Suburban Poverty and the Health Care Safety Net

Suburban Poverty and the Health Care Safety Net

HSC Research Brief No. 13
July 2009
Laurie E. Felland, Johanna Lauer, Peter J. Cunningham

While suburban poverty has grown over the past ten years, the supply of health care services for low-income and uninsured residents in these outlying areas has failed to keep up. A new study conducted by the Center for Studying Health System Change (HSC) in five metropolitan regions -- Boston, Cleveland, Indianapolis, Miami and Seattle -- reveals that low-income individuals residing in suburban communities encounter substantial obstacles when trying to obtain care, including insufficient public transit, language difficulties and limited knowledge of available health care resources. Low-income populations frequently depend on suburban hospital emergency departments (EDs) and safety net hospitals and health centers located in urban cores. Some city-based providers are experiencing growing pressure from treating rising patient volumes originating in both urban and suburban communities. Urban and suburban providers alike are working to steer patients toward more suitable care options closer to home by broadening primary care availability, enhancing specialist access, easing transportation obstacles, and securing funding to sustain safety net operations. Initiatives to strengthen safety net services in suburban locales are complicated by the wider geographic spread of the suburban poor and jurisdictional barriers related to safety net funding. To bolster the suburban safety net, policy makers might explore adaptable and focused service delivery models, regional partnerships to pool resources, and geographic concentrations of need when distributing funding for community health centers and other safety net programs and infrastructure.

Increased Suburban Poverty

The large-scale migration of affluent and middle-class households to the suburbs throughout the second half of the 20th century, which produced higher concentrations of impoverished residents in urban centers, has stalled and in some cases shifted direction in recent years. Although poverty levels in central city neighborhoods have tracked national patterns -- falling during the 1990s but ticking upward after 2000 -- poverty rates across suburban communities have risen consistently since 1990. Owing to faster population expansion and climbing poverty rates in suburban zones relative to central cities, suburban areas represented more than half of all impoverished individuals in major metropolitan regions by 2005, up from 46 percent in 1990.

Moreover, suburbs have grown increasingly diverse in cultural and ethnic composition. By 2000, over a quarter of suburban inhabitants were non-white, 10 percent were born outside the United States and roughly one in six suburban residents spoke a language besides English. Factors contributing to the growth of suburban poverty include: a renewed preference among well-off professionals for city living, which can drive up housing prices past what low-income families can manage; the dispersal of subsidized housing options; the relocation or growth of low-wage employment opportunities in suburban areas; and the departure of many middle-class families from older, inner-ring suburbs to wealthier, outer-ring, or exurban, communities.

Even as suburban poverty has climbed, the creation of social service programs to help those in need has lagged behind. One analysis determined that publicly funded or subsidized programs -- such as food assistance, workforce development and adult education -- are far less prevalent in suburbs experiencing rising poverty than in central-city neighborhoods. Comparable shortfalls have been documented for certain health care services, including mental health treatment, substance abuse programs and hospital care. Impoverished suburban areas have less hospital capacity than more affluent suburbs, and the most disadvantaged suburbs experienced the steepest decline in the number of hospitals across both urban and suburban areas between 1996 and 2002.

This research offers a community-level analysis of the suburban safety net: the health care providers and services accessible to low-income individuals in the suburbs. It is not restricted to those formally classified as poor, meaning those with incomes at or below the federal poverty level, or $22,050 for a family of four in 2009, since the income range of populations served by safety net providers is broader -- generally at least twice the federal poverty level. The study assessed five metropolitan areas -- Boston, Cleveland, Indianapolis, Miami and Seattle -- examining two suburban areas in each that showed increasing poverty rates (see Data Source). All five communities feature comparatively robust safety nets in their central-city cores, supported by long-established public funding.

While these five communities do not represent all metropolitan areas, conversations with health care providers in these locations yield valuable insights into the difficulties of delivering care to low-income populations in suburban settings and the interplay between urban and suburban safety nets. The five areas also vary in the demographic makeup of their low-income residents, the proximity of suburbs to central cities, and whether poverty in the suburbs has been a longstanding phenomenon or a more recent development (see maps).

Limited Suburban Safety Net

Throughout the five communities, interviewees noted that urban areas offer superior access to free or reduced-cost care for low-income individuals compared with suburban areas. Greater numbers and density of low-income and uninsured residents in cities have fostered more capacity and a wider selection of providers than is generally available in the suburbs. Safety net services in the central cities of the five communities are typically anchored by a major teaching hospital (either public or private not-for-profit), augmented by numerous outpatient primary care facilities, including not-for-profit community health centers (CHCs), religiously affiliated or other free clinics, and, in certain locations, local health departments.

Among the suburban areas examined, very few had a public safety net hospital. Instead, a local hospital (usually not-for-profit) typically filled that function either by organizational mission or by default. Some hospitals' safety net responsibilities are primarily confined to their emergency departments, and they may restrict access to additional services. Other hospitals provide a more comprehensive array of services for low-income patients.

For instance, the suburban areas of Indianapolis and Miami are served by religiously affiliated hospitals whose missions include treating patients regardless of their financial capacity. Yet, suburban hospitals do not always prioritize serving low-income populations. Access is reportedly harder at for-profit hospitals, and some urban hospital systems that expanded into suburban locations to capture higher-income patient populations likely did not anticipate encountering larger numbers of low-income patients. In one suburban area studied -- Beech Grove in suburban Indianapolis -- the hospital serving a critical safety net function is shutting down as the St. Francis Hospital system consolidates its operations at a location farther from the city center. Nevertheless, there are plans to maintain some outpatient health center services in Beech Grove.

Across all five communities, low-income suburban residents reportedly struggle to obtain preventive, primary and specialty care. While the suburban areas studied generally have an ample supply of private physician practices, respondents indicated that it is hard -- even more so than in urban settings -- to locate physicians willing to treat uninsured patients and those enrolled in Medicaid, which offers comparatively lower reimbursement rates than commercial insurers and Medicare. Identifying private specialists to see uninsured and Medicaid patients is particularly difficult. Health departments in these suburban counties tend to be quite small and seldom provide direct health care services. The suburbs studied typically have at most one CHC organization along with small free clinics and/or hospital outpatient clinics -- run by either suburban hospitals or urban safety net hospitals. CHCs and suburban hospitals generally offer limited specialty, dental and mental health services, and suburban residents frequently rely on the main urban safety net hospitals, particularly for highly specialized care. Likewise, county-run and other mental health or substance abuse services are more commonly situated in urban areas.

Given the shortage of accessible, prompt care in the community, suburban hospital emergency departments have emerged as a primary source of both routine and specialty care for low-income individuals, potentially even more so than for those residing in the central city. Homestead Hospital outside of Miami experienced a substantial rise in ED visits in recent years, which respondents attributed to the limited availability of primary care for uninsured and Medicaid patients in the area, along with convenience factors, including the hospital's new location adjacent to a highway and its 24-hour care availability. A suburban Seattle community hospital reported a similar pattern: "Many people come to our ED because they can't obtain care in the community. There are no free clinics. We don't have the same infrastructure they have in Seattle."

Escalating demand over the previous five years has imposed financial strain on numerous suburban hospitals and health centers. Growing charity care expenditures at Stevens Hospital in suburban Seattle have contributed to fiscal difficulties and postponed facility upgrades. And St. Francis Community Health Center in suburban Indianapolis has experienced a 35 percent surge in patient visits over the past five years, exceeding the center's limited capacity. Some suburban providers noted that much of the heightened demand comes from the so-called new poor -- higher-income individuals who have lost their employment and health coverage. Furthermore, respondents described many suburban working poor: people employed in low-wage positions that do not provide health insurance and who earn too much to be eligible for Medicaid or other subsidized coverage.

However, because suburban providers generally serve smaller shares of low-income patients compared with their urban counterparts, they are less likely to receive public funding for these services. They vie for general hospital and health center funding pools and do not benefit from separate geographic designations and funding channels like rural hospitals and rural health centers. Some suburban hospitals in the five communities receive Medicaid disproportionate share hospital (DSH) funding -- especially those in suburbs with longer-established low-income populations, such as Brockton, Mass. -- but few obtain support from other state or local sources to help cover care for the uninsured. Suburbs located in separate counties from the city center typically do not direct local revenues (e.g., property or sales tax revenue) toward the health care safety net, and suburbs within the same jurisdiction generally compete with urban safety net providers for available funding. In Massachusetts, for example, safety net providers are heavily dependent on federal and state funding due to the absence of municipal or county financial support.

Although federally qualified health centers (FQHCs) exist in some suburban areas, securing federal designation and funding remains a challenge. Community Health of South Dade, an FQHC in suburban Miami, tried to construct a new facility in the Kendall community but could not obtain a public or private grant because, despite pockets of poverty in the area, the Census tract as a whole does not demonstrate sufficient need. Consequently, many suburban providers depend on private grants and charitable donations to sustain their safety net role.

Suburban Access Barriers

Residing in the suburbs poses a range of additional challenges that impede low-income individuals' ability to receive timely, appropriate health care services, including: limited transportation options; insufficient cultural and linguistic competency among providers; lack of awareness of available services; and community resistance, though limited in scope.

Transportation: Nearly every respondent cited transportation as a major obstacle to receiving health care in the suburbs, where homes and providers are more spread out and patients must travel greater distances. Many low-income individuals lack personal vehicles and must depend on relatives, friends or public transit -- options that are frequently unreliable or inadequate. Bus and rail systems do not always extend to suburban areas, and those that do are usually designed around a hub-and-spoke model, offering routes from suburbs into the city but not between or within suburban communities. A CHC representative in suburban Indianapolis observed, "If it [a procedure or test] can't be done [at the closest hospital to the CHC], you can tell the patient's stress level rises." While Medicaid does offer some transportation assistance and FQHCs are mandated to provide or arrange for transportation services, these requirements are limited to the least expensive option (typically buses), which may not address a given patient's specific needs.

Transportation difficulties reportedly drove greater reliance on emergency departments for routine care, follow-up visits and tests. Because EDs provide around-the-clock care without requiring appointments, individuals can seek treatment whenever they manage to secure transportation. EDs also tend to be more reachable via public transit than other providers. Still, a handful of EDs across the five communities have noted increased ambulance usage in recent years, representing the costliest form of medical transport.

Cultural and Linguistic Competency: Even though the suburban areas studied have seen waves of immigrants -- Hispanic populations as well as people from diverse other regions -- suburban health care providers generally trail their urban counterparts in offering interpreter and language services and delivering culturally competent care -- care that recognizes an immigrant or other minority group's beliefs and preferences regarding medical consultations and treatments.

As an executive at a Boston urban safety net hospital noted, "We offer 18 languages onsite 24 hours a day. No other hospital in the state matches that level of cultural and linguistic competency." Suburban providers -- for example, those in Indianapolis working to address the language and cultural requirements of recent refugees from Myanmar (formerly Burma) -- find it challenging to recruit clinicians and other staff with the requisite skills and frequently do not treat enough patients from particular ethnic or language groups to sustain the necessary services. As a respondent from a suburban Seattle hospital explained, "Our populations are changing so rapidly and expanding. We're getting more and more people with much more diverse needs, so we're constantly reassessing what kind of services we're providing."

Lack of Awareness: Numerous low-income individuals, particularly those who have recently become uninsured or lost their jobs, reportedly do not know what services exist in the suburbs or may perceive facilities such as community health centers as being exclusively for the most impoverished uninsured and Medicaid recipients.

Some of the earliest county clinics in suburban Indianapolis had difficulty drawing sufficient patients, especially those with incomes above the poverty level who were not accustomed to utilizing safety net providers. A community assessment informed St. Vincent Indianapolis Hospital that low-income residents were frequently unaware of the hospital's services and that language issues represented a key barrier. In response, the hospital expanded its website and produced materials in multiple languages. Even so, discovering effective ways to publicize their services continues to be a challenge for suburban safety net providers. According to a suburban Cleveland CHC director, "We've conducted studies on what brings patients to us. Word of mouth is number one: family and friends encourage them to come to us." Even when low-income people are aware of safety net providers, they may not know about support services, such as transportation assistance, that are available to help them receive care.

Local Resistance: Most interviewees had not witnessed pushback from suburban residents against the establishment of services for low-income people, although Framingham, Mass., stands as an isolated but notable case of community opposition. In 2003, local residents opposed the development of an FQHC intended to deliver primary care primarily to Brazilian immigrants who were otherwise traveling to Boston or Worcester (over an hour away) to seek health care. Opponents contended the center would draw more impoverished people to the town and obstruct business development.

As one interviewee put it, "[Residents] saw their town develop and now they see [the poverty] they tried to escape from in Boston in their backyards." Although the local planning board initially rejected the health center proposal, three small sites were constructed that did not require board approval, and a subsequent lawsuit permitted the building of a larger freestanding facility. Respondents indicated that the feared wave of low-income arrivals from other areas had not materialized.

Urban Safety Nets Feel Strain

Several urban safety net providers across the five communities reported a rise -- monitored through patients' zip codes -- in patients coming from suburban locations, adding further strain to already overburdened and financially stretched urban providers. Suburban patients seeking care from urban safety net providers frequently need hard-to-access services, including specialty, dental and mental health care. Roughly 16 percent of patients at Codman Square Community Health Center in Boston reside in the suburbs, compared with approximately 6 percent a decade earlier. Although some urban safety net hospitals reported minimal demand from suburban patients, none observed an overall decline in combined urban and suburban patient volumes that would suggest a net migration of low-income patients and demand for care to outlying areas.

Urban county hospitals in Cleveland, Seattle and Indianapolis have identified growing numbers of low-income individuals traveling from outlying areas for care. MetroHealth System in Cleveland, which is reportedly fairly easy to reach from the suburbs, receives substantial county funding to support indigent care and provides a sliding-fee scale for low-income patients. As a result, many suburban low-income individuals both within Cuyahoga County (Cleveland) and in surrounding counties seek care there or are referred. A respondent from a suburban Cleveland hospital remarked, "If someone [a low-income patient] became expensive and needed specialist services, [the county hospital] is where they [suburban providers] effectively shift everyone to."

Because many of the suburban patients funneled to these urban county hospitals originate from different counties, the urban hospitals are challenging the insufficient support from other jurisdictions for safety net services. They maintain that counties should fund their own providers to care for these patients, that not-for-profit hospitals are obligated to deliver community services in return for their tax-exempt status, and that some referrals or transfers are not in the patient's best interest.

In response, MetroHealth adopted a policy to no longer accept non-emergent patients from outside Cuyahoga County, while the county hospital in Seattle, Harborview Medical Center, has partnered with the state hospital association and suburban hospitals to curb referrals of low-income suburban patients. According to a Seattle respondent, "As the safety net hospital for our county, [Harborview] has quickly become the safety net hospital for the entire state. We've really had to push back. It wasn't uncommon to get patients from 100 miles away with a nice letter from their physician saying the person lost their insurance and they can't care for the patient anymore."

Stretching and Improving the Suburban Safety Net

Urban and suburban providers alike are striving to enhance the availability of health care services for low-income suburban residents. Their motivation is twofold -- an organizational mission or commitment to improving access, and a desire to promote appropriate utilization of services. Key strategies include: expanding primary care capacity; decreasing reliance on emergency departments; improving access to specialists; reducing transportation challenges; and generating revenue by pursuing higher-income patients.

Expand primary care capacity. Among the five communities, only in Miami has the primary safety net hospital -- Jackson Health System -- opened new hospitals in suburban areas in recent years. Instead, urban and suburban hospitals, together with health centers, have concentrated on growing primary care capacity. Many suburban CHCs have enlarged their existing facilities, increased staffing and extended clinic hours to include evening and weekend appointments, which are especially valuable for employed, low-income patients who commute to the city. Indeed, respondents noted that people tend to seek health care near their residence rather than near their place of work. Health centers have also introduced specific services, including dental and mental health care, and are working to recruit clinicians and interpreters whose languages and cultural backgrounds match those of their patient populations.

Some urban and suburban CHCs are also constructing new facilities. Sea Mar Community Health Centers, an FQHC in the Seattle area, recently opened two new locations in the southern suburbs. Some of these new clinics are designed to serve particular racial and ethnic minority groups. Wishard Health Services in Indianapolis has partnered with St. Vincent's Indianapolis Hospital to establish a clinic for the growing suburban Hispanic population. Wishard operates and staffs the Pecar Health Center with Spanish-speaking personnel, while St. Vincent's provides in-kind support, including services and products (e.g., cribs and car seats) that encourage women to obtain prenatal care.

However, CHCs frequently concentrate their expansions within relatively confined geographic areas to avoid overextending themselves, competing with other health centers, or facing financial shortfalls if they locate in areas without a substantial Medicaid population base (for which FQHCs receive enhanced reimbursement).

Decrease reliance on emergency departments. While many suburban hospitals are expanding ED capacity to address immediate demand -- both Brockton Hospital in suburban Boston and Highline Medical Center in suburban Seattle are doubling the size of their EDs -- they are simultaneously working to improve primary care access and alleviate pressure on their emergency departments. Hospitals in suburban Indianapolis and Boston have established primary care clinics, and Brockton Hospital acquired a primary care physician practice to deliver follow-up care to uninsured patients. Several hospitals support CHCs and free clinics by providing direct funding, physical space, supplies, services (such as laboratory and radiology) and personnel (even grant-writing assistance and management in some instances) rather than assuming the capital and operating costs required to open their own clinics.

Part of the effort to redirect patients away from the ED involves collaborating with providers and patients to raise awareness of primary care alternatives. St. Francis Neighborhood Health Center in suburban Indianapolis discovered that private-practice physicians and ED physicians were seeing non-urgent patients multiple times before realizing they could refer them to the CHC. In the Miami suburbs, Homestead Hospital and Community Health of South Dade cooperate to tackle this issue: the hospital provided a grant to the CHC to offer after-hours appointment availability and distributes brochures in the ED to notify patients about follow-up care options at the health center.

Improve access to specialists. Some urban safety net hospitals are working to place specialist physicians at suburban hospitals and health centers on a regular schedule to improve access and lower the missed-appointment rate. As a Jackson Health System representative in Miami explained, "In specialty clinics, there's still a no-show rate greater than 30 percent. So we're always looking at ways to improve compliance. And sometimes it's a matter of taking the care to the people, or being more flexible and adjusting our hours and days of operation." Jackson is also hiring additional physicians to treat uninsured individuals under its charity care policy. Similarly, some suburban health centers are collaborating with urban medical and dental schools to create training opportunities for students who, in return, provide patient care at the health center.

In certain communities, safety net providers are recruiting physicians, especially specialists, in suburban areas to volunteer to treat a designated number of uninsured patients in their own practices through programs typically coordinated by local medical societies, commonly known as Project Access programs. Harborview Medical Center in Seattle has engaged suburban private physicians in this manner as part of its initiative to transition the care of low-income patients back to the communities where they reside.

Reduce transportation challenges. Providers are working to establish more dependable and direct transportation options for patients. Health centers in suburban Miami, for example, operate a van service linking their facilities to the Jackson Health System. MetroWest Medical Center in Framingham, Mass., collaborated with a community bus line to improve transit access to and from its hospital.

Additionally, provider and community initiatives to bring specific services directly into low-income neighborhoods have emerged, particularly in Miami and Seattle, which cover relatively large geographic areas with scattered pockets of low-income residents. In the Miami-Dade County area, Jackson Health System, the health department and CHCs run mobile services for medical screenings and dental care. The King County (Seattle) Health Department is deploying mobile vans to serve homeless populations. King County is also developing school-based clinics in suburban schools, and Miami-Dade County has launched an extensive effort to introduce school-based health services in all of its schools -- urban and suburban -- funded through a property tax assessment for children's services approved by voters in 2002.

Generate revenues by pursuing higher-income patients. Because poverty and affluence frequently coexist in suburban areas, some urban safety net hospitals' expansion of services into suburban locations reflects a dual strategy to broaden access for low-income individuals while also attracting higher-income, well-insured patients, who help cross-subsidize care for low-income patients. This was one impetus for MetroHealth in Cleveland to open suburban primary care centers and for Jackson Health System in Miami to extend hospital services into suburban areas.

Broad Community Strategies Lacking

Beyond the efforts of individual urban and suburban providers to enhance access, there is scant broad community or regional collaboration aimed at strengthening the suburban safety net across the five communities. Some community planning organizations and coalitions are investigating suburban poverty as part of wider initiatives to improve access to care for low-income populations.

For instance, the Marion County Health Department in Indianapolis has worked with area hospitals to carry out a needs assessment and to coordinate community benefit activities that address gaps in care. And CHCs in some locations are collaborating with one another, often through regional CHC consortiums. CHC partnerships are underway in Seattle to expand obstetrical/gynecologic and prenatal care in suburban areas and, in Miami, to develop a shared electronic medical record across the area's CHCs, health department and county hospitals, which could help facilitate and coordinate care between suburban and urban providers.

Policy Implications

Growing numbers of low-income individuals in suburban areas -- including the "new poor" who have lost their employment and health insurance -- point to an expanding need for a suburban health care safety net. In particular, improving the availability of outpatient primary and specialty care in suburban communities may reduce utilization of expensive emergency departments for non-urgent needs or urgent circumstances that could have been prevented through more timely access to care.

Nevertheless, because suburban poverty is frequently dispersed, constructing a comprehensive system independent of the urban safety net may be neither practical nor cost-effective in many suburbs, particularly since low-income groups will continue relocating to new areas. Instead, state and local governments and community organizations could enhance access to appropriate care by subsidizing services through existing providers; supporting more targeted and adaptable approaches to delivering services where people live, for example, through school-based clinics and mobile vans; and addressing transportation needs. Moreover, because low-income individuals are often largely unseen in suburban areas, wider efforts to increase awareness of available services could help improve access. The suburban safety net could also benefit from urban and suburban policy makers paying closer attention to how funding is distributed and other barriers to expanding access across county lines and other jurisdictions. Establishing regional alliances could enable urban and suburban areas to share resources and develop networks of care that span jurisdictional boundaries.

Although national health reform could improve access to insurance coverage and care for low-income individuals regardless of geographic location, designated safety net providers will likely continue to be essential in areas with large concentrations of low-income people. Such providers readily accept patients with public insurance and possess expertise in serving vulnerable populations, including offering translation services for patients with limited English proficiency, culturally appropriate care, transportation and other support services.

Indeed, the federal government demonstrated strong support for sustained community health center funding through the American Recovery and Reinvestment Act of 2009, which included grants for 126 new health center sites and to support increased demand for services at existing FQHCs. As federal, state and local policy makers weigh future funding for safety net facilities, they could examine ways to refine how medically underserved areas and populations are identified and selected for federal funding to ensure that significant concentrations of low-income individuals in otherwise higher-income areas are not overlooked.

Notes

1. U.S. Census Bureau, "Historical Poverty Tables," available at http://www.census.gov/hhes/www//poverty/trends.html.

2. Berube, Alan, and William H. Frey, A Decade of Mixed Blessings: Urban and Suburban Poverty in Census 2000, Brookings Institution, Washington, D.C. (2002); Berube, Alan, and Elizabeth Kneebone, Two Steps Back: City and Suburban Poverty Trends 1999-2005, Brookings Institution, Washington, D.C. (December 2006).

3. Berube and Kneebone (2006).

4. Andrulis, Dennis P., and Nadia J. Siddiqui, "Health Insurance Coverage Reform: Implications for Improving Access in Suburban America," presentation before the Institute of Medicine (Sept. 23, 2008).

5. Murphy, Alexandra K., "The Suburban Ghetto: The Legacy of Herbert Gans in Understanding the Experience of Poverty in Recently Impoverished American Suburbs." City & Community, Vol. 6, No. 1 (2007).

6. Andrulis and Siddiqui (2008).

7. Puentes, Robert, and David Warren, One-Fifth of America: A Comprehensive Guide to America's First Suburbs, Brookings Institution, Washington, D.C. (2006).

8. Allard, Scott W., Access to Social Services: The Changing Urban Geography of Poverty and Service Provision, Brookings Institution, Washington, D.C. (August 2004).

9. Ibid.

10. Andrulis, Dennis, and Lisa Duchon, "The Changing Landscape of Hospital Capacity in Large Cities and Suburbs: Implications for the Safety Net in Metropolitan America," Journal of Urban Health, Vol. 84, No. 3 (2007).

11. Andrulis and Siddiqui (2008).

Data Source

The five study communities -- Boston, Cleveland, Indianapolis, Miami and Seattle -- were drawn from the 12 nationally representative Community Tracking Study (CTS) sites. Combining data from the 1990 and 2000 Census with the 2006 American Community Survey, maps were generated for each of the 12 CTS sites showing the percentage of the population below the federal poverty level, with assistance from Social Explorer software (available at www.socialexplorer.com) and the U.S. Census Bureau website. Using these maps along with data collected during the 2007 CTS site visits, five sites were chosen that appeared to have substantial or expanding areas of suburban poverty. From a demographic data standpoint, there is no formal definition of a suburb; two areas within each metropolitan statistical area but outside the center city were identified that appeared to have elevated or increasing poverty rates. These selections were validated qualitatively through a brief interview with a health care expert in each community. Between July and December 2008, a total of 60 telephone interviews were conducted in the five communities with representatives of urban and suburban hospitals playing a safety net role, community health centers and clinics, local health departments, and other informed observers. A two-person research team conducted each interview, and notes were transcribed and jointly reviewed for quality and validation purposes. The interview responses were coded and analyzed using Atlas.ti, a qualitative software tool.

Funding Acknowledgement

This research was funded by the Robert Wood Johnson Foundation.

Sources and Further Reading

The U.S. Census Bureau maintains comprehensive data on poverty rates and income thresholds across metropolitan and suburban areas. Their statistics on suburban poverty trends informed much of the demographic analysis in this research brief. For current poverty data, methodology, and geographic breakdowns, visit the Census Bureau Poverty page.

Federally qualified health centers are a central component of the safety net discussed in this brief. The Health Resources and Services Administration oversees the Health Center Program, which sets eligibility standards and operational requirements for FQHCs serving underserved populations. Details on program eligibility and procedures are available through HRSA's eligibility procedures page.

The rate of uninsured individuals in suburban communities is a key factor driving demand for safety-net services. The Kaiser Family Foundation tracks insurance coverage gaps, Medicaid enrollment, and the characteristics of uninsured populations across different geographies. Their ongoing research and data tools are accessible at the KFF Uninsured topic page.

The Robert Wood Johnson Foundation has long supported research into how poverty, geography, and health care access intersect. Their grant-funded studies on safety-net capacity and health disparities in suburban settings provide important context for the challenges described in this brief. Explore their library of reports and policy analysis at rwjf.org.

The Commonwealth Fund produces research on health system performance, insurance coverage, and access to care for vulnerable populations. Their work on safety-net providers and the broader health care infrastructure offers additional perspective on the suburban coverage gaps addressed here. Visit commonwealthfund.org for their full collection of publications on health care access and equity.