Abstract

his paper examines how health system change in 12 metropolitan areas is shaping the organization and delivery of health care to poor populations, and the viability of safety net providers such as public hospitals, academic health centers, community health centers and other entities that serve the poor. These findings are based on systematic interviews with a wide array of providers, health plans, community leaders, policy makers, employers, and consumer advocates in each site. Safety net providers are actively trying to adapt to health system changes in much the same way as other providers. Health care for the poor was not typically a priority in the 12 markets, but it surfaced rapidly when events raised the potential to redistribute responsibility for uncompensated care. Competition for Medicaid patients continues to grow as Medicaid managed care becomes more prevalent, threatening some other providers that historically have served the poor. Community health centers appeared particularly vulnerable to the competition for Medicaid patients and reported increases in the uninsured. Safety net hospitals, on the other hand, while vulnerable because of their high-cost and low-income patient base, appeared to be adapting successfully in many cases. In contrast to the traditional description of a safety net, we found little evidence of real comprehensive service networks among traditional providers of care to the poor and we did encounter competition among those providers.