[cross-posted from the United States of Care blog]

Policies have reformed the health care system so that millions of Americans are able to access health coverage. However, for many, health coverage does not always translate to access to health care. The health care safety net plays a key role in filling coverage gaps that the traditional insurance system creates and ensures that health care is accessible and affordable for those who are uninsured or have high-deductible or high cost-sharing plans that leave them unable to access care.

The safety net, which includes everything from free clinics to city-wide direct access programs, is a critical part of the system, one that has undergone a transformation since the implementation of the Affordable Care Act. In a brief released today, in conjunction with Professor Mark Hall, at Wake Forest University Schools of Law and Medicine, and Janet Weiner, Co-Director for Health Policy at the Leonard Davis Institute at the University of Pennsylvania, we explore the landscape of the health care safety net and the evolving challenges that these programs and providers face.

Despite historic coverage gains, nearly 30 million people remain uninsured in the United States, including individuals who are unable to access health coverage due to their citizenship status. Millions more are underinsured, forgoing needed health care because of high out-of-pocket costs. For all of these individuals, safety-net programs, such as those at community health centers, charity care institutions, and public hospitals, continue to fill gaps in health care coverage and provide critical access to care.

States and localities have been leaders in expanding and ensuring access to safety-net programs, and have built programs that best meet their unique local needs. A “guaranteed health care for all” plan in New York City and San Francisco’s Healthy San Francisco Program make health care services available to uninsured residents regardless of citizenship, employment, or health status. Healthy San Francisco has allowed the city’s residents to access regular primary care and has resulted in decreased utilization of emergency department services. Additionally, the “Harris Health” financial assistance program in Houston provides low-income, uninsured county residents with comprehensive services in county-operated facilities on a sliding scale basis. Since 2008, Harris Health has doubled the number of safety-net clinics they run with funding through federal and state grants and increased their patient visits by over 300%.

While safety-net programs are a critical component of health care access, they are not a substitute for the protection often afforded by comprehensive health insurance. Evidence shows that health insurance allows people to access regular care and a range of covered benefits, leading to overall better health outcomes. Moreso, insurance coverage provides individuals with financial security by reducing the cost burden of unexpected health catastrophes. The Affordable Care Act greatly reduced the number of uninsured Americans by creating more affordable health insurance with federal tax credits and extending Medicaid coverage to millions of low-income, childless adults. For states looking to make coverage more available, the evidence is clear that expanding Medicaid eligibility (for the states that have not yet done so) significantly reduces rates of uninsured individuals, increases health service utilization, and improves health outcomes. Additionally, expansion has resulted in state savings from shifting health costs for eligible beneficiaries onto the Medicaid program, which contributes to a reduction of uninsured visits to hospitals and clinics, improving hospitals’ finances, and preventing rural hospital closures in many communities. 

While approaches look different from state to state and town to town, the diverse health care safety net is an essential source of regular care for many people. A strong health care safety net benefits us all, providing people who don’t have insurance coverage with regular care to prevent and manage illnesses outside of emergency departments. Until policymakers pass a solution that will provide affordable and accessible health care coverage to all people, Congress must ensure that safety net programs receive federal funding to continue to provide crucial health care to vulnerable communities and adapt to fit the unique needs of the people they serve.

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This blog was authored by Elizabeth Hagan, Senior Policy Manager, and Christine Nguyen, Policy Coordinator, at United States of Care. The featured brief was produced as part of research partnership between Penn LDI and United States of Care.