The Safety-Net Health Care System


Gunnar Almgren (author of The Safety-Net Health Care System: Health Care at the Margins and Associate Professor in the School of Social Work at the University of Washington) discusses the current state of health care and its role in the media

SpringBoard: How have current events, such as the recession, unemployment, and health care reform, affected the safety-net health care system?

GA: In what has become known as the Great Recession of 2008, the civilian unemployment rate doubled from 5% to 10% of the civilian labor force, the nation shed 7.5 million jobs, and the annual federal budget deficit grew by 85% in the wake of declining tax revenues and stimulus spending.  During 2010, by which point the economy was beginning to show signs of sustained recovery, the poverty for Americans age 18 to 64 had reached 13.7%—its highest level since 1959.

These economic shocks adversely affected the nation’s health care safety net in several ways, but two sources of adversity in particular stand out. First, as a consequence of rising unemployment, reduced hours of work, and employee health benefit reductions, the number of persons without health  insurance increased from 43 million in 2007 to 49 million by 2010. According to the National Association of Public Hospitals and Health Systems (NAPH), the uncompensated care costs of public safety net hospitals thus increased by 17% over the pre-Recession level. Second, as more families have lost their employment-based insurance benefits and have fallen into poverty, the safety net hospitals have seen a dramatic increase in the volume of Medicaid patients.

The problem for safety net hospitals is that the increase in Medicaid patient volume has coincided with both federal and state reductions in Medicaid spending—cuts that make it difficult for safety net hospitals to recover their costs for providing essential health care services to Medicaid patients.  It should be kept in mind that because safety net hospitals operate with net margins far below that of the hospital industry as a whole, they cannot sustain their fiscal viability should these worrisome trends continue in their current direction.

SpringBoard: What is your opinion of The Patient Protection and Affordable Care Act that President Obama signed into law in 2010?

GA: As the most sweeping health care legislation that has been signed into law since the mid-1960’s and the first federal legislation in history to extend the promise of near universal health insurance coverage to all American citizens, the Patient Protection and Affordable Care Act (PPACA) represents a historic achievement.  Remarkably, the nation’s first African American president is also the only U.S. President of several, going back to the administration of Theodore Roosevelt a century ago, to have realized his legislative goal of making universal health care coverage a right of citizenship. Whatever happens with the PPACA provisions considered before the Supreme Court this summer, the fact of the PPACA’s successful passage through Congress has shifted the terms of the health care debate towards the means of universal coverage as opposed to the principle.

These things noted, the PPACA is in reality a very centrist approach to health care reform that originates in the incrementalist approach to health care reform favored by the moderate traditions within the GOP. That is, the PPACA seeks to preserve an employment insurance approach to health care coverage supported by means-tested subsidies and entitlement programs, as opposed to a social insurance approach that would be more likely to achieve both universal coverage and needed reductions in health care inflation. In addition, the PPACA will not achieve de facto universal coverage—most notably because it excludes millions of undocumented workers and their dependents.

There are, of course, many formidable obstacles to the PPACA’s implementation, both judicial and political. Judicially, while some form of a mandate to carry health insurance coverage is common to all democracies with universal health insurance, a libertarian interpretation of the U.S. Constitution would clearly place this critical provision of the PPACA in jeopardy. Politically, because the PPACA contains myriad provisions that are vulnerable to partisan and stakeholder opposition at both the state and federal levels of government, it is unlikely to be enacted either in its current form or in accordance with the timeline envisioned.  However, as noted by eminent historian Theda Skocpol, the history of successful fundamental comprehensive social legislation is that such legislation is amended and enacted in stages over a period of years. She cites as her example the Social Security Act of 1935, which did not include some its most crucial amendments pertaining to dependents and survivor benefits until 1939.

SpringBoard: What do you think of the role of health care in the current presidential debates? Does the media’s coverage of current health care debates among public figures and presidential hopefuls help the cause or divert us from the real issues?

GA: Thus far, the PPACA is only second to unemployment as the preferred target of opposition party presidential candidates. The favored rhetorical tactic is to characterize the PPACA as “a government takeover of health care,” which while grossly inaccurate, has gained traction with the sizable share of voters who feel that the individual mandate is both unnecessary and an overreach of government—even though they might believe that the government should play a strong role in facilitating access to health care for all citizens.

The irony of course, is that the most notable policy accomplishment of the presumptive GOP presidential candidate, former Massachusetts Governor Mitt Romney, is his successful advocacy of a state level version of the PPACA that he ultimately signed into law—legislation that included an individual insurance mandate. The mainstream media for the most part has ignored this fundamental inconsistency in Governor Romney’s record and rhetoric, but the mainstream media has also failed to point out that President Obama had criticized the individual mandate when it was a part of the health care reform strategy advocated by his then presidential primary opponent Hillary Clinton.

I think we can count on these inconsistencies on the part of both Governor Romney and President Obama being brought much more to the forefront as the presidential election moves forward—but I am doubtful that the American public will end up understanding more about the essential necessity of some of the less politically popular aspects of health care reform.

To read more about The Safety-Net Health Care System: Health Care at the Margins, by Gunnar Almgren and Taryn Lindhorst, click here.

Gunnar Almgren, PhD, is an Associate Professor in the School of Social Work at the University of Washington. He is also a Faculty Affiliate of the West Coast Poverty Center and a Faculty Research Associate at the Center for Studies in Demography and Ecology. His professional interests include health care policy and the social determinants of health. His research interests include the study of the effects of racial segregation and economic disadvantage on urban mortality trends, and the health care policy effects on the health care safety net.