Safety Net Providers

In recent years the term safety net has been applied to the programs taking care of people who do not have employment-related benefits of various types. It implies that a safety net of programs is in place, such as unemployment insurance, welfare programs, and Medicaid. Services for Medicaid enrollees may or may not be available in a community. In health care the term safety net providers refers primarily to those who care for the uninsured and the underinsured. In some communities this is a local health department that provides primary care services. In other cases it may be the outpatient department of a city or county hospital, a rural health center, or a school nurse. If these public health providers are not available in a community, there is either no safety net or there is a second tier of charity providers such as a clinic run by church groups or by medical students or uncompensated care given by existing providers, such as hospitals or community physicians. As budgetary restraints have led to reductions in the payments made by Medicare and Medicaid, more and more providers have withdrawn their services from the medically needy populations, forcing more and more of such people onto safety net providers.

The biggest group in need of a medical safety net is the working poor, who work for relatively low wages and whose employers usually do not provide much in the way of health care insurance. The wealthy can purchase their own insurance and typically work in organizations with good health benefits, whereas the unemployed and disabled are eligible for government-financed health programs such as Medicaid. However, the working poor, even when employed or on Social Security, have trouble meeting the ever-increasing deductible and copayment requirements of their health insurance programs.

There is no national plan to provide the so-called safety net for health care. There is still an unresolved debate over whether health care is a right or a privilege in the United States. Available services for uninsured and the working poor are sparse and quixotic. Full funding is available for individuals needing kidney dialysis, but not for transplants. Mental health treatment costs are covered under Medicare, if one is ruled disabled, but not under most employer-financed health plans. A separate mental health delivery system functions in most states. Although receiving some federal support, it is inadequately funded. Many centers have tended to wander away from their original objective of focusing on the chronically and severely mentally ill. Coordination between community mental health clinics and state hospitals is poor, and many mentally ill fall through the cracks, adding to the burden of homeless shelters and prisons. The one group experiencing increasing access to medical care is children. Each year another cohort of children is added to those receiving Medicaid coverage at incomes up to almost twice the local poverty level.

What must precede the design of a health care safety net system is consensus about what level of care the working poor are to be afforded and where payment is to come from. Then expert opinion can be called on to design a more reliable and comprehensive safety net system.

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