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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Henry Waxman: Architect of the Health Care Safety Net

As a medical student in New York and then a resident in San Francisco, I received a substantial amount of my training in safety-net hospitals. Like many students who have this sort of opportunity, I loved learning in an environment where the effects of my efforts to help were immediately visible and appreciated.

Andrew Bindman, MD

I didn’t pause to ask where the resources sustaining the health care safety net came from; I was just thankful that there were institutions that supported my interest in learning how to fight against disease and for social justice. Each patient I cared for offered a lesson on the harmful effects of barriers to health care and the capacity of a safety-net institution to aid healing.

After my training, I became an attending physician at San Francisco General Hospital, a public safety-net health system. I came to understand the fragile nature of the safety net’s funding and the degree to which it relies on Medicaid. In addition to functioning as the main payer of claims for safety-net hospitals, Medicaid also provides supplemental payments to safety-net hospitals to help offset their uncompensated costs for uninsured patients. In California, for example, about 70% of patients served by county-operated safety-net hospitals are either Medicaid beneficiaries or are uninsured.

A 40-Year Legacy

In 2009, as a Robert Wood Johnson Health Policy Fellow, I had the opportunity to meet and work for one of the primary architects of the health care safety net, Congressman Henry A. Waxman (D, California). During that time I joined the staff of the US House of Representatives’ Energy and Commerce Committee, which Rep Waxman chaired.

Although Henry Waxman was not in Congress when Medicaid was enacted in 1965, his legislative efforts during his 40 years in Congress steadily broadened the proportion of the low-income population that is eligible for Medicaid coverage, providing them financial security against catastrophic health events. As patients use this coverage, financial assistance flows to the safety-net providers whose mission it is to care for them.

I observed Rep Waxman perform his legislative feats during the passage of the Affordable Care Act (ACA). Through his role as chairman of the Energy and Commerce Committee, he was a leading figure in drafting the legislation and negotiating its passage. He used the ACA as another opportunity to expand the health care safety net by providing Medicaid coverage for millions of low-income childless adults, the one remaining group of US individuals living in poverty who were not entitled to Medicaid coverage until the ACA became law. Waxman hoped to make this expansion a federal requirement, but the Supreme Court decision that upheld the constitutionality of the ACA also gave states the authority to block the expansion. To date, 26 states have moved ahead with the Medicaid expansion and several more are expected to follow soon.

Throughout his career, Henry Waxman has worked toward the goal of universal health insurance coverage, while also leading federal efforts to ensure that a network of financially viable safety-net providers would be available to care for underserved communities. For example, in 1981 he worked with Sen Robert Dole (R, Kansas) to establish the Medicaid Disproportionate Share Hospital (DSH) payment program for hospitals serving a “disproportionate number of low-income patients with special needs.” Over the next 3 decades, he led legislative efforts (in 1987, 1988, 1991, 1993, and 2009) to defend and refine this program in the face of federal and state opposition. The program currently provides $11.5 billion in supplemental funding to safety-net hospitals nationwide. It is far from perfect in how states distribute the resources to serve the most needy, but there is no question that these funds have been critical in preserving the financial viability of hospitals, like mine, that otherwise might have closed.

Survival of Safety-net Clinics 

During his time in Congress, Henry Waxman also championed the financial survival of safety-net clinics. In the 1980s, community health centers faced great financial risk as states reduced their Medicaid payment rates to providers and private physicians dropped out of the program. This left community health centers overwhelmed with additional patients and insufficient funding for their care. To address this financial crisis, Rep Waxman worked with the late Sen John Chafee (D, Rhode Island) in 1989 to create a federal law requiring states to pay Federally Qualified Health Centers rates for Medicaid patients based on the full cost of their services. In subsequent years, he expanded the policy to include tribal-run clinics (1990) and urban Indian clinics (1993). Without his efforts, many of the community health centers poised to play a significant role in turning the ACA’s expansion of health insurance coverage into access to care in underserved communities would not be available today.

Henry Waxman’s success comes from using strategies that we admire in medicine. First, he is an extremely smart and hardworking individual who, like a top specialist, is the go-to expert among his colleagues when it comes to health care policy. Even his political foes acknowledge that it would be hard to find someone inside or outside Congress who is more knowledgeable than Henry Waxman about Medicaid and the health care safety net.

Second, he recognizes and values teamwork. His long-standing relationships with members of his staff are an anomaly in Congress, where it is routine for staffers to leverage their current positions for something better. Rep Waxman has cultivated extraordinarily bright staff members who share his ability to maintain focus over time, to not lose sight of the details, and to persevere in the face of adversity. They don’t tend to seek a “better” job because they know they already have it.

Third, he is committed to using science and research to improve health and health care. This was perhaps most visibly demonstrated when he chaired public hearings on the tobacco industry’s concealment of their own scientific knowledge of the dangers of smoking. He used their misuse of science as the basis for creating statutory requirements regarding the labeling, marketing, and sale of cigarettes and smokeless tobacco.

On January 30, Rep Waxman announced that he would be retiring from Congress when his term ends later this year. It is difficult to overestimate the void his departure will create in Congress. Henry Waxman has been to the health care safety net what Robert Moses was to designing the landscape in and around New York City. There is no member of Congress who has Waxman’s depth of knowledge about and commitment to Medicaid and the health care safety net.

With the ACA’s expansion of health insurance coverage, questions are emerging about the future of the health care safety net. Will those who gain coverage continue to rely on the safety net or will they seek care elsewhere? How does the payment model used to support care in the safety net need to evolve to promote greater value and accountability? Without Henry Waxman in Congress, finding answers to guide the health care safety net into the future is likely to become significantly more difficult.

About the author: Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.
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