Achieving universal access through an adequate safety net

The safety net for the uninsured is often neglected in proposals for health insurance coverage despite the fact that, under most health care reform scenarios, millions of people will remain uninsured. Expanding insurance coverage without a coordinated delivery system could further fragment care and diminish access for disadvantaged populations. Existing studies of the safety net are localized, incomplete, and lack the careful conceptual, economic and policy modeling that is required for serious consideration as part of national reform. This study develops a financial framework for improving access to care for low-income uninsured, as a complement to currently proposed insurance expansions.

A case study approach was applied, using both quantitative and qualitative data analysis across six safety net health care delivery systems located in: Asheville NC, Boston, Denver, Flint MI, San Antonio, Portland ME. Each site has a safety net program for low-income uninsured that covers a fairly comprehensive range of services based in a primary care medical home. These sites were selected after an extensive literature review, to reflect a variety of geographic, demographic, and delivery system characteristics, as well as the availability of data and willingness to participate. Included are safety net systems based on public hospitals, community hospitals, community health centers, and on physicians in private practice.

Similar measures across each of the six sites were applied, including measures related to: 1)Level of access to care provided, 2)Cost of delivering care, and 3)Descriptions of the programs and populations served. Access measures were derived from BRFFS and state/local health insurance surveys and included usual source of care, difficulty affording care, and satisfaction with care – compared to populations with comprehensive insurance.

Cost measures were derived from safety net health care system administrative and claims data. Each site's risk adjusted per person cost for non-elderly adults was calculated for 2008 and adjusted for any non-covered benefits. Costs were estimated for covering the same population by Medicaid or subsidized private insurance. The cost comparisons were risk-adjusted for differences in demographics and between each safety net group and its comparison groups, and were possible also for chronic disease using standard risk adjustors (CDPS, DxCG) applied to claims data.

These cost comparisons will help public officials, policy makers, and health care administrators determine whether safety net funding is being well spent, and whether improvements in safety net structure and funding can adequately fill gaps left by the patchwork of insurance coverage.