nformants perceive Seattle’s safety net as strong, and they believe that responsibility for providing indigent care is shared among several providers. Nearly all of Seattle’s providers serve some segment of the medically indigent population, a fact that informants attribute to Seattle’s rich array of not-for-profit, mission-oriented health care providers. Most informants believe that as long as not-for-profits continue to dominate the market, the safety net will remain viable. Most of the care for indigent and Medicaid populations is provided by the community health centers, three publicly funded hospitals (University of Washington Medical Center, Harborview and Children’s Hospital) and the Catholic, mission-oriented Providence hospitals. Virginia Mason Medical Center and Group Health historically have served the Medicaid population. Group Health is involved in local health promotion and advocating for care for the underserved, but typically does not provide direct care for the indigent population as do Providence, Virginia Mason Medical Center and the University of Washington-operated hospitals. The King County Health Department provides some clinical services, but sees its primary role as providing population-oriented services (e.g., immunizations) with integrated delivery systems that work with publicly funded health plans (e.g., Healthy Options, the Basic Health Plan).

Community health centers are an important part of the delivery system for Medicaid and uninsured populations. Respondents report that the eight community health centers in Seattle are competing with each other for patient volume. To help ensure their viability, community health centers statewide created a Community Health Plan to receive Medicaid Healthy Options and Basic Health Plan contracts. In doing so, the centers had to forgo retroactive federally qualified health center fee-for-service payments to which they were entitled, but instead received what they viewed to be generous Medicaid capitation rates. Community Health Plan operates statewide; in Seattle, it refers patients to the hospitals that historically have worked with indigent and Medicaid populations.

Native Americans access care through county-level Indian health boards that provide care funded by the federal government’s Indian Health Service. Commercial insurers and Medicaid typically do not include Seattle’s Indian Health Board in their contracts, although some insurers outside King County do.

Washington’s prepaid Medicaid program, Healthy Options, has streamlined access and created continuity for Medicaid recipients, many of whom did not have a dedicated primary care provider. Informants reported fewer unnecessary emergency room visits. The state has also undertaken measures to protect and strengthen providers that have traditionally served the uninsured and Medicaid populations. For example, the state awards additional consideration in selective contracting to plans that include traditional providers in their networks.

However, some respondents expressed concern about the impact of policy changes on the Medicaid and uninsured populations. They predicted that welfare reform will decrease the number of Medicaid eligibles in the area, particularly among the large immigrant population, and that price competition for Healthy Options contracts will drive prices down and hurt providers that traditionally have cared for the uninsured and Medicaid populations.

The state’s subsidized Basic Health Plan has reduced the number of uninsured in Seattle. Passed in 1993 as part of the Health Services Act, the Basic Health Plan is the state’s primary vehicle to provide access to insurance -- and medical care -- for the uninsured. It is funded through tobacco, alcohol and hospital taxes. Purchasing is centralized at the state level, and most of the major carriers in Seattle participate. Networks, services and benefits are all reportedly comparable with commercial health plan products. Although the Basic Health Plan is considered a success, one informant noted that, with the demise of the Health Services Act, strategies for dealing with the uninsured are now incremental rather than comprehensive, because no one entity is responsible for addressing this problem.