"Safety-Net" Hospitals Need Support to Survive

Health care reform may make life easier for low-income Americans in the future, but for now, it’s “safety-net” hospitals that need rescuing in order to serve the needs of millions of uninsured patients and meet the disaster response needs of communities, say experts in the June 18, 2009 New England Journal of Medicine (NEJM).

Safety-net hospitals are typically found in areas in which the uninsured are concentrated – inner-city neighborhoods and economically depressed rural communities. Private hospitals with a large base of paying patients can shift their relatively modest costs of uncompensated care onto other patients’ bills, safety-net hospitals have little capacity for shifting costs.

Nearly 30 years ago, the federal government developed a plan to partner with states to provide supplemental Medicaid payments to facilities that provided a disproportionate share of care to the uninsured and Medicaid beneficiaries. These facilities came to be called “disproportionate share hospitals (DSHs)” and the supplements were called DSH payments.

But in the years that followed, many state governments figured out how to exploit loopholes in the program to secure large federal DSH payments and direct the money to other purposes. After several cycles of reform, most of these abuses have been eliminated, but wide disparities in DSH payments persist.

“Over the years, the program has had its flaws, but the DSH funds that finally reach safety-net hospitals are vital to their survival,” says Arthur L. Kellermann, MD, MPH, professor of emergency medicine and associate dean, Emory University School of Medicine. In addition to providing ‘safety net’ care, these institutions play several vital roles in their communities.”

Kellermann and co-author Michael Spivey, JD, a principal with Spivey/Harris Health Policy Group, say in the NEJM Perspective article that four changes to the federal law would allow the DSH program to achieve its original purpose.

“First, we believe that DSH funding should be restricted to truly disproportionate providers,” the authors say. “The legislative clause that deems certain hospitals to be DSH facilities should be revised so that DSH payments can be made only to these facilities.” Currently, state governments can direct DSH payments to hospitals that provide little or no charity care if they choose to do so.

Second, say Kellermann and Spivey, the flexibility given to states to designate special classes of DSH providers should be eliminated. They believe that states should not be allowed to favor certain hospitals over those that provide a greater proportion of uncompensated care. DSH payments should be based on a single, uniform method.

Third, because trauma and emergency care are vital to public safety, a hospital should be required to operate an emergency department and participate in its state’s trauma system to receive DSH funds.

Fourth, large DSH hospitals that anchor their region’s disaster plan should receive supplemental funds, provided that they meet strict performance and readiness criteria. A portion of current federal DSH money - perhaps 10 percent - should be held back and awarded for this purpose through competitive grants.

“By allocating federal funds to hospitals that need them most, the reforms we propose would go a long way toward correcting the program’s deficiencies,” say Kellermann and Spivey.

The authors acknowledge that they could have gone farther with their recommendations.

“Our proposals do not correct historical inequities in the allocation of DSH funds among the states,” they concede. “Attempts to do so would probably trigger a legislative battle that would doom any chance for reform.

“Until fundamental health care reform is achieved, millions of low-income Americans will remain dependent on safety-net facilities for care,” say the authors. “Everyone - insured and uninsured alike - benefits from the specialized services, medical education, and trauma and disaster care that many safety-net hospitals provide. Today, DSH is needed more than ever. The program is broken, but we believe it can and should be fixed.”

From Woodruff Health Sciences Center News

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CBO: Dem's Health Care Plan Costs $1 Trillion, Leaves 36 Million Uninsured, Forces 23 Million Out of Their Current Plans

Yesterday’s Congressional Budget Office (CBO) report on a Democratic health care “reform” bill has sent shockwaves through Washington – and middle-class families, small businesses, and all taxpayers are right to take notice. Here’s what CBO has uncovered:

The Democratic plan will cost taxpayers at least $1 trillion;
The legislation will leave at least 36 million Americans uninsured; and
The proposal will force at least 23 million Americans to give up the health coverage they currently enjoy.

This is reform?

House Republicans are working on a better solution to ensure that every American has access to affordable health care. To that end, tomorrow, the House GOP’s Health Care Reform Solutions Group will outline a common-sense plan to reduce costs, expand access, and increase the quality of care in a way that Americans can afford. The GOP plan will:

Expand access to affordable, quality care regardless of pre-existing conditions;
Protect Americans from being forced into a government-run plan, making certain that medical decisions are made by patients and their doctors, not Washington bureaucrats; and
Let Americans who like their health care coverage keep it, while giving all Americans the freedom to choose the plan that best meets their needs.

With the Democratic and GOP plans now coming into clearer focus, middle-class families and small businesses across the country are beginning to ask: is a $1 trillion government takeover of health care really worth it if it leaves at least 36 million Americans uninsured and forces at least 23 million Americans off their current plans? Or, is the better solution a proposal that will expand access to affordable care while protecting Americans’ relationships with their doctors? That choice will become increasingly evident in the weeks to come, as Democrats in charge of Washington continue pushing their costly plan onto Americans who just don’t support it.

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Georgia’s Uninsured Rate Holds Steady but Employer Coverage Loses Ground

Georgia’s Uninsured Rate Holds Steady but Employer Coverage Loses Ground

Georgia has the sixth highest number of residents without health insurance in the United States and ranks 11th in its percentage of the population lacking coverage, according to a new report from the Georgia Health Policy Center and the Center for Health Services Research at Georgia State University. In 2007, about 18 percent of all Georgians and 20 percent of those under age 65 (approximately 1.66 million people) were without health insurance — roughly the same number reported in 2005 and 2006 but higher than the national average of 15 percent (45.7 million Americans).

Nationally, the number of uninsured Americans decreased from 46.9 million in 2006 to 45.6 million in 2007 while Georgia’s number of uninsured remained constant.

The report is a combination of data from the U.S. Census Current Population Survey (CPS) and an independent Georgia Population Survey of more than 15,800 people commissioned by the Georgia Department of Community Health. The Georgia Population Survey was conducted between February and April 2008.

Though the overall number of uninsured Georgians remains relatively unchanged over the past few years, the share of the population with employer-based private insurance has declined over the past eight years while the share with publicly funded health plans (Medicaid, PeachCare) has edged upward. Between 2000 and 2007, the percentage of Georgians with private health insurance coverage dropped by about eight percentage points. And from 2000-'06, the percentage of uninsured non-elderly Georgians rose from 16 percent to 20 percent. All Georgians 65 or over are eligible for Medicaid and are therefore not included in the report.

Unemployment or employment with a small firm increases an individual’s likelihood of being uninsured. According to the report, roughly half of Georgia’s uninsured live in a family headed by someone who works for a small business with fewer than 100 employees.

And while the majority of Georgians have private insurance through companies large enough to provide it, the economic slowdown could leave thousands without coverage. More than 90 percent of Georgians with private health insurance have employer-based health plans, the report finds.

“When people lose their jobs, they lose their coverage,” said Bill Custer, director of the Center for Health Services Research in the J. Mack Robinson College of Business at Georgia State. “And throughout economic downturns, more people move into poverty, putting added strain on sources of public health coverage.”

According to the report, only one in five individuals living below poverty have private insurance and nearly 38 percent are uninsured.

In addition to employees of small businesses and those in poverty, other groups at particular risk for being uninsured include those in families headed by a part-time or part-year worker and young adults between the ages of 18 and 24, according to the report. And while those aged 45 to 65 were once the least likely to be uninsured, they’re the only age group to see an increase in the percentage of uninsured over the past two years.

Georgia’s men are also at risk – they’re more likely than women to go without coverage, but women are more likely than men to have public coverage.

Those surveyed who were without health coverage were also more likely to report being in poor health, increasing their likelihood of needing emergency care in the near future, Custer said.

As in past years, residents of Georgia’s rural areas, who are more likely to have low incomes and work for small firms, were also found to be more likely to lack health insurance than those living in urban/suburban areas. When grouped by public health district, about 22 percent of residents in Southeast and South Central Georgia health districts are uninsured; 21 percent in Southwest Georgia; 20 percent in North Georgia; and 19 percent in West Central, Northwest and Northeast Georgia districts.

By contrast, metro Atlanta has a significantly lower percentage of uninsured (though greater in its total number of uninsured due to its larger population). Only 12 percent of residents in the East Metro Georgia health district (including Gwinnett) are uninsured, 13 percent in Fulton, and 15 percent in the Cobb-Douglas and DeKalb districts. The only exception, according to the report, was Clayton County, in which 24 percent of residents are uninsured.

“Georgia’s relatively high rank nationally for uninsured residents has several causes,” said Patricia Ketsche, an associate professor in the Robinson College of Business. “We have a large rural population and rural workers are more likely to be employed at small firms. Rural residents usually have fewer options for employment and for coverage. And although parts of metro Atlanta have high coverage rates, there are other areas where a large number of families live at or near poverty.”

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