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The passage of the Patient Protection and Affordable Care Act (ACA) presents both opportunities and significant challenges for the safety net, a system of health care providers that primarily serve patients who otherwise cannot afford or gain access to care. In 2014, the ACA will extend health insurance coverage to more than 30 million currently uninsured people. The law also promises some significant investments to build provider capacity and help deliver care in a more coordinated manner. However, safety net providers are concerned that changes in the ACA regarding health care financing may affect the availability of adequate and sustainable funding as they continue to care for the most vulnerable consumers, particularly the millions who will still lack insurance. Safety net providers note that the successes of health reform and of the safety net are bound together as the health of the nation will not improve unless providers are available to deliver care. All providers recognize the need to plan strategically in anticipation of major changes in the health care system, but safety net providers also face the immediate challenge of responding to a significant increase in the demand for services that accompanied the recent recession. At the same time, cuts in Medicaid, the largest single revenue source for safety net providers, have occurred in states that face large budget deficits. Safety net providers must focus on sustaining current services while planning for the major changes to come in 2014 The ACA gives federal agencies the discretion to define critical terms and concepts in the law. The manner in which they are interpreted can have a profound impact on the viability of the safety net.
The Health Care Safety Net in a Post-Reform World examines how national health care reform will impact safety net programs that serve low-income and uninsured patients. The “safety net” refers to the collection of hospitals, clinics, and doctors who treat disadvantaged people, including those without insurance, regardless of their ability to pay. Despite comprehensive national health care reform, over twenty million people will remain uninsured. And many of those who obtain insurance from reform will continue to face shortages of providers in their communities willing or able to serve them. As the demand for care grows with expanded insurance, so will the pressure on an overstretched safety net. This book, with contributions from leading health care scholars, is the first comprehensive assessment of the safety net in over a decade. Rather than view health insurance and the health care safety net as alternatives to each other, it examines their potential to be complementary aspects of a broader effort to achieve equity and quality in health care access. It also considers whether the safety net can be improved and strengthened to a level that can provide truly universal access, both through expanded insurance and the creation of a well-integrated and reasonably supported network of direct health care access for the uninsured. Seeing safety net institutions as key components of post-health care reform in the United States—as opposed to stop-gap measures or as part of the problem—is a bold idea. And as presented in this volume, it is an idea whose time has come.
America's Health Care Safety Net explains how competition and cost issues in today's health care marketplace are posing major challenges to continued access to care for America's poor and uninsured. At a time when policymakers and providers are urgently seeking guidance, the committee recommends concrete strategies for maintaining the viability of the safety netâ€"with innovative approaches to building public attention, developing better tools for tracking the problem, and designing effective interventions. This book examines the health care safety net from the perspectives of key providers and the populations they serve, including: Components of the safety netâ€"public hospitals, community clinics, local health departments, and federal and state programs. Mounting pressures on the systemâ€"rising numbers of uninsured patients, decline in Medicaid eligibility due to welfare reform, increasing health care access barriers for minority and immigrant populations, and more. Specific consequences for providers and their patients from the competitive, managed care environmentâ€"detailing the evolution and impact of Medicaid managed care. Key issues highlighted in four populationsâ€"children with special needs, people with serious mental illness, people with HIV/AIDS, and the homeless.
Many of the elements of the Affordable Care Act (ACA) went into effect in 2014, and with the establishment of many new rules and regulations, there will continue to be significant changes to the United States health care system. It is not clear what impact these changes will have on medical and public health preparedness programs around the country. Although there has been tremendous progress since 2005 and Hurricane Katrina, there is still a long way to go to ensure the health security of the Country. There is a commonly held notion that preparedness is separate and distinct from everyday operations, and that it only affects emergency departments. But time and time again, catastrophic events challenge the entire health care system, from acute care and emergency medical services down to the public health and community clinic level, and the lack of preparedness of one part of the system places preventable stress on other components. The implementation of the ACA provides the opportunity to consider how to incorporate preparedness into all aspects of the health care system. The Impacts of the Affordable Care Act on Preparedness Resources and Programs is the summary of a workshop convened by the Institute of Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Events in November 2013 to discuss how changes to the health system as a result of the ACA might impact medical and public health preparedness programs across the nation. This report discusses challenges and benefits of the Affordable Care Act to disaster preparedness and response efforts around the country and considers how changes to payment and reimbursement models will present opportunities and challenges to strengthen disaster preparedness and response capacities.
Many Americans believe that people who lack health insurance somehow get the care they really need. Care Without Coverage examines the real consequences for adults who lack health insurance. The study presents findings in the areas of prevention and screening, cancer, chronic illness, hospital-based care, and general health status. The committee looked at the consequences of being uninsured for people suffering from cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental illness, traumatic injuries, and heart attacks. It focused on the roughly 30 million-one in seven-working-age Americans without health insurance. This group does not include the population over 65 that is covered by Medicare or the nearly 10 million children who are uninsured in this country. The main findings of the report are that working-age Americans without health insurance are more likely to receive too little medical care and receive it too late; be sicker and die sooner; and receive poorer care when they are in the hospital, even for acute situations like a motor vehicle crash.
The expansion of public insurance eligibility that occurred with the Affordable Care Act (ACA) Medicaid expansions may have spillover effects to other public assistance programs. We explore the impact of the ACA on two large safety net programs: the Earned Income Tax Credit (EITC) and the Supplemental Nutrition Assistance Program (SNAP). We use a county border-pair research design, examining county-level administrative measures of EITC and SNAP participation in contiguous county pairs that cross state lines where the county on one side of the border experienced the Medicaid expansion and the county on the other side did not. This approach allows us to focus narrowly on differences arising from the ACA Medicaid expansion choice, implicitly controlling for local economic trends that could affect safety net participation. Our results suggest that the Medicaid expansion increased participation in SNAP, and possibly in the EITC, in counties that expanded relative to nearby counties that did not expand. We corroborate and extend these results using individual level data from the American Community Survey (ACS). Our results show that access to one safety net program may increase take-up of others.
This comprehensive work provides a lucid examination of the difficult problems that arise with the implementation of effective primary care. The book has four purposes: to help practitioners of primary care understand what they do and why; to provide a basis for the training of primary care practitioners; to stimulate research that will provide a more substantive basis for improvements in primary care; and to help policy makers understand the difficulties and challenges of primary care and its importance. In addition to discussing systems of primary care and alternative ways of evaluating them, the author addresses important issues such as practitioner-patient communication, information systems and medical records, referral processes, personnel, managed care, financing, quality assessment and community orientation. This unique volume provides a clear and valuable assessment of the basic concepts, issues and challenges in this increasingly important field.
The Patient Protection and Affordable Care Act (ACA) was designed to increase health insurance quality and affordability, lower the uninsured rate by expanding insurance coverage, and reduce the costs of healthcare overall. Along with sweeping change came sweeping criticisms and issues. This book explores the pros and cons of the Affordable Care Act, and explains who benefits from the ACA. Readers will learn how the economy is affected by the ACA, and the impact of the ACA rollout.
Overall, the future viability of safety net hospitals may hinge on potential changes to their financial supports, as well as adoption of strategies to reduce hospital costs and better manage care so they can continue to serve both insured and uninsured patients, and fare well under expanded payment reforms. Safety net hospitals across states face several potential funding challenges. With the federal government soon passing along a portion of the cost of the Medicaid expansion to the states, non-expansion state hospitals expressed concern that their states will become less inclined to expand their Medicaid programs. Also, respondents at expansion state hospitals felt that this new cost could lead some of their states to reduce Medicaid eligibility, benefits, or provider payments. This possibility was a particular concern for the Kentucky study hospitals because their Medicaid expansion was so large and because of a change in governor.26 Such changes, along with planned reductions in subsidies, could place some safety net hospitals in particularly vulnerable positions.
The Affordable Care Act (ACA) authorized the largest expansion of public health insurance in the U.S. since the mid-1960s. We exploit ACA-induced changes in the discontinuity in coverage at age 65 using a regression discontinuity based design to examine effects of the expansion on health insurance coverage, hospital use, and patient health. We then link these changes to effects on hospital finances. We show that a substantial share of the federally-funded Medicaid expansion substituted for existing locally-funded safety net programs. Despite this offset, the expansion produced a substantial increase in hospital revenue and profitability, with larger gains for government hospitals. On the benefits side, we do not detect significant improvements in patient health, although the expansion led to substantially greater hospital and emergency room use, and a reallocation of care from public to private and better-quality hospitals.