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OBJECTIVES

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Objectives

  • Describe the core functions of health-care financing.

  • Explain how health-care financing may be tailored to address the challenges that vulnerable populations face.

  • Describe the provisions in the Affordable Care Act and how they affect the financing and organization of health care.

  • Describe the types of providers that constitute the safety net.

  • Explain why the organization and financing of the health-care safety net does not adequately meet all the health needs of vulnerable populations.

  • Articulate the arguments for increasing the numbers of primary care safety net providers to improve the access for vulnerable populations.

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INTRODUCTION

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John Walsh is a 56-year-old man with essential hypertension and type 2 diabetes. Since being laid off from full-time work, Mr. Walsh and his dependents, a wife and two children, were left without insurance. Neither of his part-time jobs, as a security guard and a deliveryman, offered any health insurance benefits.

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Mr. Walsh and his family members have slipped through the cracks of a fragmented system of health-care insurance coverage. The United States has lagged behind almost all developed nations in establishing universal health-care coverage. In 2013, there were approximately 40 million uninsured people in the United States.1 The majority of the uninsured live in households with at least one full-time working adult.2 Absence of insurance creates obstacles to obtaining health care in a timely way. Without a means to pay, patients forgo necessary health services resulting in worsening health.

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In 2010, President Obama signed into law the Affordable Care Act (ACA). The ACA establishes an individual mandate for health insurance coverage and has numerous provisions to assist low-income individuals with financing to obtain health insurance. Nonetheless, the ACA has not removed all barriers to health care, nor has it resulted in universal coverage for Americans. The high costs of care and the dearth of providers serving vulnerable populations are persistent and substantial challenges.

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A safety net system exists to care for those who face barriers in access to care, such as Mr. Walsh. The safety net is a geographically variable patchwork of providers available to care for individuals with barriers to care, such as a lack of insurance or those residing in a community that is medically underserved because of an inadequate supply of practitioners. Individuals with low family income, minority status, rural residence, limited English proficiency, and poor health status are more vulnerable to not receiving needed health care, and when they do obtain care, they are more likely to receive it from safety net providers. Even in nations with universal financial coverage, safety net programs often exist to address the needs of populations with special access challenges, such as the homeless, recent immigrants, and residents of remote rural regions.

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The financing and organization of the health system are the starting points for understanding how health care is delivered to populations. No health system ...

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