The Covid-19 pandemic has been a crucible for the U.S. health care system, particularly for the safety-net hospitals, community health centers, and independent clinicians who provide a lifeline for underinsured and uninsured people. Despite facing immeasurable strain in the past year, the safety net has played an essential and often innovative role at the intersection of health care, public health, and emergency response. As we enter a new stage of pandemic response and recovery — in which we must address issues of racial health inequities, frontline health care infrastructure, and community preparedness — the country faces questions about what constitutes adequate support for the safety net, both immediately and over the longer term.
The challenges encountered by all health systems during the pandemic were compounded in safety-net systems, given their central role in serving the low-income communities hit hardest by Covid-19. Although many emergency and inpatient settings were overwhelmed by Covid-19 cases, in several regions, safety-net hospitals serving predominantly Medicaid-insured and uninsured populations cared for the preponderance of patients with Covid-19. In a system already stretched thin by prepandemic payment cuts, hospital closures, and bare-bones staffing infrastructure, this added strain has had chilling implications for patient outcomes and has resulted in higher mortality in safety-net hospitals than in other facilities.
In addition, safety-net systems faced greater financial, workforce, and technological pressures than other systems. The suspension of profitable services, the transition to telehealth, and inadequate access to federal emergency funding were felt especially acutely by safety-net providers that had historically slim margins and minimal cash reserves. The trauma experienced by the health care workforce was compounded in safety-net institutions, whose staff members often come from the communities they serve, which were disproportionately affected by the pandemic; this resulted in increased rates of burnout and staff turnover. Though most safety-net hospitals have weathered the pandemic, these strains have led to closures of many community-based independent practices that had served as key access points for immigrant and Black and Latinx communities.
Even as the pandemic exposed the vulnerability of the health care safety net, it has shown that this system is too important to fail. It is difficult to imagine a robust pandemic response and vaccination drive without the critical contributions of safety-net providers, with their mission of serving vulnerable communities and their expertise in doing so. Safety-net hospitals were more prepared than other providers to support public health departments, drawing on long-standing relationships and experiences collaborating with government and community partners. In cities such as New York, Los Angeles, and Dallas, safety-net systems provided much-needed surge capacity for Covid-19 testing, treatment, and vaccination. Safety-net providers are now essential to reaching national vaccination targets, owing to their history as trusted messengers, particularly in marginalized communities that have justifiable concerns about government and systemic mistreatment.
As our focus turns to community recovery and mitigating risks for future pandemics, the role of the safety net is even more crucial. There is national consensus that upstream determinants of poor health — from inadequate housing to lack of protections for essential workers — predisposed low-income communities to higher rates of Covid-19 illness. Safety-net health care systems have already led the charge in integrating social services and behavioral health care with general medical care and are well positioned to work with public health and community partners to further reduce health inequities and build preparedness for future crises. If they are to do so, however, we cannot afford further safety-net closures, because we face an impending surge in demand. Many states suspended Medicaid disenrollment during the pandemic, causing Medicaid enrollee numbers to swell. The expiration of this emergency protection, however, may increase the number of uninsured Americans reliant on safety-net services. Given that the pandemic has led to higher rates of unemployment in Black and Latinx communities than in White communities, this shift may also exacerbate the inequities that predisposed communities to Covid-19 in the first place.
The glaring health inequities — particularly racial inequities — that have characterized the Covid-19 pandemic argue against returning to business as usual with respect to the safety net. Fundamental aspects of the U.S. health care system, including emergency surge capacity, medical–public health partnerships, absorption of Medicaid and uninsured patients, and culturally competent care in historically disenfranchised communities, rely on the leadership of safety-net systems. Inadequate support of safety-net providers would put both national recovery and the ecosystem of private and academic health care providers at risk. The divide between the safety net and the rest of the health care system is already widening: safety-net organizations continue to deal with pandemic fallout in vulnerable communities, and many other health care institutions, at least outside of Covid hot spots, have returned to near-normal operations with minimal long-term impact. This disparate burden is likely to have long-term ripple effects, causing demand to overflow into private systems, threatening the health of underinsured U.S. workers, and slowing our national pandemic recovery.
Payment reform aimed at increasing funding for safety-net providers is essential for reducing their financial instability, supporting long-term investments in community health, and improving preparedness for future crises. The pandemic is only the latest threat to their precarious financial situation, but it has shed a light on their most urgent needs. In the short term, essential mechanisms include ongoing federal emergency funding to support community-based pandemic response and recovery, as well as Medicaid reform to avert looming cuts to enrollments and reimbursement rates once the federal public health emergency declaration expires. In the long term, it is critical to accelerate investment in value-based care models, particularly chronic disease management and home-based care — in the form of reimbursements, capital funding, and workforce training.
Private health care systems can also be urged or required to contribute additional resources to the safety-net and public health systems that buffer them from financial losses and community health responsibilities. Nonprofit hospitals, in particular, face an imperative to address their known underinvestment in community benefit in this time of great need. During the pandemic, some (though not all) private hospitals answered the call of safety-net hospitals for load balancing, particularly for ICU patients. Now that pandemic response has shifted toward vaccination and meeting the pent-up demand of chronic and preventive care needs, we believe private health care systems have a responsibility to engage in a new kind of load balancing — by investing directly in community health, building partnerships with public health departments, and providing affordable preventive care services where needed.
Safety-net systems should continue to lead better coordination among health care, public health, and social services, which will require the full integration of safety-net providers into public health and emergency-preparedness infrastructure and greater unification of the components of the safety-net system. This integration should not leave out primary care providers, who are now recognized as key partners in vaccination efforts and preventive services but who were sidelined during the pandemic response as resources, patients, and vaccines were diverted to hospitals. Regional networks and budgeting models, such as state-based Accountable Communities for Health or Oregon’s Coordinated Care Organizations, could be fostered to ensure enhanced coordination among hospitals, primary care clinics, public health departments, social services, and community organizations.
Finally, safety-net health care providers should be given recognition and incentives for leading the charge against the racial inequities that were major drivers of the pandemic. The neighborhood-based approaches needed to address these entrenched issues can best be led by the safety-net providers, community organizations, and public health departments whose mission is to understand and meet the needs of underserved communities. Financial mechanisms to support these efforts can include payment models that incorporate racial and community-based equity indexes, as well as alignment of payers, delivery systems, and purchasers at the neighborhood level. Workforce and technological investments — in hospital staffing, community health worker models, and telehealth infrastructure — can further redress inequities and increase preparedness for future crises in marginalized communities and in the United States as a whole.