The Health Care "Safety Net" in a Post-Reform World

The Health Care "Safety Net" in a Post-Reform World

The Health Care "Safety Net" in a Post-Reform World

The Health Care "Safety Net" in a Post-Reform World


The Health Care Safety Net in a Post-Reform World examines how national health care reform will impact safety net programs that serve low-income and uninsured patients. The "safety net" refers to the collection of hospitals, clinics, and doctors who treat disadvantaged people, including those without insurance, regardless of their ability to pay. Despite comprehensive national health care reform, over twenty million people will remain uninsured. And many of those who obtain insurance from reform will continue to face shortages of providers in their communities willing or able to serve them. As the demand for care grows with expanded insurance, so will the pressure on an overstretched safety net.

This book, with contributions from leading health care scholars, is the first comprehensive assessment of the safety net in over a decade. Rather than view health insurance and the health care safety net as alternatives to each other, it examines their potential to be complementary aspects of a broader effort to achieve equity and quality in health care access. It also considers whether the safety net can be improved and strengthened to a level that can provide truly universal access, both through expanded insurance and the creation of a well-integrated and reasonably supported network of direct health care access for the uninsured.

Seeing safety net institutions as key components of post-health care reform in the United States--as opposed to stop-gap measures or as part of the problem--is a bold idea. And as presented in this volume, it is an idea whose time has come.


Mark A. Hall and Sara Rosenbaum

The Patient Protection and Affordable Care Act (Affordable Care Act, or ACA) is expected to extend public and private insurance to about thirty million more people, more than half of those who are currently uninsured. Experts estimate that when fully implemented in 2019 the ACA will increase coverage from about 83 percent to 94 percent of the total US population. This is a monumental achievement.

As with all major leaps forward, this one comes with challenges because of who the law includes and excludes, the levels of subsidies that will be available, and the retention of multiple insurance markets that individuals must traverse as income, work, and family circumstances change. The first and perhaps most important limitation is that more than twenty million people—about 8 percent of the nonelderly population—will remain uninsured. Some will be excluded because they will be unable to satisfy the act’s requirement of legal US status to receive premium subsidies or nonemergency Medicaid benefits, the two principal forms of direct federal aid under the law for low- and moderate-income populations. Others will be individuals for whom coverage will remain unaffordable, as defined by the law. Still others will be individuals who experience interruptions in coverage because of lapses in Medicaid or subsidy eligibility, as well as enrollment barriers that persist despite the relatively aggressive enrollment assistance efforts that the law requires.

A second challenge arises from the fact that insurance coverage alone does not cure nonfinancial barriers to health care. Millions of Americans live in urban and rural communities officially designated as medically underserved because of a serious shortage of primary care providers coupled with lower . . .

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