After the Affordable Care Act: Health Reform and the Safety Net

J. Tolbert and K. Young , Paying for Health Coverage: The Challenge of Affording Health Insurance Among Marketplace Enrollees (Kaiser Family Foundation: Washington, D.C., April 2016), available at <http://kff.org/health-reform/issue-brief/paying-for-health-coverage-the-challenge-of-affording-health-insurance-among-marketplace-enrollees/> (last visited October 17, 2016).

State Reforum: Where States Stand on Medicaid Expansion Decisions as of April 22, 2016, National Academy for State Health Policy, available at <https://www.statereforum.org/Medicaid-Expansion-Decisions-Map> (last visited October 17, 2016).

Affordable Care Act Section 1311(C)(1)(C) (2010). The Act specific names six categories of essential community providers: (1) Federally Qualified Health Centers and FQHC “look-alike” clinics, outpatient health programs/facilities operated by Indian tribes, tribal organizations, program operated urban Indian organizations; (2) Ryan White HIV/AIDS Program Providers; (3) Family Planning Providers, including Title X family planning clinics and Title X “look-alike” family planning clinics; (4) Indian Health Providers, including Indian Health Service (IHS) providers, Indian tribes, tribal organizations and urban Indian organizations; (5) certain hospitals such as hospitals receiving or eligible for Medicaid Disproportionate Share Hospital payments, children's hospitals, rural referral centers, sole community hospitals, free-standing cancer centers, and critical access hospitals); and (6) other ECP Providers. The Act specifically names some of these other ECO providers (STD clinics, TB clinics, hemophilia treatment centers, and black lung clinics) but also leaves open the possibility of other providers meeting the definition if they serve predominately low-income, medically underserved individuals.

J. Paradise , Medicaid Moving Forward (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2015) available at <http://files.kff.org/attachment/issue-brief-medicaid-moving-forward> (last visited October 17, 2016); Health and Human Services, Nationwide Nearly 11.7 Consumers are Enrolled in 2015 Health Insurance Marketplace Coverage, March 10, 2015, available at <http://www.hhs.gov/about/news/2015/03/10/nationwide-nearly-11-point-7-million-consumers-are-enrolled-in-2015-health-insurance-marketplace-coverage.html> (last visited October 17, 2016).

Patient Protection and Affordable Care Act, § 18001 42 U.S.C. § 5508 (2010), available at <https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm> (last visited October 17, 2016).

Community health centers were categorized as a distinct category of safety net providers – FQHCs – under §1861(aa)(4) and §1905(l)(2)(B) of the Social Security Act. The FQHC legislation established a prospective payment policy by requiring reasonable cost payments for FQHCs from both Medicaid and Medicare. This new prospective payment system was intended to protect health center grant funds were not be diverted to subsidize low Medicaid and Medicare reimbursements. To be eligible for FQHC payments, health centers must meet 19 key program requirements, including serving federally-designated medically underserved communities and populations and being governed by a patient-majority board, to maintain their viability and mission.

Bureau of Primary Health Care, Health Resources and Services Administration (2016), National 2015 Health Center Data, available at <http://bphc.hrsa.gov/uds/lookalikes.aspx?state=national> (last visited October 20, 2016).

Bureau of Primary Health Care, Health Resources and Services Administration (2016), National 2015 Look-Alikes Data, available at <http://bphc.hrsa.gov/uds/lookalikes.aspx?q=tall&year=2015&state=> (last visited October 20, 2016).

The federal poverty level is $11,770 for one person and $20,090 for a family of three in 2015, available at <http://aspe.hhs.gov/poverty/15poverty.cfm> (last visited October 17, 2016).

Based on percentages for patients who reported their income; Bureau of Primary Health Care, Health Resources and Services Administration (2016), National 2015 Health Center Data, available at <http://bphc.hrsa.gov/uds/lookalikesaspx?state=national> (last visited October 20, 2016).

Available at <http://bphc.hrsa.gov/about/healthcenterfact-sheet.pdf> (last visited October 17, 2016).

Congressional Research Service, Federal health Centers Program, 2013.

Kaiser Family Foundation. How Is the Primary Care Safety Net Faring? Community Health Centers in the Midst of Massachusetts' Health Reform, 2009, available at <https://kaiserfamilyfoundation.files.wordpress.com/2013/09/8479-providing-outreach-and-enrollment-assistance1.pdf> (last visited October 20, 2016).

U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement (2015), available at <http://www.census.gov/cps/data/cpstablecreator.html> (last visited October 20, 2016).

In 2000, in its landmark report on the health care safety net, The Institute of Medicine identified two defining characteristics of “core” safety net providers: (1) the organization had a legal mandate or explicitly adopted mission to offer patients access to services regardless of their ability to pay; and (2) a substantial share of the provider's patients were uninsured, covered by Medicaid, or members of other vulnerable populations. See M. Lewin and S. Altman , eds., America's Health Care Safety Net: Intact but Endangered (Washington, D.C.: National Academy Press, 2000). In practice, safety net hospitals are defined in the health services research literature in different ways, including the hospital's proportion of uninsured and/or Medicaid patients, amount of uncompensated care, and various facility or market characteristics. For additional information on ways to define safety net hospitals, see M. McHugh, R. Kang, and R. Hasnain-Wynia, “Understanding the Safety Net: Inpatient Quality of Care Varies Based on How One Defines Safety-Net Hospitals,” Medical Care Research and Review 66, no. 5 (2009): 590-605.

America's Essential Hospitals, Results of America's Essential Hospitals Annual Characteristics Report, FY 2013. March 2015, available at <http://essentialhospitals.org/wp-content/uploads/2015/03/Essential-Hospitals-Vital-Data-2015.pdf> (last visited October 20, 2016).

See America's Essential Hospitals, supra note 16.

Section 1902(a)(13)(A)(iv) of the Social Security Act.

Medicaid and Chip Payment and Access Commission: Disproportionate Share Hospital Payments, available at <https://www.macpac.gov/subtopic/disproportionate-share-hospital-payments/> (last visited October 17, 2016).

See id.

A. Mitchell , Congressional Research Services Report on Medicaid Disproportionate Share Hospital Payments, June 2016, available at <https://www.fas.org/sgp/crs/misc/R42865.pdf>.

L. Ku , E. Jones , P. Shin , F. Byrne , and S. Long , “Safety-net Providers after Health Care Reform: Lessons from Massachusetts.” Archives of Internal Medicine 171, no. 15 (2011): 1379-1384.