Safety Net Still Active After State Reform

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Where Will the Newly Insured Seek Care?

"The conventional wisdom has been that the role of safety-net providers would shrink under health reform. After all, once uninsured patients have Medicaid or are covered under [a health insurance] exchange, they will have other choices of where to receive their care," said Dr. Mitchell H. Katz. But the report by Ku et al. shows the opposite. "The important lesson from Massachusetts is that the newly insured continued to seek care in the safety net," he said.

Whether this pattern will hold true in other parts of the country under federal health reform will depend on two factors: "the perceived quality and convenience of safety-net providers, and the degree of competition from other providers to attract persons who newly gain insurance," Dr. Katz said.

Mitchell H. Katz, M.D., is at the Lost Angeles County Department of Health Services. He reported no financial conflict of interest. These remarks are from his editorial accompanying Dr. Ku’s report (Arch. Intern. Med. 2011;171:1319-20).



Even though the 2006 health care reform in Massachusetts dramatically reduced the proportion of uninsured patients to less than 2% today, the demand for services from "safety-net facilities" there continues to rise, according to the results of a data analysis.

Most patients at the community health centers, clinics, charity hospitals, and public hospitals in the state are insured and have the option to seek care elsewhere, but they continue to use these safety-net providers, reported Leighton Ku, Ph.D., and his coauthors in the Aug. 8/22 issue of Archives of Internal Medicine.

Surveyed patients said they use these facilities because they are familiar and provide desired services that these patients want, such as language assistance, wrote Dr. Ku of the department of health policy at George Washington University, Washington, and his coinvestigators.

Key elements of the Massachusetts law are similar to those in the federal health care reform passed last year. The researchers said it is likely that that national demand for safety-net services will show a similar increase, at least for the next few years.

"States and the federal government should consider whether adequate transitional and long-term support exist to help meet the needs of patients served by safety-net facilities," Dr. Ku and his colleagues said (Arch. Intern. Med. 2011;171:1379-84).

They examined the experience in Massachusetts using a combination of administrative data, the results of a 2009 telephone survey about the state’s health reform, and data from case-study interviews with medical staff and administrators in four communities with a history of poor access to health care.

Between 2005 and 2009, the number of patients served at safety-net facilities in Massachusetts increased by 31%, from 431,005 to 564,740, and the number of such facilities increased from 33 to 36. At the same time, the percentage of uninsured patients at these facilities dropped from 36% to 20%, the authors reported.

Low-income patients using safety-net facilities and other patients had similar patterns of general medical visits, preventive care visits, specialty care visits, and dental care visits. Where they differed was in their use of emergency departments. One-third of adult safety-net patients reported visiting an ED for a nonemergency condition, whereas only 15% of other adult patients did.

A majority of patients, medical staff, and medical administrators cited as reasons for the continuing use of safety-net facilities convenient location (79%); affordable care (74%); and the availability of nonmedical services such as language services, assistance with insurance forms, transportation assistance, and community outreach programs (52%). Existing ties to the providers at safety-net facilities and the high number of bilingual providers there also encouraged patients who were newly insured to continue to seek care there.

Only 25% of patients said they attended safety-net facilities because they had difficulty getting appointments elsewhere.

This study was funded in part by the Blue Cross Blue Shield of Massachusetts Foundation. No financial conflict of interest was reported.

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