Healthcare Reform and Safety-Net Providers

The Patient Protection and Affordable Care Act (ACA) is designed to address the issue of uninsured adults in the United States by providing more choices for coverage and expanding Medicaid coverage. At present, a portion of uninsured patients seek primary care from community health centers (CHCs) or clinics of safety-net hospitals and specialty and inpatient care from safety-net hospitals (those that received ≥20% of the net patient service revenue from Medicaid, Commonwealth Care, or the Health Safety Net Program in Massachusetts). With implementation of the ACA, the role of the healthcare safety net may change, with patients shifting away from safety-net providers, thus reducing the need for safety-net facilities, according to researchers. In 2006, Chapter 58, the Massachusetts healthcare reform law, was implemented. Elements of the Massachusetts law are similar to the ACA, including the so-called individual mandate for coverage, the expansion of public coverage, and a health insurance exchange to create more affordable private health insurance coverage. A recent survey found that by 2010, the uninsurance rate in Massachusetts had fallen to 1.9%. Researchers recently analyzed various administrative data to determine the effect of the 2006 law on the demand for ambulatory and inpatient care and use for safety-net providers. They reported results of the analyses in Archives of Internal Medicine [2011;171(15):1379-1384]. The Uniform Data System findings are reported each year to the federal government by CHCs receiving Section 330 grants; this analysis utilized data from the Uniform Data System in Massachusetts for 2005-2009. Data for hospitals were obtained from the Massachusetts Division of Health Care Finance and Policy for calendar years 2006-2009. Data on patients’ perspectives were gathered from the 2009 Massachusetts Health Reform Survey, a statewide telephone survey conducted in fall 2009. Finally, the researchers conducted case study interviews from January 26 through March 30, 2010, with CHC and hospital administrators and staff in Boston, Fall River, Springfield, and Pittsfield. CHCs provide primary care services regardless of a patient’s ability to pay. In 2005, there were 33 CHCs in Massachusetts; in 2009, there were 36 CHCs, providing services at 312 sites. The number of patients served increased by 31.0% between 2005 and 2009 (431,005 patients compared with 564,740). During that same period, the number of uninsured individuals decreased from 35.5% of the CHC caseload to 19.9%, a decrease primarily due to more individuals being covered by Medicaid and Commonwealth Care. Between 2006 and 2009, nonemergency ambulatory care hospital visits from outpatient departments and hospitals’ community clinics rose 9.2% for safety-net hospitals and 4.1% for non–safety-net hospitals. The growth level for inpatient admissions was approximately 2% for safety-net hospitals and non–safety-net hospitals between 2006 and 2009. The majority (79.3%) of patients using safety-net services cited convenience as the reason to use the service; just over half (52.0%) cited the availability of services other than medical care at the facility. Affordability was mentioned by 73.8% of those using the safety-net facilities; 25.2% said they used the safety-net facilities because they had difficulty getting an appointment elsewhere. In summary, the researchers stated, “despite the significant reduction in uninsurance levels in Massachusetts that occurred with healthcare reform, the demand for care at safety-net facilities continues to rise. Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there. It will continue to be important to support safety-net providers, even after healthcare reform programs are established.”