An ‘open door’ for the vul­ner­a­ble

Even af­ter re­form is in place, need for safety net providers will be great

Modern Healthcare - - Opinions Editorials -

Afre­quently asked ques­tion in health re­form dis­cus­sions is, “Will there still be a need for the health­care safety net?” This is an in­ter­est­ing ques­tion for sev­eral rea­sons. First, it re­flects the be­lief that health­care safety net providers’ prime role is to care for unin­sured pa­tients who can­not ac­cess care else­where. This be­lief con­forms to the In­sti­tute of Medicine’s def­i­ni­tion of the core safety net: “Those in­sti­tu­tions who by legal man­date or ex­plic­itly adopted mis­sion main­tain an ‘open door’ of­fer­ing ac­cess to ser­vices to pa­tients re­gard­less of their abil­ity to pay.”

Pub­lic hos­pi­tals and com­mu­nity health cen­ters fit this def­i­ni­tion as the pa­tients they serve are of­ten unin­sured. About 18% of pub­lic hos­pi­tal ad­mis­sions are unin­sured pa­tients, reach­ing more than 50% in some hos­pi­tals. And unin­sured pa­tients con­sti­tute 31% of out­pa­tient vis­its, climb­ing to more than 60% of vis­its in some hos­pi­tals. With the re­ces­sion, Den­ver Health’s unin­sured care in­creased from $275 mil­lion in 2007 to $389 mil­lion in 2010. The Na­tional As­so­ci­a­tion of Pub­lic ity and pro­vid­ing pre­mium sub­si­dies would elim­i­nate or markedly de­crease the num­ber of unin­sured and the need for these in­sti­tu­tions. How­ever, even the most op­ti­mistic es­ti­mates pre­dict that 23 mil­lion peo­ple will re­main unin­sured, in­clud­ing many of the most vul­ner­a­ble, such as the chron­i­cally men­tally ill, sub­stance abusers and the home­less—who are un­likely ever to en­roll in a plan—as well as an es­ti­mated 11 mil­lion un­doc­u­mented im­mi­grants. The unin­sured pop­u­la­tion may be larger if there is no in­di­vid­ual man­date or if the penal­ties for fail­ure to en­roll are small com­pared with the cost of sub­si­dized pre­mi­ums.

The sec­ond in­ter­est­ing as­pect about ques­tion­ing the fu­ture of the safety net is the as­sump­tion that other providers want to or can ef­fec­tively care for the poor and so­cially dis­en­fran­chised even if they are in­sured. Med­i­caid provider data may

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