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Strengthening the Health Care Safety Net

Workshop Brief for State and Local Health Officials

This workshop was designed for State and local health officials who make policy decisions regarding Medicaid, health insurance coverage, and programs to directly provide or seek to improve access to care for low-income individuals and families. The workshop was held in Milwaukee, Wisconsin, October 25-27, 2000.

About the Workshop Sponsor.


The health care safety net is "intact but endangered," according to a recent Institute of Medicine (IOM) report. This conclusion is raising major concern among State and local policymakers and others who are concerned about meeting the health care needs of the poor and vulnerable. Key factors causing the increased stress on the already fragile patchwork of health care providers and institutions include the steadily rising numbers of uninsured people—now more than 44 million—and the erosion of both direct and indirect subsidy dollars, such as the capping of disproportionate share hospital (DSH) payments and reduced "cost-shifting" to pay for charity care.

To prevent the safety net from unraveling, the IOM calls for a review of all safety net programs (especially Medicaid), Federal investments in systems to monitor the viability of safety net providers, and new dollars to improve the coordination of safety net services delivery.

Policy analysis and research in this area is difficult, especially because the term "safety net" means different things to different people. In its broadest sense, the safety net refers to all service providers and financing mechanisms that provide or support care to persons unable to afford needed health care services. These populations include uninsured persons, Medicaid enrollees, and other vulnerable persons such as immigrants, farm workers, and homeless persons, who often have difficulty accessing care.

Another confounding factor is that the health care safety net is not comprehensive, nor is it well integrated. It is a patchwork of institutions, financing, and programs that vary dramatically across the country as a result of economic, political, and structural factors, such as:

  • Strength of the local economy.
  • Concentration of poor and uninsured individuals.
  • State and local tax dollars devoted to health care.
  • Medicaid policies.
  • Underserved inner-city or rural areas.
  • The historic commitment of community providers.

States with the greatest demand for safety net services often have the weakest infrastructure to effectively respond to local needs.

This workshop offered a forum for State and local policymakers to examine the problem of the safety net and to discuss policy options for ensuring access to health care services for those without adequate insurance or other financial means.

The objectives for participants in this workshop included:

  • Describing the status of the health care safety net in the United States and the major pressures affecting the viability of core safety net providers.
  • Understanding how certain Medicaid managed care rules and practices can affect safety net providers.
  • Identifying the main sources of funding for safety net services and how direct and indirect subsidies have been eroding.
  • Identifying new Federal resources for strengthening the safety net.
  • Understanding the difficulties involved with monitoring the status of safety net providers and populations, and efforts to overcome these barriers.
  • Describing key lessons from efforts to create safety net "systems" that more closely coordinate and integrate services provided by hospitals, community health centers, and other safety net providers.


Workshop participants included representatives from State and county health departments, including children's health, mental health, and substance abuse; Medicaid agencies; legislative staff; research and policy analysts from the Association for State and Territorial Health Officials and the National Conference of State Legislatures; and Federal agencies including the Health Resources and Services Administration, Office of Minority Health, Indian Health Service, and the Office of the Assistant Secretary for Management and Budget. Twenty-one States were represented.

AHRQ's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of Federal, State, and local policymakers, and other health services research users, such as purchasers, administrators, and health plans.

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