Strengthening Health Care Infrastructure and Supporting Safety-Net Providers


Safety-net providers typically include community health centers, public hospitals, free clinics, rural clinics, and local health departments. Many of these providers play a crucial role in providing services and care in otherwise underserved communities. Since the enactment of the Affordable Care Act (ACA) in 2010, safety-net providers have seen an increase in the number of Medicaid and marketplace-plan-covered patients, particularly in states that have expanded Medicaid eligibility. However, many still see significant numbers of uninsured patients. 

Community health centers (CHCs): CHCs typically provide a range of services, including primary care and preventive care, and serve a disproportionate number of low-income, uninsured, Medicaid-covered, and racial and ethnic minority patient populations. Many community health centers are designated Federally Qualified Health Centers (FQHCs). This means they have met specific requirements to qualify for and receive federal funds to serve an underserved population or community. Medicaid programs must cover FQHCs services. FQHC “look-alikes” function much like FQHCs and receive some of the same federal funding and benefits. They are often set up by hospitals for outpatient care and have relationships with the hospitals for referrals. Hospitals increasingly use look-alike models as a way to manage patient care and maximize reimbursements. CHCs are funded, at the federal level, primarily through discretionary appropriates, and, since FY2011, with additional funds appropriated through the ACA. That funding has currently been extended through 2023. 

Many community health centers also qualify as essential community providers, a designation created by the ACA. ACA marketplace plans must include a required number of these providers in their provider networks. CHCs may also participate in provider networks of Medicaid managed care plans. CHCs also have increasingly assisted patients in completing applications for programs for which they may be eligible (for example, Medicaid or ACA marketplace plan subsidies). FQHCs are required to provide this assistance. 

Safety-net hospitals: These hospitals serve a disproportionate share of patients from communities that are low income or otherwise underserved. 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 (DSH) payments. Since the passage of the ACA and expansion of Medicaid in many states, many of these hospitals have seen decreases in uninsured patients and an increase in Medicaid-covered patients. This shift to more patients being covered by Medicaid was anticipated by the ACA. As a result, the act included a cut to DSH payments. Implementation of these cuts was delayed. They are currently scheduled to take effect in 2024. 

Community mental health centers: Congress authorized funding for state demonstrations to improve community mental health services. Demonstrations began in eight states in 2017. The goal was to increase access, quality, and integration of community mental health services. To participate in the demonstrations, clinics must apply to be Certified Community Behavioral Health Clinics (CCBHCs). They must show that they meet specific criteria emphasizing accessibility, quality, and evidence-based practices. The Centers for Medicare & Medicaid Services (CMS) provides an enhanced federal medical assistance percentage to states for services provided through CCBHCs. CCBHCs cover mental health and substance use disorder treatment services. The demonstration program has been extended and expanded. It now includes community outreach and education activities and provides services regardless of a patient’s ability to pay. Currently, there are 450 CCBHCs in 42 states and the U.S. territory of Guam. 

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

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 and delivery of services in a culturally competent manner. In 2022, CMS announced a health equity framework that includes advancing language access, promoting health literacy, and providing culturally tailored services among the priorities. 

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 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. This includes growing the health workforce by establishing new medical residence programs in rural areas and increasing health care capacity, involving 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 preventative 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).

Indian Health Service (IHS): Federally recognized tribes receive some health assistance through the Indian Health Service (IHS), a division of the Department of Health and Human Services. The IHS supports a network of hospitals and clinics in both 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 important 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

All levels of government should adopt policies ensuring that individuals with limited or no English proficiency have adequate language access to their health care provider. 

All levels of government should ensure that professional language services providers are adequately trained, certified, and compensated. 

Safety-net facilities

Federal, state, and local governments should take steps to ensure adequate funding for safety-net providers to meet the needs of those who remain uninsured. All levels of government should ensure that publicly funded interventions are sensitive to communities’ particular needs and preferences. 

Reductions in Disproportionate Share Hospital (DSH) payments

In light of the statutory reduction in federal DSH payments and the resulting negative impact on safety-net health funding, states should expand their Medicaid programs to cover all eligible individuals with income at or below 138 percent of the federal poverty level. 

States that do not expand their Medicaid programs should have concrete and transparent plans to make up the safety-net funds lost because of cuts in federal DSH payments. In addition, these states should demonstrate adequate safety-net capacity. 


Federal and state governments should provide incentives for health educators to conduct training in medically underserved areas. They should also encourage physicians, nurses, and other health care personnel to practice in medically underserved areas. Incentives might include targeted scholarships and grants, student loan-forgiveness programs, and training stipends. 

Federal and state governments should establish programs to train, recruit, and retain health care providers to work in rural and urban underserved areas. In addition, federal and state governments should target education subsidies to those health care professions in which practitioners are in shortest supply. 

Federal and state governments should take steps to ensure that grants awarded to public and nonprofit entities to address certain curriculum issues among health providers (namely, cultural competency, public health, prevention, reducing health disparities, and working with individuals with disabilities) are rigorously evaluated and best practices quickly disseminated. 

Rural access

Policymakers should support innovative efforts to improve access to health care services for residents of rural and other underserved communities.

Federal and state governments should help rural communities improve local access to health care by facilitating community-based discussions about potential solutions for access problems. 

Federal and state governments should provide: 

  • relevant demographic and utilization data, 
  • appropriate incentives for managed care plans to extend needed coverage to rural areas, 
  • incentives and assistance in recruiting and retaining all types of health care personnel, and 
  • technical assistance to rural and underserved communities that seek to develop delivery systems and identify alternative ways to provide access to health care (such as telemedicine systems and improved transportation resources). 

Emergency medical services

Consumers should have access to affordable emergency medical services, including emergency transportation. Policymakers should act to reduce barriers to access in areas where they exist, such as rural communities.

Indian Health Service (IHS)

Congress should take steps to strengthen the Indian Health Services (IHS) and improve access to care for tribal members, including:
•    providing more stable and increased funding to the IHS,
•    funding pilots that seek to improve care for tribal elders,
•    reducing disparities in access to IHS facilities and in the services offered at those facilities,
•    reimbursing the IHS 100 percent of the Medicare reimbursement rate for Medicare beneficiaries,
•    making reimbursement for IHS telehealth services consistent with Medicare and Medicaid reimbursement for these services (see also Telehealth), and 
•    ensuring all IHS providers have access to high-speed internet and equipment for provision of telehealth services (see also High-Speed Internet Services and Telehealth).

Uncompensated care

Federal and state governments should adopt policies that: 

  • encourage hospitals to provide free care to people who are indigent and lack access to health insurance coverage, 
  • require or encourage for-profit and nonprofit hospitals to charge uninsured people discounted prices comparable to those negotiated with insurers, and 
  • prevent both types of hospitals from engaging in onerous debt collection practices against people who are indigent or uninsured. 

Federal and state governments should require hospitals to freely disclose information about charity care and discounts available to qualified patients. In addition, hospitals should be required to make information about their prices available to patients in usable, meaningful formats so that patients can anticipate the costs of care. 

States should monitor uncompensated care and other community benefits provided by nonprofit hospitals. They should also evaluate whether those benefits are commensurate with the value of the tax exemptions that hospitals receive.

To ensure access to care, the federal and state governments should also assess the financial stability of hospitals on an ongoing basis to identify and offer assistance to facilities at risk of closure, particularly in rural and other underserved areas. 

Wellness plans

The federal government should monitor patients with individualized wellness plans through community health centers to ensure that the plans adequately respond to their health needs. Particular attention should be given to those with multiple health conditions.

Training for community health workers

States and federal governments should ensure that community health worker education includes content on working with older adults. 


Until health coverage is attained for all, federal, state, and local governments should support efforts to increase and maintain access to health care for the uninsured through innovative community-based approaches, like the use of volunteer health care personnel or donated medical equipment. 

When health care is offered through voluntary efforts or provided using donated equipment, consumer protections should be maintained. This can be done by checking the adequacy of professional licenses, ensuring practice competencies, making sure that donated equipment meets standards, retaining patients’ rights to full and just compensation for injuries resulting from improper care, ensuring that volunteers have adequate malpractice insurance coverage, and implementing other appropriate quality control measures.