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Safety-net Clinics May Remain Important Options for Many Patients

Safety-net clinics are likely to continue to play a critical role in meeting the needs of insured minority and low-income populations despite expanded insurance coverage under the Affordable Care Act (ACA), a University of Texas (UT) Southwestern study suggests.

Based on results of federal government healthcare surveys from 2006 to 2010, the study showed that adults with private insurance or Medicare comprised more than a third of all primary care visits to safety-net clinics, representing more than 6.6 million visits annually, researchers said.

The study appears in PLOS ONE, a peer-reviewed, multidisciplinary, open-access journal.

“Our study revealed that these individuals have a high burden of chronic illness such as diabetes and hypertension, and that they rely on safety-net clinics despite having what is typically considered ‘good’ insurance coverage,” said lead author Oanh Nguyen, MD, assistant professor of internal medicine and clinical sciences at UT Southwestern. The strongest predictors of safety-net clinic use among adults with private insurance or Medicare were:

  • Being from a high-poverty neighborhood
  • Being eligible for both Medicare and Medicaid
  • Being black or Hispanic

Compared to users of healthcare facilities not defined as safety-net clinics, adults with insurance other than Medicaid who received care in safety-net clinics had a higher prevalence of diabetes, hypertension, multiple illnesses, and use of multiple medications.

Researchers also found that nearly one-third (28.9 percent) of Medicare beneficiaries in safety-net clinics were covered by Medicaid (i.e., dually eligible), compared with less than 7 percent of Medicare beneficiaries in non-safety-net clinics. Dually eligible beneficiaries are a subset of Medicare patients who typically have more complex health needs and higher healthcare use than other Medicare beneficiaries.

Safety-net clinics and hospitals provide care to individuals regardless of ability to pay, serving a critical role as providers of “last resort” for roughly 44 million uninsured and underserved Americans who are disproportionately minorities, immigrants, Medicaid beneficiaries, or people living in disadvantaged communities. In contrast, individuals with private insurance or Medicare are generally thought to be less reliant on safety-net providers given their potential access to care in other settings.

“Many people are anticipating that newly insured individuals will choose to seek care elsewhere given broader insurance coverage under the ACA,” said study senior author Ethan A. Halm, MD, chief of the William T. and Gay F. Solomon Division of General Internal Medicine and chief of the Division of Outcomes and Health Services Research in the Department of Clinical Sciences at UT Southwestern. “However, our findings suggest this assumption may not necessarily be the case, since safety-net clinics were important outlets for certain insured populations even before ACA.”

Potential reasons for choosing safety-net health settings are comparative advantages in addressing unmet social needs-potential barriers such as language, culture, employment, and transportation-compared with non-safety-net providers, the researchers said.

Newly covered individuals are likely to have previously gone without care while uninsured and have higher healthcare use after receiving insurance coverage. In addition, those with expanded insurance coverage who still find healthcare unaffordable due to high out-of-pocket costs may gravitate to the more affordable safety-net clinics, researchers said.

“We think that expanding coverage will not eliminate the important role that safety-net hospitals and clinics provide in caring for minority, low-income, and high-need individuals, irrespective of insurance type,” said Nguyen, “and that maintaining adequate support for a strong safety-net system, in addition to expanding insurance coverage, will be critical to ensuring access and addressing racial/ethnic and social class disparities in healthcare.”

This article was adapted from information provided by UT Southwestern Medical Center.

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