Erosion in the Healthcare Safety Net: Impacts on Different Population Groups

Abstract

Safety net hospitals (SNHs) have played a critical role in the U.S. health system providing access to health care for vulnerable populations, in particular the Medicaid and uninsured populations. However, little research has examined how access for these populations changes when contraction of the safety net occurs. Institutional policies, such as hospital closure or ownership conversion, could affect the supply of minority health care providers, thus exacerbating disparities in outcomes. We use multilevel logistic modeling of person-level hospital discharge data to examine the effects of contractions in the California safety net over the period of 1990–2000 on access to care as measured by changes in ambulatory care sensitive condition (ACSC) admissions, using geographic methods to characterize proximity to a contraction event. We found that presence of a contraction event was associated with a statistically significant increase in the predicted probability of impeded access, with an increase of about 1% for Medicaid-insured populations and about 4–5% for the uninsured. The Medicaid-insured group also maintained the highest rates of ACSC admissions over time, suggesting persistent access problems for this vulnerable group. This research is timely given continued budget problems in many states, where rising unemployment has increased the number of Medicaid enrollees by 6 million and uninsured individuals by 1.5 million, increasing pressure on remaining SNHs.

The Effect of Hospital Safety-Net Burden Status on Short-term Outcomes and Cost of Care After Head and Neck Cancer Surgery

“…For these same reasons, many uninsured or underinsured patients receive primary care services at safety-net hospitals. 3 However, not all pa- tients treated at these hospitals are underinsured or uninsured. Patient who have the means to seek care elsewhere but choose to seek care at safety-net hospitals often do so because they offer a variety of services that other institutions do not, including language assistance, social work, insurance enrollment assistance, transportation, and other services.…”

“…2 In fact, a significant proportion of members of these communities receive their primary care at these institutions because they do not have access, with regard to proximity or insurance status, to private physicians in the community. 3 However, it should be noted that these hospitals care for not only uninsured and underinsured patients, but also for a considerable number of patients with commercial insurance plans. 2 Many published reports have commented on the nature and quality of care at safety-net institutions, and these reports almost always demonstrate significantly decreased quality of care and worse outcomes.…”

Local Health Department Activities to Ensure Access to Care

“…6–10 The availability and quality of public health services vary widely across communities. 11–15 However, evidence is limited on LHD involvement in ensuring healthcare access, and on factors that influence this involvement.…”

Changes in the Health Care Safety Net 1992–2003: Disparities in Access for Uninsured Persons in Florida

“…Following previous research (16, 23) we measured access to care using hospital admissions for ambulatory care sensitive conditions (ACSCs). ACSC admissions are validated indicators of impeded access to adequate primary and preventive care services.…”

“…Following previous research that examined factors associated with changes in the healthcare safety net (16), our analysis included both patient characteristics and community contextual characteristics as key control variables. We used data from the SID to characterize patients, including age categories (25–34, 35–44, 45–54, and 55–64 years old), gender, and race or ethnicity (white, black, and Hispanic).…”