Safety net hospital

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A safety net hospital is one of the medical centers in the United States that has a legal obligation to provide healthcare for individuals regardless of their insurance status (the United States does not have a policy of universal health care) and regardless of their ability to pay.[1][2][3] Because of this legal mandate to serve all populations, safety net hospitals typically serve a proportionately higher number of uninsured, Medicaid, Medicare, Children's Health Insurance Program (CHiP), low-income, and other vulnerable individuals than their non-safety net hospital counterpart.[1][2][3] Safety net hospitals are not defined by their ownership terms; they can be either publicly or privately owned.[3][2] The missions of safety net hospitals are rather, to focus and emphasize their devotion to providing the best possible care for those who are barred from health care due to the various possible adverse circumstances. These circumstances mostly revolve around problems with financial payments, insurance plans, or health.[3][1] As per America’s Health Care Safety Net: Intact But Endangered[4], safety nets are known for maintaining an open-door policy for their services.

Some safety net hospitals even offer high-cost services like burn, trauma, and neonatal treatments. Some also provide training for medical professionals. The Health and Hospital Corporation in NYC, Cook County Health and Hospital System in Chicago, and Parkland Health & Hospital System in Dallas are three of the United States' largest safety net hospitals.[citation needed]

Financing a safety net hospital[edit]

Safety net hospitals oftentimes find themselves in difficult financial positions due to the vulnerable financial state of the patients and lack of sufficient federal, state and local funding; safety net hospitals have high rates of Medicaid and Medicare payers[5][6][1] (Medicaid has unreliable/insufficient processes of government to hospital repayment[5]) and a large proportion of safety net hospital patients serve traditionally low income and marginalized/vulnerable populations.[5][7][1] There is a complex array of public funding that comes to safety net hospitals (as being legally defined as a safety net hospital entitles these entities to financial compensation to overcome the cost of medical expenses not paid for by patients) mostly through Medicaid Disproportionate Share Hospital Payments, Medicaid Upper Payment Limit Payments, Medicaid Indirect Medical Education Payments, and state/local indigent health programs.[5][8] However, these financial entities created to sustain safety net hospitals in repayments are often not enough. In 2013, hospitals across the United States generated $44.6 billion in uncompensated care costs; uncompensated care costs are costs accrued from services that the hospitals provided to patients that were not able to pay and that also went unpaid by government entities[8]). Additionally, there tends to be a lack of socioeconomic development and a lack of health care providers (both general and specialized) in the geographical regions where safety net hospitals tend to be located; this observation is made by Waitzkin and he refers to these facts as part of the social and structural "contradictions" that safety net hospitals face further negatively impact there financial stability and care performance.[3]

Prospects for safety net hospitals under the Patient Protection and Affordable Care Act[edit]

Under statute, Medicaid and Medicare issue disproportionate share hospital (DSH) payments that offset hospitals’ expenditures for uncompensated care. These payments are intended to improve access for Medicaid recipients and uninsured patients, as well as to shore up the financial stability of safety-net hospitals. Prior to the Patient Protection and Affordable Care Act (ACA, also known as "Obamacare"), the Medicare portion of the program has already been limited, and under the ACA the Medicaid portion of the program is also scheduled to be restricted.[9] This was built into the law under the assumption that the amount of uncompensated care would decline substantially under the ACA due to expanded coverage.[9] However, coverage did not expand as much as anticipated in many states due to the unanticipated choice not to expand Medicaid access under the Act (a result of National Federation of Independent Business v. Sebelius).[9] An additional issue with Obamacare and safety net hospitals arises from the coverage gap for those who have too high of an income to qualify for Medicaid but have too low of an income to afford a private plan; it is projected that even with the implementation of the health care law in 2016, roughly 30 million people are still expected to be without insurance coverage[10][11] and find service in safety net hospitals. Another issue revolves around the fact that hospitals are required to provide care for patients in the emergency department, even if the person cannot pay or is an illegal immigrant.[6]

Prospects for safety net hospitals under the Trump Administration[edit]

Paul Ryan, Speaker of the House, advocates for many large-scale tax cuts which would serve to reduce the federal funds that financially supports federal programs such as Medicare and Medicaid,[12] in an effort to decrease the federal deficit that America faces.[13] These potential federal cuts and proposed increased enrollment criteria for federal welfare programs will make it more difficult for Americans to be able to participate and receive aid from federal programs (especially with less money allocated to these programs) and will create an inevitable cost shift on patients; Less money allocated to federal programs and the simultaneous repeals to Obamacare will lead to less patients receiving financial help and qualifying for insurance programs, which means they will have to pay more money out of pocket. It is estimated that there will be 15 million (or more)[14] fewer individuals insured with "Trumpcare" than with Obamacare.[13] This will directly impact safety net hospitals because that means the number of patients without insurance will increase at safety net hospitals but in turn, safety net hospitals will also be suffering a decrease in financial support from the federal government and will not be able to absorb as many costs for these patients (decreasing the number of patients that can receive help).[12][15] The aforementioned proposed acts will place financial burdens and operational constraints on both patients and safety net hospitals.

Patient experience in safety net hospitals[edit]

Studies have shown that safety net hospitals, when compared to non-safety net hospitals (and other healthcare institutions[2]), do not perform as well in overall patient care and patient experience ratings.[16][7] In response to these critiques, safety net hospitals have put emphasis on their attempts to increase their patient experience scores and are developing training classes for customer service that includes employee evaluations as well as employee orientations and advocating for policy changes that could improve the patient experience.[17]


  1. ^ a b c d e Becker, Gay (2004). "Deadly Inequality in the Health Care "Safety Net": Uninsured Ethnic Minorities' Struggle to Live with Life-Threatening Illnesses". Medical Anthropology Quarterly. 18 (2): 258–275. doi:10.1525/maq.2004.18.2.258. JSTOR 3655479. 
  2. ^ a b c d Anderson, Ron; Cunningham, Peter; Hofmann, Paul; Lerner, Wayne; Seitz, Kevin; McPherson, Bruce (2009). "Protecting the Hospital Safety Net". Inquiry. 46 (1): 7–16. doi:10.5034/inquiryjrnl_46.01.7. JSTOR 29773398. 
  3. ^ a b c d e Waitzkin, Howard (2005-06-01). "Commentary—The History and Contradictions of the Health Care Safety Net". Health Services Research. 40 (3): 941–952. doi:10.1111/j.1475-6773.2005.00430.x. ISSN 1475-6773. PMC 1361178Freely accessible. 
  4. ^ Medicine, Institute of (2000-03-30). America's Health Care Safety Net: Intact but Endangered. doi:10.17226/9612. ISBN 9780309064972. 
  5. ^ a b c d Fagnani, Lynne (Nov 1999). "The Dependence of safety net Hospitals and Health Systems On the Medicare and Medicaid disproportionate Share Hospital Payment Programs" (PDF). 
  6. ^ a b W., Burt, Catharine; E., Arispe, Irma (October 18, 2017). "Characteristics of emergency departments serving high volumes of safety-net patients; United States, 2000". Center for Disease Control and Prevention. 
  7. ^ a b Werner, Rachel M. (2008-05-14). "Comparison of Change in Quality of Care Between Safety-Net and Non–Safety-Net Hospitals". JAMA. 299 (18). doi:10.1001/jama.299.18.2180. ISSN 0098-7484. 
  8. ^ a b Gaskin, Darrell J.; Hadley, Jack (1999-09-01). "Population characteristics of markets of safety-net and non-safety-net hospitals". Journal of Urban Health. 76 (3): 351–370. doi:10.1007/BF02345673. ISSN 1099-3460. PMC 3456829Freely accessible. 
  9. ^ a b c Rudowitz, Robin (18 November 2013). "How Do Medicaid Disproportionate Share Hospital (DSH) Payments Change Under the ACA?" (PDF). Kaiser Family Foundation. Retrieved 9 April 2018. 
  10. ^ Sommers, M.D., Ph.D., Benjamin D. (2015). "Health Care Reform's Unfinished Work — Remaining Barriers to Coverage and Access". The New England Journal of Medicine. 373: 2395–2397. doi:10.1056/nejmp1509462. 
  11. ^ Oberlander, Jonathan (2012-12-06). "The Future of Obamacare". New England Journal of Medicine. 367 (23): 2165–2167. doi:10.1056/nejmp1213674. ISSN 0028-4793. PMID 23171062. 
  12. ^ a b Oberlander, Jonathan (2016-11-16). "The End of Obamacare". New England Journal of Medicine. 376 (1): 1–3. doi:10.1056/nejmp1614438. 
  13. ^ a b "H.R. 1628, Better Care Reconciliation Act of 2017". Congressional Budget Office. 2017-06-26. Retrieved 2017-11-09. 
  14. ^ "Obamacare repeal could leave 32 million uninsured and double premiums, report finds - ProQuest". Retrieved 2017-11-09. 
  15. ^ Bazzoli, Gloria J.; Lindrooth, Richard C.; Kang, Ray; Hasnain-Wynia, Romana (2006-08-01). "The Influence of Health Policy and Market Factors on the Hospital Safety Net". Health Services Research. 41 (4p1): 1159–1180. doi:10.1111/j.1475-6773.2006.00528.x. ISSN 1475-6773. 
  16. ^ Chatterjee, Paula; Joynt, Karen E.; Orav, E. John; Jha, Ashish K. (2012-09-10). "Patient Experience in Safety-Net Hospitals". Archives of Internal Medicine. 172 (16). doi:10.1001/archinternmed.2012.3158. ISSN 0003-9926. 
  17. ^ Goldman, L. Elizabeth; Henderson, Stuart; Dohan, Daniel P.; Talavera, Jason A.; Dudley, R. Adams (2007-05-01). "Public Reporting and Pay-for-Performance: Safety-Net Hospital Executives' Concerns and Policy Suggestions". INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 44 (2): 137–145. doi:10.5034/inquiryjrnl_44.2.137. ISSN 0046-9580. 

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