 104 3.10 Trends in state and local subsidies and uncompensated care costs at NAPH member hospitals, 1991 to 1997, 105 3.11 Percentage of HMOs reporting a profit, 1988 to 1997, 110 3.12 Change in safety net hospitals' market shares of Medicaid and unin- sured patients, 1991 to 1994, 115 3.13 Medicaid and self-paying patient discharges as a percentage of total discharges at NAPH member hospitals, 1993 to 1997, 118 3.14 Actual and projected declines of total Medicare margins for public hospitals as a result of the BBA of 1997, 119 3.15 Percentage growth in numbers of uninsured compared with 1990 levels: rates for CHCs versus national rates, 123 6.1 Percentage of nonelderly persons with disabilities (PWD) in Medic- aid managed care, 1998, 183 6.2 Medicaid enrollees and expenditures by enrollment group, 1996, 184

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xvIll CONTENTS Tables 2.1 Revenue for Public Versus Private Hospitals, 58 2.2 Patients by Revenue Source: Physicians and Federally Qualified Health Centers, 61 3.1 Changes in the Balanced Budget Act (BBA) of 1997 Phaseout of Health Center Cost-Based Reimbursement Made by the BBA Refine- ments Act of 1999, 102 3.2 Hospital Gains and Losses by Payer, by Hospital Group, 1992, 116 3.3 Hospital Gains and Losses by Payer, by Hospital Group, 1997, 117 3.4 Trends in Federally Qualified Health Center Revenue, 1990-1998, 120 3.5 Trends in Federally Qualified Health Center Users, 1990-1998, 121 3.6 Trends in Federally Qualified Health Center Revenues per Patient User, 1990-1998, 121 Boxes 1.1 Medicaid Managed Care: Selected Provisions in the Balanced Bud- get Act of 1997, 36 2.1 The Core Safety Net Serves a Wide Range of Vulnerable Popula- tions, 51 2.2 Funding Sources for a Major Urban Safety Net Health System, Den- ver Health, 56 2.3 Funding Sources for a Rural Safety Net System, Rural Health Group, Inc., 57 4.1 Safety Net Providers: Keys to Successful Adaptation and Future Viability in a Managed Care Environment, 155 5.1 Characteristics of Medicaid Managed Care That Make It Different from Commercial Managed Care, 161 5.2 Lessons Learned from Managed Care Enrollment, 168

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