The Safety Net and Health Care Reform

November 1, 2010

On October 29, CHRT sponsored a symposium to look at issues surrounding the safety net and the future of health care after the Affordable Care Act takes effect. While there are some who believe that getting to (or close to) universal coverage would mean the end of the safety net, our panelists came to the opposite conclusion. That is, we all believe that in the reform environment, the safety net will be at least as important as it is today – perhaps more so. But demands on safety net providers will change when health reform is fully implemented and the structure and organization of the safety net needs to be ready for those changes.

The existing network of safety net providers – that is, federally qualified health centers (FQHCs), free clinics, and individual practitioners serving a mix of insured and uninsured patients – are today challenged in their ability to care for all who need their services. As individuals in our state (and every state) have lost health coverage, more are turning to this network of providers for critical care, and providers are overwhelmed with the needs and demands of this ever growing patient base.

Though one often hears that there is not enough funding to support these programs, in fact, many of the challenges faced by these providers have nothing to do with financing. Peter Jacobson presented a compelling look at some of the infrastructure issues within these clinic programs: noting that many of them have grown up over the years as a response to a critical need but without the structures that would be in place for most small businesses (measurement, clear lines of leadership, adequate IT systems, and the like). Indeed, some safety net providers felt strongly that their work was mission based and that they should be working themselves out of existence to be replaced by a re-vamped health care system. As a result, some never developed the kinds of systems that one would expect from an entity that was planning to be a going concern.

On the other hand, we know from the experience of Massachusetts and Hawaii that with significant expansion of health care coverage, the demand for primary care services increases significantly and with it, the importance of the safety net. Indeed, Sara Rosenbaum contends that the Affordable Care Act anticipated that demand and expects safety net providers – in particular, the FQHCs, to play a key role in delivery of care in the reform environment. In that context, the best of the FQHCs today operate in a manner that parallels the Patient Centered Medical Home approach. Those approaches will clearly be more critical post reform when there is a significant influx of individuals with Medicaid coverage.

Brent Williams emphasized the importance of the Patient Centered Medical Home model as he shared his clinical experiences in working with the uninsured – especially the low income uninsured – who often enter care with long untreated issues and a complex set of social as well as medical needs. With insurance coverage in the future, there is an opportunity to provide these individuals with earlier care and a more comprehensive set of services. But it will take time for the impact of these services on health status to be seen. The system will be challenged to think about ways to change traditional care patterns that rely on emergency room services and better integrate mental health and other supportive services into the safety net system.

Finally, our reactor panel of those on the ground at the community level caring for patients – Vern Davis Anthony, Deborah Riddick, David Share and Kim Sibilsky – all emphasized both the opportunity and the challenges ahead for the safety net. All agreed that the importance of the safety net will continue in a reform environment and that the challenges to respond to the demands in the future will be no less than they are today – just different as providers try to respond to the influx of new patients.

2014 may sound like a long time from now but in many ways, it is just around the corner. If we want to be ready with an integrated delivery system that builds on the many strengths of our current safety net providers but also fills in some of the gaps noted in Peter Jacobson’s research, we need to be planning today. We hope our October 29 panel was a start to that more formal planning effort in our state so that Michigan is prepared to lead the way.