Health Care Access For Low-Income People: Significant Safety Net Gaps Remain

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Health Care Access For Low-Income People: Significant Safety Net Gaps Remain

Issue Brief No. 84 | June 2004 | Laurie E. Felland, Suzanne Felt-Lisk, Megan McHugh

Even as low-income and uninsured people's access to primary health care services showed signs of improvement, serious gaps persisted in specialty physician, mental health, and dental care, according to HSC's 2002-03 site visits to 12 nationally representative communities. Key factors driving these gaps included declining private physician and dentist participation in safety net care, shifts in funding and facilities, and growing numbers of people in need. Community leaders had developed a variety of creative strategies to expand specialty, mental health, and dental services but could benefit from greater state and federal policy support.

The Need for More Specialty, Mental Health and Dental Services

While many communities had expanded primary care services for low-income and uninsured populations in recent years, widespread problems existed in obtaining specialty, mental health, and dental care. Community health centers and local clinics primarily offered preventive and primary care, and hospitals often had limited capacity for mental health, outpatient specialty, and dental services. Many low-income people turned to private physicians and dentists, but access to these providers had been declining.

Health leaders in 10 of the 12 communities reported that low-income people had great difficulty obtaining specialty care, and observers in six communities said access had worsened over the preceding two years. Five specialties were cited repeatedly as particularly difficult to access: gastroenterology, orthopedics, cardiology, endocrinology, and dermatology. In Miami, patients reportedly waited months for specialty care at the county hospital. Mental health access surfaced as a significant problem in eight communities, with one respondent describing the mental health delivery system as "in shambles." Dental services were problematic in eight communities as well, with some patients facing two-year waits and emergency tooth extractions often being the only available option.

Why Gaps Persist

Several forces sustained these long-standing access gaps. Private physician and dentist participation in safety net care had declined -- nationally, the share of physicians providing charity care fell from about 76 percent in 1997 to 72 percent in 2001. Low Medicaid and SCHIP payment rates relative to commercial payments were cited as the biggest obstacle to provider participation, with administrative burdens as a secondary factor. Some communities reported specialist shortages, while others saw rising malpractice premiums as a contributing concern. State budget deficits had led to cuts in mental health and dental funding, with 29 states reducing mental health spending and several states eliminating or restricting adult dental coverage under Medicaid. Growing patient demand -- driven by immigration, unemployment, and expanded primary care capacity generating more referrals -- compounded the problem.

Communities Address Problems

While state-level efforts remained limited, many communities had developed systematic approaches to improve access. Community health centers in most HSC sites had added mental health and dental services, often funded through federal expansion grants, tobacco settlement funds, and other sources. Some free clinics recruited volunteer physicians and dentists to provide specialty sessions, though capacity remained limited. A few communities created formal volunteer networks, such as programs in Little Rock and Greenville where physicians agreed to see a set number of uninsured patients. In Indianapolis and Lansing, managed care programs linked uninsured people to established provider networks with payment mechanisms funded by a mix of federal, state, and local dollars. These strategies showed promise but faced persistent challenges in recruiting specialists and dentists.

Sources and Further Reading

Kaiser Family Foundation -- Employer Health Benefits Survey -- Annual data on employer-sponsored health insurance.

Health Affairs -- Peer-reviewed health policy research.

Robert Wood Johnson Foundation -- Health policy research and programs.

Commonwealth Fund -- Research on health care coverage.