Commentary
A Net Worth Saving
Minnesota’s health care safety net is a needed now more than ever.
By Michael Scandrett, J.D.
Minnesota’s health care safety net consists of hospitals, clinics, and providers who deliver services to low-income, uninsured, and vulnerable patients. Although most health care providers serve these patients some of the time, safety-net providers have an explicit mission or legal mandate to care for them regardless of whether they can afford to pay for their care. In addition to treating the uninsured, safety-net providers serve many patients who are insured through state health care programs including Medical Assistance, General Assistance Medical Care, and MinnesotaCare. A small percentage of their patients have private health insurance.
Safety-net providers are an important component of the health care system in Minnesota. Not only do they provide needed medical care, they also lend stability to some of our most vulnerable communities. And many are models of cost-effective care delivery. Yet our safety net is reaching its breaking point. Confronted with a growing number of people who have lost their jobs and health insurance coverage and a squeeze on government spending on health care because of the economic downturn, safety-net providers are struggling for survival at a time when they’re needed more than ever. Until the state and nation decide on health care reforms that will eliminate the need for a safety net for the uninsured, we need to make a concerted effort to ensure that the health care safety net remains strong and intact.
What Makes Up the Safety Net?
The major components of Minnesota’s safety net are community clinics, mental health centers, dental clinics, hospitals, public health agencies, and coverage programs for the uninsured. Rural clinics, hospitals, local governments, and private providers also provide services. Rural communities in particular depend more heavily on private providers, as there are fewer safety-net hospitals and clinics in those areas.
Primary care clinics. Safety-net clinics are often referred to as “community clinics.” They include primary care clinics, school-based clinics, teen clinics, family planning clinics, and tribal and multi-cultural clinics. Some community clinics are Federally Qualified Health Centers (FQHCs), which receive federal grant money and higher payment rates from government health care programs. FQHCs must meet an extensive set of federal regulations and reporting requirements. In addition to primary medical care, many also provide mental health and dental care. The federal government limits the number of FQHCs and authorizes new ones only in communities with the greatest need. Minnesota has about 30 community clinic organizations, of which 15 are FQHCs.
Mental health clinics. Community mental health centers provide mental health services to low-income and vulnerable individuals. Mental health centers that are certified by the state can receive payment from state and federal programs as well as grant money. Minnesota has 39 certified mental health centers. In addition, many community clinics and safety-net hospitals provide mental health services.
Dental clinics. Some safety-net dental clinics are located in community clinics or hospitals; others are freestanding clinics that provide dental care exclusively. A number of private dental clinics also serve low-income patients. The state of Minnesota has a Critical Access Dental Provider (CADP) program that provides an additional payment to dental providers who serve a large number of patients enrolled in state programs. The number of CADP providers fluctuates, but a 2008 state report indicated that 58 providers consistently qualify as CADPs.
Hospital and specialty care facilities. Safety-net hospitals serve as the regional hubs for health-related safety-net services. Some of these facilities are public hospitals that are operated under county authority and with county financial assistance. Others are private nonprofit hospitals that are subsidized by grants and donations. Some safety-net hospitals own or are affiliated with primary and specialty care clinics. State and federal law provide for disproportionate share payments to certain hospitals with higher percentages of low-income and uninsured patients. Hennepin County Medical Center (HCMC) in Minneapolis is the largest safety-net hospital in Minnesota in terms of volume of patients served, followed by Regions Hospital in St. Paul and St. Mary’s Duluth Clinic.
Community health and public health services. Some safety-net organizations provide in-home and community-based care. Because the people they serve often do not have transportation or have other challenges getting to clinic appointments, in-home and community-based services are sometimes the best way to make sure people receive the care they need. In addition, these services make it possible for providers to better understand living conditions, family relationships, and personal factors that can affect the outcome of treatment but often are not apparent during a clinic visit. Community health services are provided by both government agencies and nonprofit organizations. In addition to providing in-home and community-based medical care, they often provide other services including immunizations, flu vaccines, health screenings, prenatal care, and well-child services.
Coverage programs. In addition to health care providers, Minnesota’s safety net also includes organizations that arrange for low-income, uninsured individuals to receive free or reduced-cost health care through a network of clinics and hospitals. These organizations serve people who are not eligible for government health care programs and cannot afford private health insurance. Coverage programs typically receive funding from hospitals, health care providers, foundations, government grants, businesses, and other sources. The individuals and families who use their services pay a small fee to enroll in them. Coverage programs typically help people enroll in public or private health insurance programs if they are available. Additionally, they work with their members to help them improve and manage their health in order to reduce the need for emergency room visits and hospital and specialty care.
The state of Minnesota, in partnership with the Minnesota Safety Net Coalition and three coverage programs— Portico Healthnet located in St. Paul, HealthShare in Duluth, and ValuesHealth, operated by PrimeWest Health in Alexandria—recently received a federal State Health Access Program grant to expand those programs. More coverage programs are expected to be created in the future.
Rural health clinics. Federally designated rural health clinics are also part of the health care safety net. These are primary care clinics that have been designated by the Centers for Medicare and Medicaid Services as serving a rural area that has a shortage of health care personnel. These rural health clinics receive higher payment rates under Medicare and Medicaid so that they can better recruit and retain health care providers. They serve all types of patients, not just those who have low incomes and/or are uninsured. Minnesota has 79 such rural health clinics.
Cities and counties. Cities and counties also provide safety-net services either directly, through contracts with vendors or providers, or by providing grants to safety-net organizations. Examples of services cities and counties provide include immunizations, public health nursing, and in-home services for the elderly and people with disabilities.
Growing Challenges
Safety-net providers are currently under tremendous financial pressure. The revenues they receive for their services do not come close to covering the total cost of their operations. Many of their uninsured patients pay for only a small portion of their care based on their income. Most of their insured patients are covered by government health care programs that pay below-market rates to providers. Others are underinsured—they have insurance with high deductibles and copayments and cannot afford their share of the cost of treatment. Because of the special needs of the patient populations they serve, safety-net providers frequently offer services that other hospitals and clinics do not such as transportation, language interpretation, community outreach, care coordination for chronic health problems, and assistance with locating and enrolling in public or private insurance—services that add to the cost of providing care.
Safety-net providers rely on additional revenues they receive from federal, state, and local grants and enhanced payments as well as charitable donations and foundation support. However, during the recession, there have been cuts to government program payments, more competition for grant money, and a decline in charitable giving. In addition, these providers are seeing an influx of new patients who have lost jobs and health coverage as well as more patients referred by other providers who are doing less free and reduced-cost charity care because of their own financial pressures. All this is happening at a time when health care providers are expected to make major investments in electronic health records, medical technology, and care-management programs.
What the Future Holds
The mission of Minnesota’s safety-net providers is to make sure that no person in the state will go without the health care they need because of their income, language, or ethnicity. Unfortunately, the ability of these individuals and organizations to fulfill this mission is being seriously threatened. As Minnesotans, we have long prided ourselves on our low rate of uninsurance and the range of government programs and safety-net services that are available. Some people have said that even though we don’t have universal health care coverage, we do have universal access because people can get health care even if they don’t have health insurance. Unfortunately, we have reached the point where this is no longer true. Financial pressures have caused some safety-net providers including La Clinica in Minneapolis to close their doors. Others such as HCMC will be cutting back their capacity and the range of services they provide. As a result, we will be seeing more and more patients seeking care from fewer and fewer providers. Patients will have to travel longer distances and wait longer for treatment than in the past. And certain types of services, such as dental care, will be increasingly difficult for low-income or uninsured patients to obtain anywhere in the state. Some community health centers already have waiting lists for dental care in excess of four months; waiting lists for specialized dental care for persons with developmental disabilities are even longer.
The outlook is not good. Health care costs are still rising dramatically, more people are losing their jobs and insurance coverage, and more cuts in government health care programs are expected. If this trend continues, many Minnesotans will no longer get needed treatment. One solution is to dramatically reform our health care system—to control costs, improve the health of the entire population, and provide treatment as efficiently and effectively as possible. Only then will health care coverage be affordable and governments able to subsidize the cost for those who cannot afford it on their own. Until that happens, the safety net will need increased support from public and private sources so that needy Minnesotans will not be deprived of the health care they need.
In the meantime, we can learn lessons from our safety-net providers about reforming our system. Safety-net providers have a strong incentive to keep their uninsured patients healthy and keep health care costs low. Their survival depends on it. As a result, they developed disease-management programs, health care homes that coordinate patients’ care, and ways to engage patients in their own care long before these ideas emerged as central to health care reform.
Ironically, some of the first victims of our rapidly deteriorating health care system may be the providers who could be role models for the kind of low-cost, high-quality care we will need in the future. Let’s hope that meaningful reform takes place soon and that the reformers recognize the value safety-net providers offer and look to them for ideas for making health care accessible to all. MM
Michael Scandrett directs the Minnesota Safety Net Coalition, a nonprofit association working to improve access to health care for low-income, uninsured, and disadvantaged Minnesotans.