Erosion in the Healthcare Safety Net: Impacts on Different Population Groups.

Safety net hospitals (SNHs) have played a critical role in the U.S. health system providing access to health care for vulnerable populations, in particular the Medicaid and uninsured populations. However, little research has examined how access for these populations changes when contraction of the safety net occurs. Institutional policies, such as hospital closure or ownership conversion, could affect the supply of minority health care providers, thus exacerbating disparities in outcomes. We use multilevel logistic modeling of person-level hospital discharge data to examine the effects of contractions in the California safety net over the period of 1990-2000 on access to care as measured by changes in ambulatory care sensitive condition (ACSC) admissions, using geographic methods to characterize proximity to a contraction event. We found that presence of a contraction event was associated with a statistically significant increase in the predicted probability of impeded access, with an increase of about 1% for Medicaid-insured populations and about 4-5% for the uninsured. The Medicaid-insured group also maintained the highest rates of ACSC admissions over time, suggesting persistent access problems for this vulnerable group. This research is timely given continued budget problems in many states, where rising unemployment has increased the number of Medicaid enrollees by 6 million and uninsured individuals by 1.5 million, increasing pressure on remaining SNHs.