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Safety Net is Really a Health Care Tightrope

Posted on: Wednesday, 17 August 2005, 12:00 CDT

Gov. Phil Bredesen has embarked on a dramatic effort to expand the health care safety net in a partial response to the elimination of TennCare coverage for more than 190,000 Tennesseans.

What is this "safety net"? Why does it exist?

The safety net in health care generally refers to groups or organizations that provide care for those who cannot access care in our mainstream, private health care system. Most often, this is because they do not have health insurance and cannot otherwise pay for the care they need. In our community the safety net is usually identified as the Regional Medical Center at Memphis, but in reality it includes a much broader range of hospitals, clinics and providers who deliver care for limited or no direct payment.

The role of a safety net in health care can be compared to the role of the safety net in a circus. All but the most daring high- wire performers and acrobats perform with a safety net under them. It is there for the single and crucial role of preventing harm in case of an accidental fall, and then to get the performer back up to the high wire as quickly and as safely as possible. A circus safety net is not intended to be used. Rather, the acrobats' goal is to enhance their skills so that the safety net will never be needed.

Are these the features of our health care "safety net"? Is it intended to provide urgent, short-term services to those who are normally cared for in our predominantly private health care system but who fall, accidentally and temporarily, from the mainstream?

The answer is clearly no. Our health care "safety net" is needed instead to provide ongoing care for those who cannot access our health care system because of its basic design.

More than 40 million Americans do not have health insurance, and most rely on our so-called "safety net" for routine as well as emergent care.

Thus, what we call a health care "safety net" is not, truly, a safety net, and we should not call it one. It is an intrinsic part of our fragmented health care system intended to be used routinely by a large portion of society who are poor, uninsured or otherwise unable to access other forms of private care. It is not, as in the circus, needed for only the rare (and, we hope, never occurring) misstep through an otherwise well-functioning system.

This distinction in terminology makes a difference in how we view the safety net. Referring to it as a safety net suggests that it requires minimal, very targeted support and resources to meet a very narrow need - and only when someone falls through the regular health care delivery system. Referring to it as an integral component of the health care system acknowledges that it deserves broad-based support to provide basic and emergent care to a large and, unfortunately, growing portion of the population that relies on publicly supported systems for all forms of health care.

Identifying these alternative health care systems as an integral part of our health care system also forces us to concede the shortcomings of our delivery and finance system. We do have a system that depends, by design, on public support and charity to provide basic and advanced services to a large proportion of our population. We do have a system that, at a minimum, tolerates a lower standard of care, as shown by worse health outcomes for those without health insurance who rely on this alternative delivery system.

By relegating this system to the role of a "safety net," in language if not in fact, we are hiding from the realities of our health system. Perhaps we should think of this system not as a "safety net" but as a tightrope, and realize that the people who rely on it are like acrobats who are tenuously balanced on a tightrope without a real safety net below.

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David M. Mirvis is director of the Center for Health Services Research at the University of Tennessee Health Science Center.

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Source: Commercial Appeal, The

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