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Health Care Safety-Net Ambivalence

I’m conflicted about the health care safety net. I say this as someone who has worked as a primary care physician in a public hospital for more than 25 years. The health care safety net I’m referring to includes public hospitals, community health centers, and other health care organizations and practitioners who care for a disproportionate number of Medicaid and uninsured patients.

Andrew Bindman, MD

The patients cared for in the health care safety net are among the nation’s most vulnerable. They have a disproportionate burden of disease and are at risk for suboptimal outcomes due to a variety of social factors, including their race, ethnicity, socioeconomic status, lack of insurance, sexual orientation, and immigration status. They often come to the health care safety net for their care because they do not have other options. The resources in the safety net are limited, but the efforts of safety-net practitioners often seem boundless because they are extraordinarily committed to do their best to help.

There’s something truly inspiring about working shoulder to shoulder with those who attempt to combat social injustice by helping patients who seek care in the safety net. But the inconvenient truth is that the safety net often lets these patients down. The safety net does not achieve a level of performance found in non–safety-net institutions.

Assessments of the safety net’s performance are confounded by the differences in the patients it serves as compared with those cared for by practitioners at other health care organizations. But the evolving literature on disparities indicates that a contributing factor is the segregation of vulnerable populations among a limited number of practitioners who, on average, face overwhelming challenges due to the limited availability of resources. This suboptimal performance raises questions about whether the health care safety net is the remedy for the needs of those who are most vulnerable or whether these underfunded sites for care, segregated from the mainstream, are contributing to the problem.

I’m not alone in my conflicted feelings about the safety net. Local governments that are committed to providing health care safety-net services have seen health care inflation crowd out the funding for other local services such as fire departments, schools, and libraries. They have wondered whether they can continue to afford to support a public health care safety net, and sometimes that answer has come back as “no.” Typically, these painful decisions evolve over time as communities slowly starve their public safety-net institutions of financial resources to the point that quality is undermined—and then the conflict is resolved by a growing consensus that it would be safer to close the public institution.

Judging by the policies in the Affordable Care Act (ACA), the federal government also appears to be conflicted about the future of the safety net. On one hand, the ACA increased funding for federally qualified health centers by $11 billion, but at the same time, it reduced payments to safety-net hospitals provided through the Medicaid Disproportionate Share Hospital program by $14 billion. It is possible, but not guaranteed, that safety-net hospitals will be able to make up for this payment reduction by retaining patients who are currently uninsured but who gain coverage as a part of the ACA.

With the implementation of coverage expansion under the ACA in 2014, many patients who currently receive care in the safety net because they lack insurance may find that they have options to seek care from other health care organizations and practitioners. This will lead patients to face their own conflicts about the health care safety net. Patient satisfaction surveys suggest that patients cared for in safety-net hospitals have a less favorable view of their care than those cared for in non–safety-net hospitals, and these ratings are diverging over time. With the expansion of coverage in 2014, we will learn whether current users of the health care safety net have new options for care and whether patients choose to exercise their new market power by seeking care elsewhere. The implications of that choice for the viability of safety-net institutions are enormous.

Previous expansions of insurance coverage, including the expansion of Medicaid eligibility in the 1990s to include higher-income pregnant women, resulted in a substantial shift of these patients away from safety-net health care organizations. Although the same pattern might occur among newly insured individuals after the implementation of the ACA, the experience in Massachusetts, which implemented a state-based expansion of coverage that is the model for the ACA, was associated with an increase in demand for safety-net services.

Somemight regard the preservation of the health care safety net as a proxy for ensuring access to care for this nation’s most vulnerable patients; however, there is scant evidence to indicate whether this approach of furnishing services is truly in the best interest of the patients these organizations aim to serve. Safety-net practitioners are committed to the mission of delivering care to those who need it regardless of their ability to pay, but at the same time, the availability of safety-net practitioners removes the burden of responsibility from the majority of practitioners to contribute toward a goal of providing access and equitable care to all. Charity care delivered by private physicians has been declining over time.

These developments may explain why states as politically different as California and Texas are pursuing similar strategies to preserve their safety-net hospitals. Both have obtained Medicaid waivers from the federal government to direct projected federal savings from using Medicaid managed care as a delivery model toward an investment in their safety-net hospitals. This investment will provide these states’ safety-net hospitals with resources to improve their capacity to deliver services to Medicaid and uninsured patients, while also limiting the requirement of their states’ private hospitals to deliver uncompensated services.

I would prefer a health care system that did not segregate low-income patients in the safety net. I suspect health care and outcomes would improve if we instead provided sufficient means for everyone to access care from the same pool of health care organizations and practitioners, recognizing that in many geographic areas, the option for everyone is a community health center or some other kind of health care safety-net organization.

However, given that millions of individuals, including undocumented immigrants as well as many legal immigrants, are excluded from the coverage expansion options in the ACA, it would be highly problematic and unethical to dismantle the health care safety net without first ensuring that patients who rely on these organizations and practitioners have an equivalent or better alternative for care. Even then, we need to be cautious in establishing policies that could threaten the viability of the health care safety net, because chances are good that once a safety-net institution is closed, it would be nearly impossible to resurrect.

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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