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Ethnicity, income, and public financing all influence medical safety net providers in large urban communities

Community health centers, public hospitals, and local health departments make up the medical "safety net" for many uninsured and impoverished Americans. Although a new study dispels the notion that the safety net eroded during the 1990s, as many had feared, it also confirms the importance of local economic conditions and local financing in maintaining the safety net. Thus, the economic downturn and pressure on State budgets could mean that safety-net providers may not be able to continue to care for at-risk patients, according to Jose J. Escarce, M.D., Ph.D., of the University of California, Los Angeles.

In the study, which was supported in part by the Agency for Healthcare Research and Quality (HS10770), Dr. Escarce and his colleagues used data from a variety of sources to construct a database that described the health care system in large urban communities from 1993 to 1998. They used the database to examine the impact of community demographic and market characteristics on safety net measures such as uncompensated hospital care, admissions to safety net hospitals, visits to community health centers, and local government spending on health.

The researchers found no significant decreases in any of the safety net measures they examined during the 1993 to 1998 period. For instance, uncompensated hospital care per low-income person was $248 in 1993 and $232 in 1998. They also found little support that HMO penetration and hospital competition eroded the safety net. However, they did find substantial variation in the safety net across communities. The safety net index (sum of safety net measures) was higher in communities with a high concentration of blacks or Hispanics and in communities with higher incomes, perhaps due to greater tax capacity to support the safety net. In fact, communities with higher incomes provided more uncompensated hospital care and had more admissions and ambulatory visits to safety net hospitals by low-income people than less advantaged communities. Visits to community health centers were higher in communities with more public insurance such as Medicaid, suggesting that public financing expands the safety net.

See "Recent trends and geographic variation in the safety net," by M. Susan Marquis, Ph.D., Jeannette A. Rogowski, Ph.D., and Dr. Escarce, in the May 2004 Medical Care 42(5), pp. 408-415.

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