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Practitioner Application: Shifts in Medicaid and Uninsured Payer Mix at Safety-Net and Non-Safety-Net Hospitals During the Great Recession

Research into the shift in Medicaid and uninsured payer mix at safety-net hospitals (SNHs) and non-SNHs during the Great Recession, as shared by Fingar, Coffey, Mulcahy, Andrews, and Stocks, is work that SNHs should pay attention to as healthcare continues to evolve. Achieving trust and loyalty are challenges for SNHs, especially as some long-term patients have the option to get their healthcare elsewhere. This is what competition does: It creates an avenue for people to exercise choice. This is not the first time giving newly insured patients a choice in healthcare has been discussed. In the early 1990s, when President Bill Clinton talked about universal healthcare, I was an administrative resident at an SNH. We realized that, with universal healthcare, patients could choose where to get their healthcare. Would they choose the SNH where I worked? Fingar, Coffey, Mulcahy, Andrews, and Stocks note that non-SNHs have an advantage in this situation because they have been competing for Medicaid and uninsured patients since before the Affordable Care Act (ACA). Additionally, SNHs now have a chance to market and redefine themselves. SNHs are usually associated with lowincome patients, yet they have some of the best health programs (e.g., trauma, transplant, cancer, orthopedics, cardiology) and best-trained doctors. These programs attract private-pay patients, but when they associate these programs with SNHs they often think of them for their specialty care instead of all of their care. I believe competition is good because it can make hospitals more conscientious in the care they provide and more sensitive to their patients’ needs. And that means hospitals can readily take on the challenge of becoming high-reliability organizations and not fight this golden opportunity to improve patient safety and experience. The article states SNHs could lose patients to non-SNHs due to the ACA. However, the article does not mention the fact that non-SNHs and health systems are not in all ACA health plans. With non-SNHs being out of certain plans, a number of existing and newly insured patients may turn to the SNHs, thereby increasing their volume and financial status. Non-SNHs have lower financial margins because they take care of a high-risk population—often including patients with two and three comorbidities who require a lot of resources for their care. A robust population health program for SNHs and non-SNHs