What is the “Safety Net” in the US Public Health System?
If you read about public health in the United States, you have likely heard this term, and wondered to yourself… what is the “safety net”? This is actually a great question, as it is often not clearly defined. While designing our domestic programs, we took a close look at the major components of the “safety net”, which provides healthcare to underserved populations across the US.
The US medical safety net includes >20,000 clinical sites providing health services to >25 million people regardless of their ability to pay. The safety net is an amorphous term that varies significantly depending on location and perspective. However, a simplistic view can capture the growth of the safety net via three waves.7,3
- Hospitals: Until Medicaid/Medicare in 1965 and the rapid expansion of FQHCs in the 1980s, hospitals were the core of the safety net and virtually the only option for underserved individuals.7 There are many issues with this structure, such as inconvenience for patients and the astronomical cost of treating preventable health issues in this setting. The number of safety net or “essential hospitals” is unknown on a national scale. America’s Essential Hospitals trade group counts 300 members, but there are >1,000 public hospitals nationally1,7,8
- Safety Net Clinics: Federally qualified health centers (FQHCs) are the backbone of the safety net, followed by Rural Health Centers (RHCs).2,3,4 They are more convenient than hospitals, but patients still face barriers such as lack of transportation, missed time at work/school, required documentation for the sliding fee scale, and the cost of outfitting satellite locations with expensive specialty equipment and personnel
- Mobile Health Clinics (MHC) & School-Based Health Centers (SBHC): MHCs and SBHCs recently gained momentum as they target unique patient populations.5 Both are sponsored by a range of organizations (ex: FQHCs and hospitals) and overcome the barriers faced by other types of safety net clinics, making healthcare more accessible and affordable
In our market research report, we divided safety net clinics into 6 key categories (image 1):
- Federally Qualified Health Centers (FQHCs): FQHCs are the most common and receive grants from the government to support their operations
- Rural Health Clinics (RHCs): RHCs are viewed as safety-net providers in the rural communities they serve because their patients tend to be self-paying and uninsured, Medicaid recipients, and other vulnerable populations
- School-Based Health Centers (SBHCs): SBHCs are located in schools and provide extremely accessible healthcare for students, their families, and the surrounding communities. They are run by a variety of organizations, including FQHCs
- Mobile Health Clinics (MHCs): MHCs are used by many organizations to expand their reach into further underserved communities, visiting patients who cannot make it to the brick-and-mortar clinic sites
- Free & Charitable Clinics: Free Clinics are funded by the private sector, operated by volunteers, and free for patients. They have been referred to as the “net below America’s safety net”
- FQHC Look-Alikes: These are clinics that meet the requirements of the federal FQHC program, but to do not receive federal grants
*There are two main overlaps to note in this data set: As of 2017, 51% of SBHCs were sponsored by FQHCs & 20% by hospitals/medical centers; note the overlap in the data; As of 2020, 24% of MHCs were affiliated with universities, 29% with hospitals, and 29% with nonprofits. MHCs are difficult to calculate on a national scale, but the national association estimates 2K **Free clinics are slightly under-reported on a national scale as some register with state associations rather than the national association