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Most Uninsured People Unaware of Health Care Safety Net Providers

Issue Brief No. 90
November 2004
Jessica H. May, Peter J. Cunningham, Jack Hadley

Less than half of uninsured Americans either typically use or are aware of a safety net provider in their community, according to a national study by the Center for Studying Health System Change (HSC). Among all uninsured people, those with lower-incomes, racial/ethnic minorities and people living closer to safety net providers are more likely to know of or use a safety net provider for medical care. Uninsured people identify physician offices and community health centers most frequently as sources of lower-cost medical care, while hospital-based facilities—outpatient and emergency departments—are less likely to be mentioned. Despite high levels of emergency department (ED) use by uninsured people, few identify EDs as places to get affordable medical care.


Low Awareness of Safety Net Providers

he health care safety net includes providers offering free or reduced-cost care to low-income and uninsured patients. The most common safety net providers include public hospitals, community health centers (CHCs) and local health departments, but other types of clinics, as well as teaching hospitals and community hospitals, may provide free or reduced-cost care in some communities.1 Most office-based physicians also provide some charity care, but the proportion of physicians providing charity care has declined in recent years.2

HSC’s 2003 Community Tracking Study Household Survey asked uninsured people about their use and awareness of medical care providers who offer lower-cost and affordable care—referred to as safety net providers (see Data Source). Uninsured people with a usual source of medical care were asked, “At this place, do you pay full price for medical care or do you pay a lower amount based on what you can afford to pay?” In addition, uninsured people who did not pay a lower price at their usual source of care or who did not have a usual source of medical care were asked, “Thinking of the area where you live, is there a place that offers affordable medical care for people without insurance?”

Taken together, the responses to the two questions indicate that less than half of the uninsured (48%)—or about 18 million people—use or are aware of a safety net provider in their community (see Table 1). These findings suggest that many uninsured people do not know of an affordable source of care to turn to when they need medical attention, and, therefore, they are at elevated risk of going without needed medical care.

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Table 1
Uninsured People Aware of a Safety Net Provider

  Number Aware of Safety Net Provider1 (Thousands) Percent Aware of Safety Net Provider
All Uninsured People
17,834
47.5%
Income
Below Federal Poverty Level (FPL)2
5,464
54.4
100-199% FPL
5,880
47.0
200-299% FPL
2,774
43.8*
300% FPL and above
3,716
42.8*
Race/Ethnicity
White2
7,345
40.9
Black
3,081
56.5*
Latino
6,331
52.7*
Health Status and Chronic Condition
In excellent/very good health2
9,016
45.2
In good/fair/poor health with no chronic conditions
4,442
48.7
In good/fair/poor health with 1 chronic conditions
1,539
48.3
In good/fair/poor health with 2 or more chronic conditions
1,310
52.3
Proximity to Community Health Center (CHC)
CHC within 5 miles2
8,900
53.1
No CHC within 5 miles
8,818
43.3*
1 Defined as those uninsured who pay less than full price at their usual source of care and all other uninsured who are aware of affordable sources of care in their community.

2 Reference Group.

* Comparison with reference group is statistically significant at p <.05.

Sources: HSC Community Tracking Study (CTS) Household Survey, 2003. Community health centers based on data from the Uniform Data System maintained by the Health Resources and Services Administration and linked to the CTS data.


Lower Income More Aware

mong all uninsured people, awareness of a local safety net provider varies by income, race/ethnicity, health status and proximity to community health centers (CHCs). Poor and lower-income uninsured people—those with incomes below 200 percent of the federal poverty level, or $36,800 for a family of four in 2003—were more likely to know of a safety net provider in their community than uninsured people with higher incomes. Awareness of a local safety net provider also was higher among uninsured racial and ethnic minorities, likely in part because they tend to have lower average incomes than uninsured whites.3 More than half of uninsured blacks (57%) and Latinos (53%) knew of a safety net provider in their community, compared with about four in 10 uninsured whites (41%).

Awareness of safety net providers varied little by health status and number of chronic conditions. Although 52 percent of the uninsured in the poorest health reported using or being aware of a safety net provider, this is only slightly higher and not significantly different from the 45 percent of the uninsured in very good or excellent health who used or knew of a safety net provider.

Awareness of local safety net providers may differ by income and race as a result of where safety net providers tend to be located. For example, uninsured people living within 5 miles of a CHC are more likely to be aware of a safety net provider compared with uninsured people who do not live near a CHC (53% vs. 43%). CHCs are usually located in medically underserved areas, including many urban neighborhoods with large numbers of poor and minority residents, and most receive federal funding to provide care to uninsured patients.

Nevertheless, many of the poorest and most disadvantaged uninsured people apparently do not use or are unaware of the health care safety net, including 4.6 million uninsured poor people, 5.7 million uninsured Latinos and 2.4 million uninsured African Americans. Moreover, a striking number of uninsured people—about 7.9 million—are unaware of a safety net provider despite living in close proximity to a CHC.

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Safety Net a Usual Care Source

lmost two-thirds (64%) of uninsured people identify a single place where they usually go to receive medical care. However, less than half (45%) of uninsured people with a usual source of care reported paying less than full price for care (see Table 2). The uninsured are more likely to have a safety net provider as their usual source of medical care if they are poor (55%), black (56%), cal care if they are poor (55%), black (56%), Latino (61%) and live closer to CHCs (54%). Additionally, uninsured people in poorer health also are more likely to have a safety net provider as a usual source of care.

Awareness of the safety net other than through a usual source of medical care appears to be much more limited. For those uninsured without a safety net provider as a usual source of care, less than one-third (29%) were aware of safety net providers in their community.

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Table 2
Uninsured People Aware of a Safety Net Provider, by Whether or Not Usual Source of Care is Safety Net Provider

  Safety Net Provider as Usual Source of Medical Care1 Aware of Other Safety Net Provider in Community2
All Uninsured People
44.6%
28.9%
Income
Below Federal Poverty Level (FPL)2
55.4
32.0
100-199% FPL
46.3
28.6
200-299% FPL
40.6*
24.3
300% FPL and above
32.9*
29.2
Race/Ethnicity
White2
33.3
24.4
Black
55.7*
30.0
Latino
61.2*
35.0*
Health Status and Chronic Condition
In excellent/very good health2
39.9
28.0
In good/fair/poor health with no chronic conditions
49.5*
33.0
In good/fair/poor health with 1 chronic conditions
49.9*
33.0
In good/fair/poor health with 2 or more chronic conditions
49.6
23.0
Proximity to Community Health Center (CHC)
CHC within 5 miles2
53.9
33.7
No CHC within 5 miles
37.9*
25.7*
1 Sample includes all uninsured who have a usual source of medical care.

2 Sample includes all uninsured who don’t have a safety net provider as their usual source of care or who have no usual source of care.

3 Reference group.

* Comparison with reference group is statistically significant at p <.05.

Sources: HSC Community Tracking Study (CTS) Household Survey, 2003. Community health centers based on data from the Uniform Data System maintained by the Health Resources and Services Administration and linked to the CTS data.


Few See Hospitals as Safety Net

verall, physician offices and clinics/health centers were identified as the most common sources of low-cost care (see Table 3). Of uninsured people who are aware of safety net providers, 45 percent cited a clinic or health center as a safety net provider (many of which are likely to be CHCs), while about one-fourth (26%) identified a physician office.

By contrast, hospital outpatient clinics and emergency departments were much less likely to be identified as safety net providers, although other HSC research has shown that the uninsured receive more than half of their outpatient care from hospital- based facilities.4 In particular, only 8 percent of uninsured people who are aware of safety net providers in their community identified a hospital emergency department as a safety net provider. This is surprising because hospital emergency departments are often considered to be providers of last resort for uninsured people and about a quarter of all outpatient visits by the uninsured are to emergency departments.5 While the uninsured may be frequent ED users because of the lack of alternatives—and because by law they can’t be turned away—these findings suggest that they don’t necessarily regard EDs as places to receive affordable or lower-cost care.

Sharp differences exist in the type of places the uninsured identify as safety net providers depending on whether or not uninsured people had a safety net provider as their usual source of care. Uninsured people who have a safety net provider as their usual source of care were much more likely than other uninsured people to identify a doctor’s office as a safety net provider (35% vs. 13%). In contrast, uninsured people who do not have a safety net provider as their usual source of care were much more likely to identify clinics or health centers as safety net providers—55% vs. 37% for the uninsured who have a safety net provider as their usual source of medical care.

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Table 3
Type of Place/Provider Identified as a Safety Net Provider

  All Uninsured Aware of Safety Net Provider Safety Net Provider is Usual Source of Care Other Safety Net Provider in Community Identified by Uninsured1
All Places
100.0%
100.0%
100.0%
Doctor’s Office
26.1
35.1
13.4
Hospital Outpatient Clinic
12.9
12.1
14.0
Hospital Emergency Department
8.3
10.3
5.5
Clinic or Health Center
44.6
37.3
55.1
Other
8.0
5.2
12.0
Note: Totals may not add up to 100% due to rounding.

1 Includes uninsured who are aware of a safety net provider but not as their usual source of medical care.

Sources: HSC Community Tracking Study Household Survey, 2003.

Perceptions of the Safety Net

hen asked whether any uninsured member of their family used a safety net provider in the last year, less than one-fourth of survey respondents who were aware of safety net providers reported any use by family members. The main reason cited for not using a safety net provider in the previous year was no need for care (about 60%). About 20 percent cited a variety of other reasons, including perceived ineligibility (5%) or convenience issues such as long distances, long waiting times or inconvenient hours (about 6%).

Few people explicitly mentioned negative perceptions, such as stigma associated with receiving lower-cost care, poor-quality care or concerns about the neighborhood as a reason for not using the safety net provider. About 20 percent cited other unspecified reasons for not using safety net providers.

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Implications

ncreases in the number of uninsured, rising health care costs and the uncertainty of any major coverage expansions in the foreseeable future mean that most uninsured Americans will continue to rely largely on the health care safety net for medical care. Uninsured people who live in areas without safety net providers are at especially high risk for lacking access to even basic medical care.

But even when safety net providers, such as CHCs, are present, a large number of uninsured people apparently are unaware of them as places to receive affordable medical care, including many uninsured who are poor and have a high need for medical care. If uninsured people are unaware of safety net providers, they may be at higher risk of going without needed medical care or incurring large out-of-pocket expenses and medical debt to obtain that care. Even for uninsured people without a specific need for medical care, awareness of a place to receive affordable medical care could encourage them to seek timely care if the need arises, rather than waiting until the problem becomes more severe and complicated to treat. Consequently, outreach efforts to increase awareness of safety net providers may be as important to improving access as current efforts to expand the number of CHCs.

That more than half of the uninsured are unaware of safety net providers in their communities also may reflect the fact that so few identify hospital-based outpatient settings as sources of lower-cost care. While visits to hospital outpatient and emergency departments make up more than half of all outpatient visits by uninsured people, a comparatively smaller number of uninsured identified hospital-based facilities as safety net providers. Since services received in hospital-based settings are usually more expensive than in clinics or private physician offices, the uninsured may not perceive that hospitals are lower-cost sources of care, even if the services are provided at a discounted rate.

Concerns also have been raised about some hospitals charging uninsured patients more than insured patients, implementing stringent eligibility standards for uncompensated care, and using aggressive bill collection practices as a way to discourage future use, all of which may add to the perception among many uninsured people that hospitals are not sources of lower-cost medical care.6

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Notes

1. Lewin, Marion E., and Stuart Altman, eds., America’s Health Care Safety Net, Institute of Medicine, National Academy Press, Washington, D.C. (2002).
2. Cunningham, Peter J., Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, 1997- 2001, Tracking Report No. 6, Center for Studying Health System Change, Washington, D.C. (December 2002).
3. Hargraves, J. Lee, The Insurance Gap and Minority Health Care, 1997-2000, Tracking Report No. 2, Center for Studying Health System Change, Washington, D.C. (June 2002).
4. Cunningham, Peter J., and Jessica H. May, Insured Americans Drive Surge in Emergency Department Visits, Issue Brief No. 70, Center for Studying Health System Change, Washington, D.C. (October 2003).
5. ibid.
6. Pryor, Carol, et al., Unintended Consequences: How Federal Regulations and Hospital Policies Can Leave Patients in Debt, The Commonwealth Fund, New York, N.Y. (June 2003).
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Data Source

This Issue Brief presents findings from the 2003 Community Tracking Study Household Survey, a nationally representative telephone survey of the civilian, noninstitutionalized population. Data were supplemented by in-person interviews of households without telephones to ensure proper representation. The survey contains information on 46,600 persons, and the response rate was 57 percent. This analysis focuses on a subsample of 4,840 unin- focuses on a subsample of 4,840 uninsured people, identified based on their self-reported insurance status on the day of the interview. The estimates in this report are representative of people in three racial or ethnic groups. Black refers to all non-Latino blacks, and white refers to all non-Latino whites.

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ISSUE BRIEFS are published by the Center for Studying Health System Change.

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