Patient Flow Enewsletter
Volume 1, Issue 6
Thursday, July 15, 2004

Perspectives
Walking a Tightrope: Assessing the State of the Safety Net in 10 U.S. Communities

According to the most recent figures from the U.S. Census Bureau, nearly 44 million Americans are without health coverage. Millions more are considered underinsured for vitally important health services. Needing somewhere to turn for their health care, many rely on what's collectively known as the health care 'safety net' - which broadly refers to the public hospitals, community health centers, public health departments, faith-based clinics and other facilities that provide significant amounts of care to those who are uninsured, underinsured or who cannot otherwise afford health care.

As the number of uninsured grows, it places increased strain on a safety net that, in many communities, is already fraying. To better understand this strain and to identify potential ways of relieving it at a critical access point - overcrowded emergency departments - The Robert Wood Johnson Foundation funded the year-long Urgent Matters assessment to be conducted by a research team at The George Washington (GW) University School of Public Health and Health Services.

And the safety nets within the 10 communities are as varied as their patient populations - ranging from those with large, public hospital systems with extensively developed hospital and community-based clinics (such as Atlanta and Queens) to those with neither a public hospital nor a federally qualified health center (such as Virginia's Fairfax County).

The Urgent Matters assessment began in the summer of 2003 with the GW team conducting on-the-ground quantitative and qualitative research in each of the 10 communities, including:

• Interviews with providers/provider groups, policymakers and health advocates;
• Focus groups of patients who rely on the community safety net as their primary source of health care services; and
• Secondary data analyses.

"When you're uninsured, you're basically walking a tightrope," said one San Antonio focus group participant. "You deal with things on your own for as long as you can, and then you just hope that somebody will take care of you."

While the assessment's findings illuminate some differences between communities, they highlight commonalities, opportunities and challenges faced by all.

"A lot of communities have a false sense of security - meaning they have some resources in place so that people who depend on the safety net won't fall through the cracks. But just because you build it, doesn't mean they will come and use it," said Marsha Regenstein, PhD, MCP, assistant research professor in the Department of Health Policy at The George Washington University School of Public Health and Health Services and leader of the Urgent Matters site assessment research team. "Most people mistakenly think that if the city hospital's emergency department and a couple of local clinics are crowded, then everyone must be using the safety net and getting the care that they need."

In many communities, the team noted valiant efforts by safety net providers who are incredibly dedicated to meeting increasing demands for care in the face of decreasing resources. Their communications battle, however, is an uphill one. Messages about available services are not always reaching those who most need the services. While some of the communication breakdown could be attributed to language or other cultural barriers, Regenstein and the team believe the problem is deeper than just that.

"What surprised us - and I think, the participating communities themselves - was how unfamiliar many residents are with what is available to them," said Regenstein. "In several communities, large groups of people have no idea where to turn or where to go to receive the health care they need. In others, they may know about primary care, but don't know where to turn for other critically important health services. Consequently, people wait until a health problem is unbearable, then go to the emergency department."

Another surprising finding dealt with time of day for emergency department (ED) visits. The research team found that on average across all 10 communities, 41 percent of ED visits are between the hours of 8:00 a.m. and 4:00 p.m., while a nearly equivalent 40 percent are in the evening - between 4:00 p.m. and midnight."

"We expected to find that the use of the emergency department would increase dramatically during the evenings and on weekends, when clinics are closed and people have nowhere else to go, but there was actually little variance in the numbers," said Regenstein. "Maybe people didn't know that the clinics are available during the day. Maybe they don't know what services are available to them at the clinic. Maybe they don't have any money to pay the fees - albeit usually small - that many clinics charge."

This suggests, of course, that there are opportunities for improving access to primary care during 'regular business hours' and improving communication about its availability.

----------------------------------------

Marsha Regenstein, Ph.D., M.C.P.
Assistant Research Professor, Department of Health Policy
The George Washington University School of Public Health and Health Services
Washington, DC