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The Health Care Safety Net in a Post-Reform World

Edited by Mark A. Hall and Sara Rosenbaum

Publication Year: 2012

The Health Care Safety Net in a Post-Reform World examines how national health care reform will impact safety net programs that serve low-income and uninsured patients. The “safety net” refers to the collection of hospitals, clinics, and doctors who treat disadvantaged people, including those without insurance, regardless of their ability to pay. Despite comprehensive national health care reform, over twenty million people will remain uninsured. And many of those who obtain insurance from reform will continue to face shortages of providers in their communities willing or able to serve them. As the demand for care grows with expanded insurance, so will the pressure on an overstretched safety net.


This book, with contributions from leading health care scholars, is the first comprehensive assessment of the safety net in over a decade. Rather than view health insurance and the health care safety net as alternatives to each other, it examines their potential to be complementary aspects of a broader effort to achieve equity and quality in health care access. It also considers whether the safety net can be improved and strengthened to a level that can provide truly universal access, both through expanded insurance and the creation of a well-integrated and reasonably supported network of direct health care access for the uninsured.


Seeing safety net institutions as key components of post-health care reform in the United States—as opposed to stop-gap measures or as part of the problem—is a bold idea. And as presented in this volume, it is an idea whose time has come.


Published by: Rutgers University Press

Series: Critical Issues in Health and Medicine

Title Page, Copyright

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pp. vii-viii


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pp. ix


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pp. xi

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Chapter 1 The Health Care Safety Net in the Context of National Health Insurance Reform

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pp. 1-17

The Patient Protection and Affordable Care Act (Affordable Care Act, or ACA) is expected to extend public and private insurance to about thirty million more people, more than half of those who are currently uninsured. Experts estimate that when fully implemented in 2019 the ACA will increase coverage from about 83 percent to 94 percent of the total US population. ...

Part I Community Health Centers

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Chapter 2 Dr. StrangeRove; or, How Conservatives Learned to Stop Worrying and Love Community Health Centers

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pp. 21-66

Almost sixty million Americans—about one in five—go without regular primary care (NACHC 2009a; AHRQ 2006). Lack of access is not simply a matter of insurance status; the difficulty of finding a primary care provider is a massive barrier to the use of primary care. Traditionally, charity care for the medically indigent has existed outside of government channels. From the early 1900s, ...

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Chapter 3 Reinventing a Classic: Community Health Centers and the Newly Insured

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pp. 67-90

On March 23, 2010, forty-five years after the first community health centers opened their doors in Mound Bayou, Mississippi, and Boston’s Columbia Point housing projects, President Obama signed into law arguably the most sweeping overhaul of the nation’s health insurance system ever attempted. Unlike Medicare and Medicaid, the Patient Protection and Affordable Care Act (ACA) does not merely fill the chasms created by voluntary health insurance.1 ...

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Chapter 4 Applying Lessons from Social Psychology to Repair the Health Care Safety Net for Undocumented Immigrants

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pp. 91-107

This chapter offers a new tool to advance the discussion about how the law should respond to the presence of undocumented immigrants in America. The Common Group Identity Model, formulated by social psychologists, explains the process of social categorization by which human beings naturally organize themselves into in-groups and out-groups and thus develop social ...

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Chapter 5 Community Health Center and Academic Medical Partnerships to Expand and Improve Primary Care

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pp. 108-125

A lengthy debate over how to build a more effective and affordable health care system culminated in the enactment of the Patient Protection and Affordable Care Act of 2010 (ACA). The legislation is neither the beginning nor the end of efforts to improve health care and health outcomes in the United States. Many more steps, both large and small, will be needed to establish a stable, high-performing health care system. ...

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Chapter 6 Examining the Structure and Sustainability of Health Care Safety-Net Services

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pp. 126-150

In a period of increasing patient demand and waning financial resources, the sustainability of health care safety-net organizations (SNO) is not guaranteed. This chapter focuses on primary care SNOs such as federally qualified health centers (FQHC) (also known as community health centers, or CHC) and community-based organizations such as free clinics. Their ability to remain ...

Part II Safety-Net Hospitals

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Chapter 7 Safety-Net Hospitals at the Crossroads: Whither Medicaid DSH?

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pp. 153-182

A viable safety net depends heavily on hospitals. In addition to providing inpatient services, their emergency rooms deliver vast amounts of ambulatory care to low-income Americans. Not all hospitals are, of course, equal in this regard. Of the more than 5,700 hospitals in the United States, a much smaller number have been front and center in caring for the disadvantaged. These so-called ...

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Chapter 8 The Safety-Net Role of Public Hospitals and Academic Medical Centers: Past, Present, and Future

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pp. 183-199

Public hospitals and academic medical centers (AMC) have long played an important role as safety-net providers in the United States. These institutions frequently offer outreach services to uninsured and Medicaid populations as well as an array of health and social services, either directly or through collaborative arrangements. Public hospitals and AMCs have faced many ...

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Chapter 9 The Declining Public Hospital Sector

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pp. 200-213

Public hospitals have long served as the backbone of the health care safety net, caring for the poor, uninsured, and racial and ethnic minorities, as well as providing critical regional services. In major metropolitan areas, public hospitals provide more than 20 percent of emergency and 33 percent of outpatient visits, as well as 60 percent of burn and 36 percent of trauma care. Medicaid ...

Part III Safety-Net Systems

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Chapter 10 Achieving Universal Access through Safety-Net Coverage

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pp. 217-233

The United States has long been derided as the world’s only industrialized country that falls well short of universal health care coverage. The 2010 Patient Protection and Affordable Care Act (ACA, or Affordable Care Act) will close approximately half the existing coverage gap but will leave more than twenty million people still uninsured. Can anything be done for the remaining uninsured that will bring ...

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Chapter 11 Public Coverage Expansions and Private Health Insurance Crowd-Out: Implications for Safety Nets

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pp. 234-259

Historically, high numbers of individuals without health insurance have meant that the United States must deliver care to roughly 15 percent of the population through a fragmented health care safety net that includes Medicaid, federally qualified health centers, and a variety of sources of free care, such as free clinics (Department of Health and Human Services 2005). The severe economic ...

About the Contributors

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pp. 261-264


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pp. 265-280

E-ISBN-13: 9780813553177
E-ISBN-10: 0813553172
Print-ISBN-13: 9780813553061

Page Count: 296
Illustrations: 11 graphs
Publication Year: 2012

Series Title: Critical Issues in Health and Medicine