The Safety-Net Health Care System by Gunnar Almgren and Taryn Lindhorst (review)

The Safety-Net Health Care System is a thoughtful and thorough narrative of the history and intricacies of the health care system that provides treatment for low-income, incarcerated, and otherwise stigmatized and marginalized patients in the United States. The authors embrace the definition of the health care safety net proposed by the Institute of Medicine (IOM): “[T]hose providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients.”^1[p.22]

The book is divided into two major sections starting with Systemic Foundations of the Safety-Net Health Care System. This section includes a compelling history of health care for the underserved starting with Dorothea Dix’s crusade for the mentally ill, passage of President Franklin D. Roosevelt’s Social Security Act, creation of community health centers (CHCs), Medicare and Medicaid, AIDS Drug Assistance Program, and concluding with the creation of Medicare Part D Drug benefit. Readers of this journal may find the discussion of the Theories of Poverty (e.g., p. 60) to be of particular interest. The conservative theory of poverty is explored using multiple concepts initially proposed by Charles Murray beginning with a general theory of poverty centered on three propositions: lack of motivation to seek low-wage work due to a viable alternative in the form of generous welfare transfers, perpetuation of the mechanisms of poverty (welfare dependence, promiscuity, and dependence socialization of children) through welfare transfers, and increased utilization of welfare programs in direct proportion to benefit generosity without concurrent reduction of poverty.² The authors also introduce (and then refute) arguments in Herrnstein and Murray’s The Bell Curve that poverty and dependence on welfare emerge at least in part from inborn traits rather than from environmental and historical influences on populations—in other words, that impoverished people are impoverished in part because of inborn deficiencies for success in the modern world.³ The authors also critique liberal theories of poverty, including Oscar Lewis’s theory identifying structural causes of poverty (racial segregation and deindustrialization) as preceding maladaptive traits of low-income people and not “blaming the victim” but ultimately calling for an approach to poverty to be reframed as a discussion of a larger problem of economic, political, and social inequality.⁴

In the second section, Populations and Providers, readers will find detail on the recurring theme of the cyclical nature of poverty and health disparity with an informed dialog of the multitude of entry points into this vicious cycle including homelessness, substance abuse and addiction, and interpersonal violence or trauma. Safety-net providers who eschew negative stereotypes of homeless patients (such as that they are lazy, drunkards, or immoral) will appreciate the discussion of structural causes of homelessness (labor and housing markets, federal and local social policies, and demographic trends) vs. more apparent causes identified at the individual level (physical or mental disabilities, limited education and job skills, being lesbian/gay/bisexual/transgender [LGBT], or having a limited network of family and friends). Substance abuse and addiction is discussed with an insightful mention of employment as a protective factor against health risks (including substance abuse and addiction) while regular substance abuse and dependency reduces likelihood of sustained, stable employment. Connections are drawn between interpersonal violence, injury (accidents, homicide, suicide), trauma and risk factors, such as lack of decent housing increasing risk of burn injuries due to unsafe heating devices and increased risk of LGBT youth for victimization and suicide risk.

An analysis of subgroups of patients who commonly present to safety-net clinics is presented and the authors and delve into the reality that “some patients are frustrating to treat.”^[p.271] Rather than affirming the provider’s instinct to identify patients as “difficult,” the authors provide strategies into how to help providers refrain from unnecessarily blaming patients for a difficult encounter. Safety-net providers may often work with patients with individual needs and experiences that make...