The Health Care Safety Net in a Post-Reform World

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

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 challenges over the years in maintaining their safety-net roles, especially given their need to balance these roles against others they have in the community, such as research, teaching, and patient care. However, many have demonstrated their resilience to these stresses. This chapter examines the historical context that has led public hospitals and AMCs to serve as an important component of the health safety net and how their role in the safety net has been shaped by the challenges they have faced. Drawing on interviews we undertook with key stakeholders of safety-net institutions , the chapter also explores how the Patient Protection and Affordable Care Act (ACA) will affect these institutions and their ongoing roles in the community, including how these institutions will likely build on their existing efforts to address future challenges. The questions and uncertainties that exist for public hospitals and AMCs as health care reform is implemented is also explored. Historical Context: Public Hospitals and AMCs as Safety-Net Institutions Public hospitals in the United States have a long tradition of serving individuals who do not have the means to pay for their care. This role dates back to the The Safety-Net Role of Public Hospitals and Academic Medical Centers Past, Present, and Future Chapter 8 183 Gloria J. Bazzoli and Sheryl L. Garland 1700s when the first US public hospital opened to provide shelter and charitable health services for the poor (Lewin and Altman 2000). These facilities also were the training ground for physicians because they provided patients for physicians to hone their medical skills and understanding. As medicine became more advanced, public hospitals remained but, like private hospitals, became more focused on curative treatment rather than the warehousing of sick individuals. In addition, as medical education advanced and educational standards became more specific, large AMCs arose, some of which had their historical roots in the original public hospitals. In 2008 the American Hospital Association (AHA) annual survey data indicated that there were 1,105 public hospitals nationwide and 305 hospitals listed as teaching hospitals affiliated with the Association of American Medical College’s Council on Teaching Hospitals. Holahan and colleagues (2008) reported that hospitals provided $35 billion in uncompensated care in 2008, largely to poor and uninsured individuals. The National Association of Public Hospitals and Health Systems (NAPH), which represents those public and private hospitals that have large safety-net commitments, had approximately 140 hospital members in 2008. Data reported by NAPH (2010a) indicated that 16 percent of their members’ costs of providing hospital care was uncompensated compared to 5.8 percent for all hospitals nationwide in 2008. NAPH members represented only 2 percent of the nation’s acute care hospitals but delivered 19 percent of nationwide uncompensated care. The continuing, and in fact growing, role of public hospitals and AMCs in the safety net is largely due to several unique characteristics of these institutions . The geographic location of urban public hospitals and AMCs makes them convenient sources of care for indigent populations. These institutions are frequently located in the central city, often near poor neighborhoods. In part, their location reflects historical decisions by local officials to place them in areas where services were limited, and also it may reflect the decisions of poor individuals to live near these facilities (Gaskin and Hadley 1999; Hadley and Cunningham 2004). Additionally, these institutions tend to offer a broad range of services given their teaching missions, including the public, social, and specialty services that are used by uninsured and Medicaid populations (Gaskin 1999; Zuckerman et al. 2001; Bazzoli et al. 2005; Horowitz 2005). Lewin and Altman (2000) noted that AMCs may be the only, or among the few, hospitals offering highly specialized services in a community that are used by both insured and uninsured (such as organ transplant, high-risk obstetrics care). Recognizing the special needs of the populations they served, public hospitals and AMCs developed outreach and culturally sensitive services over 184 Gloria J. Bazzoli and Sheryl L. Garland time for their uninsured populations, provided primary care services through their emergency departments or af...