Strength of States’ ‘Safety Net’ Has Little Effect on Access to Care for Uninsured, Study Finds

Uninsured adults' access to health care is not affected by the strength or weakness of a state's health "safety net," according to a study by the Urban Institute. The study, "Health Care Access for Uninsured Adults: A Strong Safety Net Is Not the Same as Insurance," uses representative population samples from 13 states as well as data from the Urban Institute's National Survey of America's Families. The study labeled the 13 states' safety nets -- health care systems for the uninsured composed of public hospitals, community health centers, local clinics and some primary care physicians -- as most vulnerable, somewhat vulnerable and least vulnerable. The researchers categorized California, Florida and Texas as having the most vulnerable safety nets because they have the highest adult uninsurance rates, relatively high commercial managed care penetration and a high percentage of for-profit hospitals. On the other hand, Massachusetts, Minnesota, Washington and Wisconsin have the least vulnerable safety nets because they have relatively low uninsurance rates and nearly all provided subsidized insurance coverage to low-income adults. The safety nets of Alabama, Mississippi, New York, New Jersey, Colorado and Michigan are considered "somewhat vulnerable" because of a mix of characteristics, including relatively high rates of uninsurance, low private managed care penetration, virtually no Medicaid managed care plans or high federal disproportionate share hospital payments. The researchers examined whether the uninsured in those 13 states had a usual source of care other than an emergency room, their access to doctors and their confidence in ability to obtain care.

• Usual source of care: In the most vulnerable states, fewer than 60% of the uninsured had a usual source of care, compared with more than 60% of the uninsured who had a usual source of care in the least vulnerable states. For states in the somewhat vulnerable category, more than 60% of the uninsured in Alabama, Colorado and New Jersey had a usual source of care, while less than 60% of the uninsured did in New York, Mississippi and Michigan. The brief notes, however, that a state's degree of safety-net vulnerability does not affect the size of the gap in access to care between the insured and uninsured because the insured in the most vulnerable states are also likely to have less access to care. In all 13 states, that gap is about 20 percentage points, regardless of the states' safety net vulnerability.
• Seeing a doctor: In the most vulnerable states, 36.9% of the uninsured had a doctor visit in the last year, compared with 42.1% of the uninsured in the least vulnerable states having a doctor visit. But the brief notes that the differences between the insured's and uninsured's doctor visits did not vary significantly with the vulnerability of the safety-net system.
• Confidence in obtaining care: In the most vulnerable states, 72.6% of the uninsured were confident they could receive care, compared with 80.3% of those in the least vulnerable states. That difference is not statistically significant, the brief notes. For all states, the uninsured are significantly less likely than the insured to have confidence in their ability to obtain care.

Relevance of Safety Nets' Strength
The brief concludes that there are state-by-state differences among the uninsured's access to care, but with the exception of having a usual source of care, the differences are unrelated to the vulnerability of the safety nets in those states. Even in states with safety nets more vulnerable because of higher uninsurance rates, more managed care plans and fewer hospitals providing charity care, the uninsured do not appear to be "significantly worse off" than the uninsured in states with less vulnerable safety nets. In addition, the brief says that it is "striking" that the large gaps in access to care between the insured and uninsured populations across the 13 states are unrelated to states' safety nets. The brief surmises, "The weakness of the safety net does not appear to worsen the uninsured's access to care. Conversely, a relatively strong safety net does not appear to improve their position relative to the uninsured" (Holahan/Spillman, "Health Care Access for Uninsured Adults: A Strong Safety Net Is Not the Same as Insurance," 1/02). The study is available online.