Strengthening Health Care Infrastructure and Supporting Safety-Net Providers

Healthcare Infrastructure

Emergency medical treatment: Under the Emergency Medical Treatment & Labor Act, hospitals are required to provide stabilizing treatment to anyone in need. If a hospital is unable to stabilize a patient or if the patient requests, they must transfer the patient. This treatment must be provided regardless of the patient’s ability to pay.

Emergency Medical Services (EMS): Access to emergency medical transportation services is not universal or guaranteed. EMS access can be particularly difficult for rural residents, often resulting in long wait times in emergencies. This can significantly impact health outcomes.

Rural access: Almost one in five Americans reside in rural areas. Residents in rural communities face significant health disparities when compared to urban areas. Rural residents face worse health outcomes across numerous measures and conditions. Between 1999 and 2019, health disparities between rural and urban communities tripled. Lack of access to services is a driver of these disparities. This includes a lack of access to essential categories of service such as primary care, mental health services, oral health, and substance use disorder treatment. Residents of rural areas also face longer drives to hospitals, as well as hospital closures that leave communities without essential services. Since 2010, more than 148 rural hospitals have closed. Recent federal efforts have focused on increasing health care access in rural communities. Key among these efforts is growing the health workforce by establishing new medical residence programs in rural areas and increasing health care capacity. It also includes telehealth among other efforts. Federal funding related to the COVID-19 pandemic has helped struggling rural hospitals, but they remain at risk due to financial and staffing challenges.

New initiatives have shown progress in improving access to primary and preventive care in rural communities. These efforts include utilizing mobile vans and partnerships between local paramedics and physicians. However, obtaining insurance coverage for such programs is a significant hurdle (see also Access to Medicare Services: Policy).

Indian Health Service (IHS): Federally recognized tribes receive some health assistance through IHS, a division of the U.S. Department of Health and Human Services. The IHS supports a network of hospitals and clinics in urban and rural areas that provide direct services. The IHS is not health insurance. As of 2021, a total of 687 IHS and tribally owned or operated facilities were located mostly on or near reservations. In addition, 41 urban programs operated in 39 cities throughout the U.S. The IHS is funded through Congressional appropriations, resulting in underfunding and a lack of predictability. People who use IHS facilities often have private insurance, Medicare, or Medicaid. Insurance coverage for tribal members is essential because IHS funding is insufficient to meet the needs of all tribal members. This results in some individuals who rely solely on the IHS not being able to access needed care.

Language access: Providers who receive federal funds (including from Medicaid) must make language services available to patients with limited English proficiency under Title VI of the Civil Rights Act and Section 504 of the Rehab Act of 1973. States have their own language access laws and regulations as well. These language guidelines also apply to Medicaid programs, providers, and managed care plans. States and state managed care plans are also required by federal law to promote access to and delivery of services in a culturally competent manner. In 2022, The Centers for Medicare & Medicaid Services (CMS) announced a health equity framework that includes advancing language access, promoting health literacy, and providing culturally tailored services among the priorities.

Safety-Net Providers: Though there is no standard definition of safety-net providers. The term typically refers to a spectrum of providers that offer health care to individuals regardless of their ability to pay. Serving these patient populations often means that many also see a high number of uninsured and Medicaid-covered patients, which can create financial challenges for providers. The continuum of safety-net providers includes community health centers, free clinics, rural clinics, local health departments, and public hospitals. In addition to reimbursement for services, safety-net providers also often rely on additional sources of federal and state funding. Most safety-net providers also qualify as essential community providers. Affordable Care Act (ACA) Marketplace plans must include a minimum number of essential community providers in their provider networks.

Non-emergency care safety-net providers: Health centers, sometimes known as community health centers, and federally qualified health centers are qualified by the federal government, through the Health Resources and Services Administration (HRSA), to provide primary and other preventive care to communities that lack access to care and are predominately low income. These clinics generally charge patients on a sliding fee scale. Health centers must also assist patients in completing applications for programs for which they may be eligible (for example, Medicaid or ACA Marketplace plan subsidies). With the federal designation comes special financial incentives, including higher reimbursement rates, grants funds and access to discounted prescription drug rates. Health centers may also participate in provider networks of Medicaid managed care plans, though in managed care arrangements their reimbursement rates are determined by their contract with the plan.

Health center look-alikes are very similar to health centers. They meet all HRSA Health center Program requirements, and receive most of the same financial benefits, such as higher payment rates from Medicare and Medicaid, and access to discount prescription drug rates. The main difference is that the look-alikes have not been chosen through a competitive process for additional federal grant funding. Some hospital systems have set up look-alike clinics as a way to manage patient care and maximize reimbursement rates but referring patients to the clinics for treatment.

Community mental health centers (CMHCs) and certified community behavioral health clinics (CCBHCs) are intended to increase access, quality, and integration of community mental health services. They may be funded through a combination of state and federal funds. CMHCs are long-established centers for mental health care in the community. Specific services provided and populations served vary among centers. In contrast, CCBHCs must provide a common set of comprehensive mental health and substance use disorder treatment services, regardless of a patient’s ability to pay. CCBHCs are an ongoing demonstration program, and participating centers receive an enhanced federal payment rate for Medicaid services.

Emergency Safety-Net Services: Safety-net hospitals serve a disproportionate share of patients from communities that are low income or otherwise lack access to care. These patients are often uninsured and cannot afford to pay for care. Many safety-net hospitals receive payments from Medicare and Medicaid to help reduce the financial burden related to the uncompensated care that they provide. These are called disproportionate share hospital payments. With the passage of the ACA and expansion of Medicaid, policymakers anticipated more patients covered by Medicaid and fewer uninsured, thus less need for uncompensated care adjustments. As a result, the act included a cut to disproportionate share hospital payments. These cuts were delayed. However, CMS announced some cuts beginning in 2024 under revised methodology.