America s Health Care Safety Net

1. America�s Health Care Safety Net Andrew B. Bindman, MD Professor of Medicine, Health Policy, Epidemiology & Biostatistics University of California, San Francisco Chief, Division of General Internal Medicine San Francisco General Hospital Hello. My name is Dr. Andrew Bindman. I am a physician and faculty member at the University of California San Francisco. I practice medicine at San Francisco General Hospital, San Francisco�s main safety net hospital. The lack of health insurance creates major barriers to health care services. Individuals who are low-income, are from under-represented minority groups, have limited English proficiency or are in poor health are most likely to be uninsured and these vulnerable populations disproportionately rely on a network of clinics and hospitals called the health care safety net for their care. This tutorial provides a quick overview of the major elements of the safety-net and discusses the major challenges facing the providers who serve among the most vulnerable members of our society. Hello. My name is Dr. Andrew Bindman. I am a physician and faculty member at the University of California San Francisco. I practice medicine at San Francisco General Hospital, San Francisco�s main safety net hospital. The lack of health insurance creates major barriers to health care services. Individuals who are low-income, are from under-represented minority groups, have limited English proficiency or are in poor health are most likely to be uninsured and these vulnerable populations disproportionately rely on a network of clinics and hospitals called the health care safety net for their care. This tutorial provides a quick overview of the major elements of the safety-net and discusses the major challenges facing the providers who serve among the most vulnerable members of our society.

2. Health Care Safety Net �Those providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients� Institute of Medicine In 2000, the Institute of Medicine identified core safety net providers as those that organize and deliver a significant level of health care and other-health-related services to uninsured, Medicaid, and other vulnerable patientsIn 2000, the Institute of Medicine identified core safety net providers as those that organize and deliver a significant level of health care and other-health-related services to uninsured, Medicaid, and other vulnerable patients

3. Variation at the Local Level Need for safety net organizations Composition of safety net providers Level of coordination in the safety net The need for health care safety services varies in association with the characteristics of the people living in a community. Also the composition of safety net providers and how they are organized and structured differs from community to community. For example, some communities provide a substantial portion of their safety net services through a single organization such as the public health department while others rely on a constellation of public, not for profit and private providers. Whether it is a single organization or as is more common a combination of different types of providers, there is also variation across communities in the degree to which different components of the safety net such as primary care, specialty care, hospital care, and long term care , are coordinated through protocols, information technology and other communication devices to ensure the efficient delivery of services.The need for health care safety services varies in association with the characteristics of the people living in a community. Also the composition of safety net providers and how they are organized and structured differs from community to community. For example, some communities provide a substantial portion of their safety net services through a single organization such as the public health department while others rely on a constellation of public, not for profit and private providers. Whether it is a single organization or as is more common a combination of different types of providers, there is also variation across communities in the degree to which different components of the safety net such as primary care, specialty care, hospital care, and long term care , are coordinated through protocols, information technology and other communication devices to ensure the efficient delivery of services.

4. Community Factors Affecting Need for Safety Net Services Rate of employer sponsored health insurance State Medicaid eligibility rules Number of undocumented immigrants Participation rate of private providers in charity care In communities where a high percentage of the population receives employer sponsored health insurance the need for safety net services is less. State policies on who is eligible for Medicaid can affect the number of uninsured and thereby also affect a community�s need for safety net services. Although many Medicaid beneficiaries rely on safety net services, Medicaid beneficiaries are less reliant on these sites of care than are the uninsured. Because undocumented immigrants are not eligible for government benefits and are less likely to have employer sponsored insurance, they are more likely to be uninsured and dependent upon the health care safety net. The degree to which private providers in a community provide charity care and participate in Medicaid also affects the residual demand for safety net services.In communities where a high percentage of the population receives employer sponsored health insurance the need for safety net services is less. State policies on who is eligible for Medicaid can affect the number of uninsured and thereby also affect a community�s need for safety net services. Although many Medicaid beneficiaries rely on safety net services, Medicaid beneficiaries are less reliant on these sites of care than are the uninsured. Because undocumented immigrants are not eligible for government benefits and are less likely to have employer sponsored insurance, they are more likely to be uninsured and dependent upon the health care safety net. The degree to which private providers in a community provide charity care and participate in Medicaid also affects the residual demand for safety net services.

5. Visible Elements of the Health Care Safety Net Public Hospitals Local Health Departments Community Clinics Variety of sponsors FQHCs qualify for federal grants and enhanced Medicaid reimbursement The most visible components of the health care safety net are public hospitals, local health departments and community clinics. Many public hospitals function as health care systems that provide inpatient, emergency services and a wide range of ambulatory or outpatient services through on-site primary and specialty care clinics. Many local health departments also provide safety net care through clinics in the community. There is a wide variety of other community clinics as well which provide care to underserved populations. Not for profit clinics that agree to provide services to all patients regardless of their ability to pay and offer other services to improve access to care such as transportation and translation services can be designated as a federally qualified health center (FQHC). This designation makes these clinics eligible for federal grants and or enhanced reimbursement from Medicaid. The most visible components of the health care safety net are public hospitals, local health departments and community clinics. Many public hospitals function as health care systems that provide inpatient, emergency services and a wide range of ambulatory or outpatient services through on-site primary and specialty care clinics. Many local health departments also provide safety net care through clinics in the community. There is a wide variety of other community clinics as well which provide care to underserved populations. Not for profit clinics that agree to provide services to all patients regardless of their ability to pay and offer other services to improve access to care such as transportation and translation services can be designated as a federally qualified health center (FQHC). This designation makes these clinics eligible for federal grants and or enhanced reimbursement from Medicaid.

6. Distinguishing Features of Safety Net Providers Organizational or legal mission to be provider of last resort Disproportionate share of uncompensated or publicly financed care Core safety net providers deliver services to uninsured and Medicaid patients because they have an organizational and/or legal mission to be the provider of last resort in their community. They provide these services out of proportion to the degree that these patients are represented in the general population. Since they provide services to uninsured patients that may not be able to pay for care, this care is called �uncompensated care� though there are other funding streams that may offset the costs of care for these providers.Core safety net providers deliver services to uninsured and Medicaid patients because they have an organizational and/or legal mission to be the provider of last resort in their community. They provide these services out of proportion to the degree that these patients are represented in the general population. Since they provide services to uninsured patients that may not be able to pay for care, this care is called �uncompensated care� though there are other funding streams that may offset the costs of care for these providers.

7. Requirements for Providing Care Federal law (EMTALA) requires hospital emergency rooms to evaluate/stabilize all patients regardless of ability to pay State/local laws may designate providers of last resort Private physicians are not legally required to accept Medicaid, Medicare, or any other payer The main federal provision that requires health care providers to deliver services regardless of a patient�s ability to pay is the Emergency Medical Treatment and Active Labor Act (EMTALA). This law requires providers in emergency department settings to evaluate all patients and to ensure that they are stable prior to discharge from that setting. There are state and local laws in some jurisdictions that also designate and determine the responsibilities of providers of last resort. For example, in California, the Welfare code 17000 designates counties as the party responsible for ensuring there is a provider of last resort for indigent patients. Private physicians are not required to provide care to uninsured patients or to publicly insured patients unless they have voluntarily entered into a contract to do so. The main federal provision that requires health care providers to deliver services regardless of a patient�s ability to pay is the Emergency Medical Treatment and Active Labor Act (EMTALA). This law requires providers in emergency department settings to evaluate all patients and to ensure that they are stable prior to discharge from that setting. There are state and local laws in some jurisdictions that also designate and determine the responsibilities of providers of last resort. For example, in California, the Welfare code 17000 designates counties as the party responsible for ensuring there is a provider of last resort for indigent patients. Private physicians are not required to provide care to uninsured patients or to publicly insured patients unless they have voluntarily entered into a contract to do so.

8. It is the mission of San Francisco General Hospital to deliver humanistic, cost-effective, and culturally competent health services to the residents of the City and County of San Francisco through a commitment to access for all residents by eliminating financial, linguistic, physical and operational barriers San Francisco General Hospital Mission Statement This mission statement at San Francisco General Hospital, the public acute care hospital in San Francisco, reflects the sorts of organizational statements that are seen at public hospitals and other safety net institutions throughout the country. The statement incorporates this institution�s legal requirement to be the provider of last resort and expresses an organizational commitment to eliminate financial and other barriers to care for the vulnerable and diverse patient population it serves. This mission statement at San Francisco General Hospital, the public acute care hospital in San Francisco, reflects the sorts of organizational statements that are seen at public hospitals and other safety net institutions throughout the country. The statement incorporates this institution�s legal requirement to be the provider of last resort and expresses an organizational commitment to eliminate financial and other barriers to care for the vulnerable and diverse patient population it serves.

9. Disproportionate Share of Care to the Uninsured One way to illustrate the impact that safety net hospitals play in the US health care system is by noting that the hospital membership of the National Association of Public Hospitals includes only 2% of the country�s hospitals but that these institutions provide 25% of uncompensated hospital costs. Safety net institutions are critical in providing care to the uninsured but they cannot do it on their own. One way to illustrate the impact that safety net hospitals play in the US health care system is by noting that the hospital membership of the National Association of Public Hospitals includes only 2% of the country�s hospitals but that these institutions provide 25% of uncompensated hospital costs. Safety net institutions are critical in providing care to the uninsured but they cannot do it on their own.

10. Physician Contribution to the Safety Net Majority have some Medicaid patients in practice Varies by specialty and state Medicaid payment Many provide reduced cost or free care Although small on individual level combined charity exceeds that provided in clinics Physician participation in Medicaid and charity care decreasing over time The majority of private physicians have some Medicaid patients in their practice and many provide some reduced cost or free care. However, the average percentage of such patients in physicians� practices is just under 5% but because of the large number of private physicians their contribution to safety net care exceeds that provided by community clinics. One major concern for the safety net is that the degree to which private physicians are contributing to the care of Medicaid and uninsured patients is decreasing over time.The majority of private physicians have some Medicaid patients in their practice and many provide some reduced cost or free care. However, the average percentage of such patients in physicians� practices is just under 5% but because of the large number of private physicians their contribution to safety net care exceeds that provided by community clinics. One major concern for the safety net is that the degree to which private physicians are contributing to the care of Medicaid and uninsured patients is decreasing over time.

11. Who Pays for Safety Net Care Federal Enhanced hospital payments: Disproportionate Share Hospital (DSH) / Indirect Medical Education (IME) Veterans Administration (VA) Community Programs: Indian Health Service (IHS), HIV/AIDS, Maternal/Child, clinic grants, National Health Service Corps State/local Tobacco settlement, general and/or designated tax funds Cost shifting from paying patients Charity Private contributions Volunteer health care providers The funding for safety net care comes from several sources. The federal government through Medicaid and Medicare provides hospitals that care for a disproportionate share of publicly sponsored patients additional payments called Disproportionate Share Hospital or DSH payments to support their associated uncompensated costs. Medicare also contributes to the safety net through supplements to hospital payments called indirect medical education (IME) funds that support the costs associated with the training of physicians that are used to provide care in many safety net institutions. The federal government also sponsors the Veterans Administration (VA) health care system to provide services to many veterans who do not have alternative sources of care. Other federal programs that support uncompensated care are those funding community-based programs such as the Indian Health Service (IHS), care for persons with HIV and AIDS, maternal and child health services, community clinics, and the National Health Service Corps (NHSC) which provides incentives such as loan repayment to providers for working in underserved sites of care. State and local government contribute funding to uncompensated care to a variable degree across regions. In recent years, many states have used funds they received as a part of the settlement with tobacco companies to support this care and will need to find an alternative source of funding when this expires. Private providers contribute to uncompensated care by cost shifting funds received for reimbursed care from private insurance, through private donations, and through unpaid volunteer work.The funding for safety net care comes from several sources. The federal government through Medicaid and Medicare provides hospitals that care for a disproportionate share of publicly sponsored patients additional payments called Disproportionate Share Hospital or DSH payments to support their associated uncompensated costs. Medicare also contributes to the safety net through supplements to hospital payments called indirect medical education (IME) funds that support the costs associated with the training of physicians that are used to provide care in many safety net institutions. The federal government also sponsors the Veterans Administration (VA) health care system to provide services to many veterans who do not have alternative sources of care. Other federal programs that support uncompensated care are those funding community-based programs such as the Indian Health Service (IHS), care for persons with HIV and AIDS, maternal and child health services, community clinics, and the National Health Service Corps (NHSC) which provides incentives such as loan repayment to providers for working in underserved sites of care. State and local government contribute funding to uncompensated care to a variable degree across regions. In recent years, many states have used funds they received as a part of the settlement with tobacco companies to support this care and will need to find an alternative source of funding when this expires. Private providers contribute to uncompensated care by cost shifting funds received for reimbursed care from private insurance, through private donations, and through unpaid volunteer work.

12. Sources of Uncompensated Care Funding, 2008 It�s estimated that more than $57 billion will be provided to support uncompensated care in the United States in 2008. While this is a substantial amount, many believe that it is about half of what is needed to provide health care coverage to the 46 million uninsured Americans that would be comparable to those who are insured. This figure provides an overview of the relative contribution of each source to the pool of uncompensated funding. DSH and IME from Medicaid and Medicare provides approximately a third of available funds for uncompensated care. The federal government contributes another 25% through its funding support of the VA (9%) and a variety of community programs (16%). State and local governments contribute 18% of the funding and private contributions largely through charity and cost shifting funds from other payers by physicians and hospitals comprises the remaining quarter of the financial support. It�s estimated that more than $57 billion will be provided to support uncompensated care in the United States in 2008. While this is a substantial amount, many believe that it is about half of what is needed to provide health care coverage to the 46 million uninsured Americans that would be comparable to those who are insured. This figure provides an overview of the relative contribution of each source to the pool of uncompensated funding. DSH and IME from Medicaid and Medicare provides approximately a third of available funds for uncompensated care. The federal government contributes another 25% through its funding support of the VA (9%) and a variety of community programs (16%). State and local governments contribute 18% of the funding and private contributions largely through charity and cost shifting funds from other payers by physicians and hospitals comprises the remaining quarter of the financial support.

13. Hospital Margins, Fiscal Year 2004 Although there is some funding for uncompensated care from public sources, it is less robust than that provided for insured patients. One reflection of this is in the hospital profit margins of safety net and non safety net hospitals. In 2004, the average margin of profit among all hospitals was 5.2% while it was only 1.2% for hospital members of the National Association of Public Hospitals. The average narrow profit margins seen among the safety net hospitals limits their capacity to make capital improvements such as investment in information technology that could improve the efficiency of their care delivery.Although there is some funding for uncompensated care from public sources, it is less robust than that provided for insured patients. One reflection of this is in the hospital profit margins of safety net and non safety net hospitals. In 2004, the average margin of profit among all hospitals was 5.2% while it was only 1.2% for hospital members of the National Association of Public Hospitals. The average narrow profit margins seen among the safety net hospitals limits their capacity to make capital improvements such as investment in information technology that could improve the efficiency of their care delivery.

14. Significant Public Hospital Closures Philadelphia General Hospital (1977) St. Louis City Hospital (1987) DC General Hospital (2001) LA�s MLK Hospital (2007) Inadequate funding of safety net institutions also leaves them vulnerable to closure. There have been some high profile closures of public hospitals in major American cities and many others in smaller communities as well. These closures create holes in the safety net that result in these communities being less able to provide care to indigent and other vulnerable patient groups. Inadequate funding of safety net institutions also leaves them vulnerable to closure. There have been some high profile closures of public hospitals in major American cities and many others in smaller communities as well. These closures create holes in the safety net that result in these communities being less able to provide care to indigent and other vulnerable patient groups.

15. Strategies to Improve Efficiency of Safety Net Care Vertical integration Different levels of care (primary, secondary, tertiary care, etc) under one organizational structure Efficiency in patient obtaining care at the most cost-effective level Communication of complex clinical data across levels of care supported by system-wide information technology Confronted with growing numbers of uninsured patients, many safety net institutions are pursuing strategies to improve the efficiency of the services they provide. Some safety net systems are borrowing and building upon the best ideas from vertically integrated delivery systems in the private sector to cost effectively match the needs of patients with the appropriate level of service whether it be primary, specialty, or hospital care. Vertical integration requires communication across the levels of care and it is increasingly possible through information technology.Confronted with growing numbers of uninsured patients, many safety net institutions are pursuing strategies to improve the efficiency of the services they provide. Some safety net systems are borrowing and building upon the best ideas from vertically integrated delivery systems in the private sector to cost effectively match the needs of patients with the appropriate level of service whether it be primary, specialty, or hospital care. Vertical integration requires communication across the levels of care and it is increasingly possible through information technology.

16. Horizontal Integration of Safety Net Services: Primary Care Horizontal integration refers to coordination of service delivery across a level of care Potential for inefficient practice variation and redundancy due to inadequate sharing of information Mismatch between demand and capacity across sites IT can support information sharing Barriers to collaboration Different governance structures Different values about teaching, research, etc Different sources of funds for uninsured Horizontal integration may also prove useful as a means to help the safety net perform more efficiently. Horizontal integration refers to the coordination of service delivery across a level of care such as primary care. The lack of coordination and inconsistent communication among different safety net primary care sites in a community may contribute to inefficient practice variation and redundant care. In many communities there may be a mismatch between the demand for services at various clinic sites and the relative capacity for these clinics to offer timely care. Information technology has the same potential to coordinate services and enhance efficiency that is proving to be useful in vertically integrated safety net systems, but there are additional barriers to horizontal integration in many communities when safety net primary care organizations have different governance structures, value systems, and sources of funds for uncompensated care. Horizontal integration may also prove useful as a means to help the safety net perform more efficiently. Horizontal integration refers to the coordination of service delivery across a level of care such as primary care. The lack of coordination and inconsistent communication among different safety net primary care sites in a community may contribute to inefficient practice variation and redundant care. In many communities there may be a mismatch between the demand for services at various clinic sites and the relative capacity for these clinics to offer timely care. Information technology has the same potential to coordinate services and enhance efficiency that is proving to be useful in vertically integrated safety net systems, but there are additional barriers to horizontal integration in many communities when safety net primary care organizations have different governance structures, value systems, and sources of funds for uncompensated care.

17. How Does Availability of Safety Net Care Compare to Insurance? Both contribute to improving access Health insurance has a bigger impact on access than availability of a safety net Health insurance is a more expensive strategy Like health insurance, the safety net contributes to improving access to care. There are challenges in making direct comparisons of the impact of each approach, but the evidence would tend to suggest that health insurance improves access to care to a greater degree than the direct investment in the safety net alone. However, the provision of health insurance is also a more costly strategy for improving access. Like health insurance, the safety net contributes to improving access to care. There are challenges in making direct comparisons of the impact of each approach, but the evidence would tend to suggest that health insurance improves access to care to a greater degree than the direct investment in the safety net alone. However, the provision of health insurance is also a more costly strategy for improving access.

18. Is the Safety Net Necessary with Universal Health Insurance? Segregating the poor in the safety net may contribute to lower quality care However: Safety net is an innovator in care of vulnerable populations Safety net likely to remain an important source of providers Immigrants, homeless and others may not be eligible for universal programs Given that one of the major roles of the safety net is to provide care to the uninsured, one might wonder whether there would still be a role for the safety net if we were able to provide universal health insurance to our population. One of the arguments for dismantling the safety net might be that segregating the poor in these institutions might contribute to their receiving lower quality care. Alternatively others might suggest that the safety net is an important site for quality improvement and innovation in the care of vulnerable patients. Furthermore, in many inner city and rural communities there is a significant shortage of private providers and therefore the safety net is likely to remain an important source of care even with the potentially enhanced access to choice with universal coverage. In addition, universal coverage may prove to be less than truly universal and we might anticipate that a safety net system will still be needed for undocumented immigrants, the homeless and other high risk vulnerable groups who might be hard to �sign up� for universal coverage. Given that one of the major roles of the safety net is to provide care to the uninsured, one might wonder whether there would still be a role for the safety net if we were able to provide universal health insurance to our population. One of the arguments for dismantling the safety net might be that segregating the poor in these institutions might contribute to their receiving lower quality care. Alternatively others might suggest that the safety net is an important site for quality improvement and innovation in the care of vulnerable patients. Furthermore, in many inner city and rural communities there is a significant shortage of private providers and therefore the safety net is likely to remain an important source of care even with the potentially enhanced access to choice with universal coverage. In addition, universal coverage may prove to be less than truly universal and we might anticipate that a safety net system will still be needed for undocumented immigrants, the homeless and other high risk vulnerable groups who might be hard to �sign up� for universal coverage.

19. Is Health Insurance Expansion a Benefit or Threat for Safety Net? Many state based proposals divert Disproportionate Share Hospital (DSH) $ from safety net to purchase insurance Adoption of coverage expansion in MA has resulted in fewer $ for safety-net providers Safety net providers face challenges in competing for their traditional patients Although safety net providers might be seen as a compliment to health insurance expansion as a means to enhance access to care for vulnerable patient populations, in many states, the financing approach to expanding insurance coverage has been a direct threat to the health care safety net. A common theme across state health insurance reform initiatives is to divert DSH funds from safety net hospitals toward the purchase of health insurance for the uninsured. This approach was used in Massachusetts which is actively trying to provide universal health insurance coverage. One of the short-term consequences in Massachusetts has been severe financial challenges for safety net institutions who have lost dedicated DSH funding and who are having a difficult time making up for this shortfall by competing for the health insurance payments of their traditional patients.Although safety net providers might be seen as a compliment to health insurance expansion as a means to enhance access to care for vulnerable patient populations, in many states, the financing approach to expanding insurance coverage has been a direct threat to the health care safety net. A common theme across state health insurance reform initiatives is to divert DSH funds from safety net hospitals toward the purchase of health insurance for the uninsured. This approach was used in Massachusetts which is actively trying to provide universal health insurance coverage. One of the short-term consequences in Massachusetts has been severe financial challenges for safety net institutions who have lost dedicated DSH funding and who are having a difficult time making up for this shortfall by competing for the health insurance payments of their traditional patients.

20. Healthy San Francisco: Health Care Reform with a Safety Net SF employers > 20 employees required to spend money on employee health care Employers may spend $ on Insurance Medical savings account Reimbursement for expenses - or - Healthy San Francisco Program Healthy San Francisco Provider network largely public health department and not for profit community health centers Health insurance reform need not necessarily be in direct competition with the safety net. One model for expanding access being tried in San Francisco, called Healthy San Francisco, is being done in conjunction with the safety net. The San Francisco Healthy Security Ordinance requires all employers with more than 20 employees who operate in San Francisco to spend a minimum amount of money to provide employees health insurance, a medical savings account, or reimbursement for health related expenses. Employers who do not provide one of these benefits may satisfy their obligation by putting money into the safety net through a newly created program called Healthy San Francisco. Healthy San Francisco promises every uninsured person in San Francisco a medical home and access to a broad range of medical services at affordable prices. The network consists almost exclusively of safety net providers with hospital and emergency services being covered only when provided at San Francisco General Hospital. Thus, the employer spending requirement has become a source of new funds for the San Francisco safety net system. With this design, the hope is that this will keep the number of uninsured in the city from increasing while providing funds to the health care safety net to provide affordable and accountable care for the city�s uninsured.Health insurance reform need not necessarily be in direct competition with the safety net. One model for expanding access being tried in San Francisco, called Healthy San Francisco, is being done in conjunction with the safety net. The San Francisco Healthy Security Ordinance requires all employers with more than 20 employees who operate in San Francisco to spend a minimum amount of money to provide employees health insurance, a medical savings account, or reimbursement for health related expenses. Employers who do not provide one of these benefits may satisfy their obligation by putting money into the safety net through a newly created program called Healthy San Francisco. Healthy San Francisco promises every uninsured person in San Francisco a medical home and access to a broad range of medical services at affordable prices. The network consists almost exclusively of safety net providers with hospital and emergency services being covered only when provided at San Francisco General Hospital. Thus, the employer spending requirement has become a source of new funds for the San Francisco safety net system. With this design, the hope is that this will keep the number of uninsured in the city from increasing while providing funds to the health care safety net to provide affordable and accountable care for the city�s uninsured.

21. Safety Net Medicine �The art and science of providing health care to people who are too poor, or too disconnected, or too new to this country to get what they need� �There needs to be a little Don Quixote in all public health practitioners� locked in on the mission, undaunted by the doubters and the half-hearted� Fitzhugh Mullan, MD Safety net health care systems are highly variable and fragile systems that provide a critical service to many of the most vulnerable patients in this country. The health care safety net faces a number of ongoing financial challenges from a growing number of un and underinsured Americans with complex medical problems and social characteristics, rapidly rising health care costs due to technological advances and an aging population with a growing list of chronic conditions, and years of underfunding that have created a backlog of capital expenditures to replace worn down facilities and to upgrade equipment. The people who work in these settings are committed to the mission of providing universal access to care for those in need. The dedication and hard work of these health care professionals helps to fill some of the gaps created by our social policies that do not ensure access to care through universal health insurance coverage. Safety net health care systems are highly variable and fragile systems that provide a critical service to many of the most vulnerable patients in this country. The health care safety net faces a number of ongoing financial challenges from a growing number of un and underinsured Americans with complex medical problems and social characteristics, rapidly rising health care costs due to technological advances and an aging population with a growing list of chronic conditions, and years of underfunding that have created a backlog of capital expenditures to replace worn down facilities and to upgrade equipment. The people who work in these settings are committed to the mission of providing universal access to care for those in need. The dedication and hard work of these health care professionals helps to fill some of the gaps created by our social policies that do not ensure access to care through universal health insurance coverage.

22. Further Resources America�s Healthcare Safety Net: Intact but Endangered. Institute of Medicine http://www.nap.edu/catalog.php?record_id=9612 Bureau of Primary Health Care http://bphc.hrsa.gov/ National Association of Community Health Centers http://www.nachc.org/research-data.cfm National Association of Public Hospitals http://www.naph.org/ National Association of County and City Health Officials http://www.naccho.org/