Many uninsured don’t know safety net is available in their community

"Build it and they will come," the saying goes. But for safety net providers and the uninsured, it appears that building it isn’t enough. You also have to be sure people know you exist and want them to come.

Many studies have been done on the need for safety net providers. But until recently, no one had looked at the level of awareness of those providers’ existence. A study by the Center for Studying Health System Change (HSC) paints a disturbing picture of how well — or not — people understand the help they have available, and what capacity problems could develop if they understood better.

HSC senior health researcher Paul Cunningham tells State Health Watch the study found that more than 50% of all uninsured Americans are unaware of a community safety net provider where they can receive lower-cost, affordable health care.

Many of the poorest and most disadvantaged uninsured people apparently do not use or are unaware of the health care safety net, he explains, including 4.6 million uninsured poor people, 5.7 million uninsured Latinos, and 2.4 million uninsured African Americans. Also, some 7.9 million uninsured are unaware of a safety net provider despite living within five miles of a community health center.

"Even if uninsured people don’t have an immediate need for care, awareness of a place to receive affordable care could encourage them to seek timely care if the need arises, instead of waiting until their condition becomes more severe," Mr. Cunningham says.

An HSC Issue Brief on the study findings says the organization’s 2003 Community Tracking Study Household Survey added questions to learn from uninsured people about their use and awareness of medical care providers who offer low-cost and affordable care.

Mr. Cunningham says he and his colleagues have done some research into whether having safety net providers makes much difference in terms of the uninsured getting care. "The missing piece," he says, "is whether they’re aware of it or use it, even though it’s there. And no one’s been able to comment on that before."

Taken together, the responses indicate that less than half of the uninsured (48%) — some 18 million people — use or are aware of a safety net provider in their community. "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," Mr. Cunningham reports.

Among all uninsured people, awareness of a local safety net provider varies by income, race/ethnicity, health status, and proximity to community health centers. Poor and lower income uninsured people 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. Some 57% of uninsured blacks and 53% of uninsured Latinos knew of a safety net provider in their community, compared with 41% of whites.

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

While 64% of uninsured people identify a single place where they usually go to receive medical care, only 45% of uninsured people with a usual source of care reported paying less than full price for their care. 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%), Latino (61%), and live close to a community health center (54%). Also, uninsured people in poorer health 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, only 29% were aware of safety net providers in their community.

Overall, physician offices and clinics/health centers were identified as the most common sources of low-cost care. By contrast, hospital outpatient clinics and emergency departments were much less likely to be identified as safety net providers, although Mr. Cunningham says that other HSC research has shown that the uninsured receive more than half their outpatient care from hospital-based facilities. In particular, he says, only 8% 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. While the uninsured may be frequent emergency department 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 emergency departments as places to receive affordable or lower-cost care," Mr. Cunningham adds.

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% to 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%).

When asked whether any uninsured members 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, according to Mr. Cunningham, was no need for care (about 60%). Some 20% cited a variety of other reasons, including perceived ineligibility (5%) or convenience issues such as long distance, long waiting times, or inconvenient hours.

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 a safety net provider. About 20% cited other unspecified reasons for not using safety net providers.

According to Mr. Cunningham, increases 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 especially at high risk for lacking access to even basic medical care, he says.

Even when safety net providers such as community health centers 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.

Avoiding medical debt

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 a problem becomes more severe and complicated to treat. Thus, Mr. Cunningham says, outreach efforts to increase awareness of safety net providers may be as important to improving access as are current efforts to expand the number of community health centers.

"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," he writes. "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."

Solution lies at the local level

Asked about a potential solution to the lack of awareness of safety net providers, Mr. Cunningham tells State Health Watch that he believes more needs to be done at the local level. "Some recent federal programs have been geared to coordination of services and outreach, but it really should be a local effort for organizations to make themselves known and make people aware of the services they provide."

He says he does not believe the lack of awareness means that facilities are underutilized. "If anything, we hear about long waiting room lines and overcrowding. And if more of the uninsured start using the safety net providers, it could mean some serious capacity constraints."

National Association of Com-munity Health Centers vice president for federal, state, and public affairs Dan Hawkins says community health centers agree that outreach should be a vital part of all safety net providers’ essential functions, and says it has been a key part of the community health center model of care since their 1965 founding. "Unfortunately, community outreach staffing at health centers has worsened for the first time in five years. In 2002, health center outreach workers served an average of 6,769 patients per worker, a 23% improvement over 1998 due to rising numbers of outreach workers. However, this trend is starting to change. The number of patients per outreach worker rose to 7,135 with no sign of rebounding any time soon," he continues.

"This is because health centers, like many other safety net providers, are caught in a brutal squeeze between rapid growth both in their uninsured patient loads and the costs for everything they need to provide quality health care, while revenues from virtually every source, including federal grants to support care for the uninsured, are failing to keep pace with inflation. This disturbing news raises deep concern that health centers may be facing a period, similar to what they experienced during the mid-1990s, when their ability to support such key nonmedical services fell dramatically amid revenue losses."

Mr. Hawkins says that unless the trend reverses itself, the association is concerned that vital services such as outreach will continue to decline.

[Contact Mr. Cunningham at (202) 484-5261 and Mr. Hawkins at (202) 296-1890. Download the HSC Issue Brief and other materials from]