Healthcare Safety Net in 2030

Stephen P. Petzinger

George Mason University


As the United States embarks on massive health care reform through the continued implementation of the Patient Protection and Affordable Care Act of 2010 (ACA), policy makers must look to the future with unrelenting support for greater access to care. Albert Einstein (1946), one of the greatest intellectuals of all time, once said, " . . . a new type of thinking is essential if mankind is to survive and move toward higher levels." How does a health care system, with such deep-rooted principles of profit making and inefficiency, accomplish such lofty aspirations? Balabanova et al. (2013) argued, policy makers need to realize the complexity of the US health care system and that no simple recipe exists for success. No one can accurately predict the state of our health care system 17 years from now or what role the safety-net system will play to increase access to care. However, this author does know that if we ignore or sublimate such important questions, we will be much worse off than we are today.

What is the Safety Net?

The safety net in the United States is "a system of health care providers that primarily serve patients who otherwise cannot afford or gain access to care" (Summer, 2011). This health care safety net serves as the default system of care for many people who fall outside the medical and economic mainstream. Unfortunately, the safety net is neither uniformly available throughout the country nor financially secure. Rather, Lewin and Altman (2000), in their landmark report under the direction of the Institute of Medicine, maintained it is a patchwork of institutions, clinics, and physician's offices, supported with a variety of financing options that vary dramatically from state to state and community to community.

There are a myriad of facilities across the country designated as safety net facilities, over 8,000 health care sites in all 50 states and the District of Columbia (Schroeder, Taugher, Tighe, Lemberger & Birdwell, 2012). Of these, Direct Relief USA has defined four specific types of facilities:

  1. Community Clinic – a nonprofit provider agency that treats anyone, regardless of ability to pay, but generally charges patients on a sliding fee scale;
  2. Federally Qualified Health Center (FQHC) – public and private nonprofit health care providers located in medically underserved areas that treat anyone regardless of ability to pay and meet certain federal criteria under the Health Center Consolidation Act;
  3. Free Clinic – a nonprofit, typically volunteer-based provider facility that treats anyone regardless of ability to pay, typically free of charge, or with nominal donation for services; and,
  4. Look Alike – an organization that meets the eligibility requirement of the Section 330 of the Public Health Service Act, but does not receive federal grant funding. (Schroeder et al., 2012)

The central purpose of the patchwork system that defines the health care safety net is the treatment of vulnerable populations. Rapid demographic changes are anticipated over the next two decades; thus these vulnerable populations are expected to increase exponentially. This expansion will involve an influx of low-income and minority individuals and families. The United States must shore up its safety net system in order to effectively manage the millions of people expected to enter the system in the coming years.

An accurate picture of the role of safety net facilities in 2030 requires an understanding of the diverse populations of vulnerable patients that these institutions serve (Meyer, 2004). The health care safety net system provides care to a myriad of people, only a fraction of which are the exclusively uninsured. This system of providers and facilities has a huge focus on bridging the gap in access to care facing racial and ethnic minorities. This system is also an important piece of the puzzle for immigrants who may be ineligible for insurance and face many other barriers to care, including language and culture. The safety net frequently serves homeless populations and individuals with mental or emotional disabilities.

The health care safety net has been found to treat sicker patients than those not requiring the safety net for services. Meyer (2004) explained that the health care safety net treats many more patients with complex and chronic diseases. He also described the multiple social problems that interact with and complicate those patients' conditions. Specifically, a homeless person will continue to have major difficulties finding a bed in the community after being treated and is ready for discharge (Meyer, 2004). Finding this person shelter may be more important than actually treating the disease in terms of recovery and averting readmission.

The current state of America's health care safety net system is being negatively impacted by a variety of factors. There are rising numbers of uninsured, an increasingly price-driven health care marketplace, and rapid growth in Medicaid beneficiaries in managed care plans due to the implementation of the ACA. The future viability of America's health care safety net is highly dependent upon the support of its core safety net providers: "institutions and physicians with a high level of demonstrated commitment to caring for uninsured and underinsured patients" (Lewin & Altman, 2000). A failure for the United States to increase that support will cause a catastrophic collapse of the safety net system.

Looking Forward

The United States is among the wealthiest nations in the world, but it is far from the healthiest. Health disparities exist among many factions of citizens in the US that are observably incorrigible. Consequently, a growing recognition of these disparities has led to fundamental changes to reshape our nation's health care system. Our entire health care system, particularly the health care safety net, must provide the best care possible to society's most vulnerable populations.

If everyone was insured with comprehensive coverage, the need for safety net services would be markedly diminished. But, we are acutely aware that starting January 2014, millions of people will still be without insurance. Some of the uninsured will be exempt from the individual mandate. Others may decide that health insurance is unaffordable, even with subsidies, and may choose to pay a penalty instead of purchasing insurance. Furthermore, undocumented immigrants will remain uninsured as well.

The ongoing health care reform places safety net systems at a crossroads. Down one path, safety net facilities and clinicians are further ostracized. They are left caring only for undocumented persons and those too impaired to be accepted by other centers and clinicians, and they are unable to generate sufficient revenue to provide this care. Down the other path, safety net facilities and clinicians rise to the challenge of providing comprehensive care to low-income persons by improving customer service, strengthening referral networks and primary care medical homes, and investing in infrastructure, all while keeping costs down. That being the case, a robust safety net system may offer the best chance of providing quality care to those excluded from health reform and those who newly acquire health insurance. As Baxter and Mechanic (1997) emphasized, "we should maintain a health care safety net for persons who are uninsured, difficult to serve, discriminated against, or who cannot get care elsewhere."

There are many models of how health care safety net systems may evolve in the future. At one end of the continuum, "safety-net systems can gear up to compete directly with other providers in the medical services marketplace" (Baxter & Mechanic, 1997). To be successful, most will have to enhance their technical capabilities in managed care contracting, clinical practice management, performance monitoring, and information technology. This response, however, may not be fully compatible with their charitable and social missions.

At the other end of the continuum, Baxter & Mechanic (1997) held that safety-net providers may focus on maintaining or expanding their original duty. They will still have to make operational changes to compete effectively. But this approach recognizes that competitive markets will not provide all of the resources necessary to realize the safety-net mission; maintaining a "public goods" role will require a social compact with one's community. As competition removes subsidies from these systems, communities will have to make more explicit investments to maintain an effective safety net.

The Safety Net in 2030

Health care safety net facilities will continue to play a critical role in the health care system of the United States in 2030. There will continue to be millions of people uninsured or underinsured and 16 years after the implementation of the ACA, citizens and legislators alike will be looking for new ways to overcome health care disparities. The United States will undoubtedly procrastinate, constantly overwhelmed by the continued struggle with pressing challenges—the most serious being the severe budget shortfalls that will face many states and the nation, putting severe financial pressure on the health care safety net system.

In addition to financial burdens that will continue to face the health care safety net system, a gap will still exist between the level of spending and the outcomes achieved compared to that spending. The gaps will continue to exist in many of the same groups they do today; that includes low-income individuals, uninsured people, racial and ethic minorities, and those living in rural areas. Barriers will continue to exist for other vulnerable populations as well, including prisoners, children and adolescents, and those facing large medical debts.

A final challenge that will certainly face the health care safety net in 2030 is the substantial shortage of the health care workforce. According to Grant Makers in Health, Issue Brief #38 (2012), researchers estimate that policies to expand coverage to all Americans will increase demand for physicians by 25 percent. This will exacerbate the shortage of providers and other health care professionals that currently exists due to the millions of baby boomers soon to reach retirement age. As the demand for care rises, the pool of primary care providers must then be expanded to meet this need.

Future Policy Recommendations

How do we take the current health care safety net system and redesign it into an organized system of support that makes sense to all parties involved? It requires restructuring of the entire social service framework in the United States to facilitate an integrated case management system. By facilitating a more one-stop approach to providing social services, including all pieces of the health care safety net, programs could cut costs and reduce errors. Within a coordinated system, families would spend less energy on inconsequential matters and could use their time better toward meeting family needs, improving job performance, investing in self-care, or meeting long-term goals through better education and training (Green, 2013). At a minimum, these coordinated programs and organizations should increase communication and collaboration to provide more effective systems of referral and access. Lastly, a massive escalation of health information technology (HIT) is necessary to accomplish a better-coordinated system. The health care safety net system will face constant challenges incorporating HIT, including the high cost of hardware and software, the need to customize off-the-shelf software products to reflect a specific health center's population restricted budgets, and limited knowledge among staff about hardware and software options (Shields et al., 2011).

Despite the challenges the health care safety net system will inevitably face, the safety net will have much to offer the broader health system. For years, the health care safety net has been doing more with less. Further attention to and advances in the quality of care will remain a top priority. Racial and ethnic health disparities will continue to plague the safety net, let alone America's entire health care system. To help eliminate these disparities in 2030, the health care safety net must implement the following policies:

  1. Further the engagement with patients, their families, and communities. Determine resources that can be used to retrieve data on the needs of various racial, cultural, ethnic, linguistic, and socio-economic groups within the service area. Collaborate with other organizations to improve the capacity to obtain and update data for understanding the communities served.
  2. Establish leadership that exudes quality and equitable care. Commit to seeking opportunities for underrepresented racial and ethnic minority professionals to serve on boards and in executive positions. Identify pools of talented individuals from diverse racial and ethnic groups through networking and proactive outreach to professional associations and advocacy groups.
  3. Provide evidence-based care to all patients. Adopt standard order sets and treatment guidelines that have been published as best practices. Adopt a set of orders that provides evidence-based treatment guidelines to the provider, while allowing the provider to opt out of those guidelines if deemed necessary.
  4. Establish quality measures. Determine whether patients receive all recommended care in a timely fashion and how patients perceive their care. Analyze the supply and demand of language and cultural services.
  5. Provide culturally competent and linguistically appropriate care. List in a visible and accessible manner the local options for culturally appropriate medical interpreters. Ensure that translated materials and signs accurately convey the meaningful substance of materials written in languages other than English. Collaborate with other hospitals in the area to improve language access and interpreter services in the community.

(Adapted from Assuring Healthcare Equity: A Healthcare Equity Blueprint, 2008)

All of these categories will be interrelated. Each one will be part of an integrated system for providing equal access to quality care. This centralized system will be instrumental in improved coordination of care, enhanced communication, and increased effectiveness of care across multiple programs and services. Rather than allowing health care safety net providers and facilities to operate as isolated entities, an integrated and coordinated system will focus on the entire health care safety net working as a team, reducing cost and disparity. This integrated system will connect those who are most vulnerable with community resources and will hold providers, practitioners, employers, families, and individuals accountable for the outcomes achieved.


The health care safety net system clearly plays a vital role in the United States and will continue to do so in 2030. All of the facilities involved will remain serving a very disproportionate share of lower-income people, racial and ethnic minorities, and those with special health care needs. Patients within the health care safety net will still present with more complex medical and social needs. The health care safety net will be a critical piece of the social welfare puzzle in 2030. The United States will be closer to universal health care coverage, and we will reduce, but by no means eliminate the health care safety net. We need to continue to support the vital role the health care safety net in meeting a range of health and social needs.


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Baxter, R.J. & Mechanic, R.E. (1997, July). The status of local health care safety nets. Health Affairs, 16 (4), p. 7-23. doi: 10.1377/hlthaff.16.4.7

Cummings, L.C., Bennett, B.A., Boutwell, A.E., & Martinez, E.L. (2008, September). Assuring healthcare equity: A healthcare equity blueprint. National Public Health and Hospital Institute. Retrieved from http://www.naph.org/Main-Menu-Category/Publications.aspx

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Green, A.R. (2013, February 12). Patchwork: Poor women's stories of renewing the shredded safety net. Affilia, 28 (1), 51-64. Doi: 10.1177/0886109912475159

Issue Brief #38. (2012, March 7). Safety net in the era of health reform: A new vision of care. Grant Makers in Health. Retrieved from http://www.gih.org/Publications/IssueDialogue Detail.cfm?ItemNumber=4629

Lewin, M.E. & Altman, S. (2000). Institute of Medicine. America's health care safety net: Intact but endangered. Retrieved from http://books.nap.edu/openbook.php?record_id=13497& page=1

Meyer, J.A. (2004, November). Safety net hospitals: A vital resource for the United States. Economic and Social Research Institute. Retrieved from http://www.esresearch.org/publications.php

Schroeder, A., Taugher, D., Tighe, T., Lemberger, J., & Birdwell, A. (2012). The state of the safety net 2012: The economic crisis and America's nonprofit clinics and health centers. Santa Barbara, CA: Direct Relief.

Shields, Alexandra E., Peter Shin, Michael G. Leu, et al. (2011, September). Adoption of health information technology in community health centers: Results of a national survey. Health Affairs, 26(5), p. 1373-1383.

Summer, L. (2011, April). The impact of the Affordable Care Act on the safety net. AcademyHealth Publications. Retrieved from http://www.academyhealth.org/ Publications/BriefList.cfm?navItemNumber=534


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