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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. This is a monumental achievement. As with all major leaps forward, this one comes with challenges because of who the law includes and excludes, the levels of subsidies that will be available, and the retention of multiple insurance markets that individuals must traverse as income, work, and family circumstances change. The first and perhaps most important limitation is that more than twenty million people—about 8 percent of the nonelderly population—will remain uninsured. Some will be excluded because they will be unable to satisfy the act’s requirement of legal US status to receive premium subsidies or nonemergency Medicaid benefits, the two principal forms of direct federal aid under the law for low- and moderate-income populations. Others will be individuals for whom coverage will remain unaffordable, as defined by the law. Still others will be individuals who experience interruptions in coverage because of lapses in Medicaid or subsidy eligibility, as well as enrollment barriers that persist despite the relatively aggressive enrollment assistance efforts that the law requires. A second challenge arises from the fact that insurance coverage alone does not cure nonfinancial barriers to health care. Millions of Americans live in urban and rural communities officially designated as medically underserved because of a serious shortage of primary care providers coupled with lower The Health Care Safety Net in the Context of National Health Insurance Reform Chapter 1 1 Mark A. Hall and Sara Rosenbaum population income. While the expansion of health insurance may ultimately attract more health care providers into these communities, medical practice remains challenging because underserved patients may be more clinically complex. Also, the proportion covered by subsidized insurance is far higher and thus provider compensation is lower. Resources ultimately may improve in these communities, but this shift inevitably will be slow to come, especially given the overall primary care shortage. A third challenge can be found in the nature of the health insurance coverage under health reform. The ACA’s nondiscrimination provisions make coverage available to millions of people that insurers previously excluded because of preexisting conditions, and the ACA’s elimination of lifetime and annual caps and coverage of “essential health benefits” promise to strengthen the scope of coverage available in the individual and small-group insurance markets. At the same time, to keep premiums affordable, the actuarial value of coverage for which the insurer is responsible will remain relatively low, leaving individuals with potentially significant cost-sharing exposure (deductibles, copayments, coinsurance) for covered benefits. In addition, the definition of essential health benefits excludes some items and services (such as vision and dental care for adults) or limits others to less than what some patients need (such as therapy interventions for a disabled child that exceed plan limits ). Thus, even with cost-sharing assistance, financial exposure will remain significant for lower-income people covered through insurance exchanges. For these reasons, safety-net providers, programs, and systems will remain essential in a postreform world, for newly insured and uninsured alike (Hall 2011a, 2011b; Katz 2010). The safety net consists primarily of publicly funded and community-supported clinics as well as public hospitals and missiondriven nonprofit hospitals that take all patients regardless of ability to pay (Lewin and Altman 2000). From one perspective, insurance reform will be a boon for these organizations. Expansion of Medicaid and private insurance coverage will reduce the collective burden of uncompensated care by over half and will increase the revenues that safety-net organizations receive from well-insured patients. Also, the ACA contains large funding increases for community health centers. However, the ACA also reduces other safety-net investments, most notably, funding for hospitals that serve a disproportionate number of low-income persons. Furthermore, dependence on the health care safety net may increase for the remaining uninsured population as providers that previously might have provided uncompensated care seek out the newly insured. These policy realities mean that some safety net providers will continue to experience significant gaps in geographic availability, scope of 2 Mark A. Hall and Sara Rosenbaum services, and capacity as well as a perception that safety...


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