Coordinated community safety net systems for low-income uninsured

Whether or not there is health reform, local communities and safety net providers will continue to play a critical role in providing care. Without universal coverage, local communities will face a particular burden to provide safety net services for low-income uninsured. One improved model for doing so that has emerged in some communities without a public hospital is to link hospital charity care with community physicians or health centers and private specialists, who either volunteer to provide free care, or are reimbursed at discounted rates. These emerging models might be called “coordinated community safety nets.” They are critically important because they are adaptable to smaller communities, possibly including those in rural areas, where safety net access is often the most difficult.

This study examined two coordinated community models for organizing and funding safety net access for low-income uninsured: one in Flint MI, and the second in Asheville NC. These two sites were selected for in-depth case studies after an extensive national review based on enrolling a majority of the area's low-income uninsured in a safety net program that is based in a primary care medical home and that includes a fairly comprehensive range of in-patient and specialist services.

Similar quantitative and qualitative measures were applied to each, including: 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 more comprehensive insurance.

Cost measures were derived from 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. Using claims data and standard risk-adjustors (CDPS and DxCG), the cost comparisons were adjusted for differences in demographics and chronic disease between each safety net group and its comparison groups.

These case studies can help smaller communities, public officials, policy makers, and health care administrators structure better safety net access for low-income uninsured, in order to help fill gaps left by the patchwork of insurance coverage.