The evolution of support for safety-net hospitals.

The federal government, mostly through the Medicare and Medicaid programs, has created and maintained a set of structural mechanisms to support uncompensated care and clinical education: disproportionate-share hospital payments and direct and indirect graduate medical education payments. This paper provides a history of how these traditional supports have evolved. We note that the need to reduce federal and state spending threatens the level of these payments, while changes in the health care delivery system highlight a range of design and technical inadequacies in the current support mechanisms.

What types of hospitals form the safety net?

This analysis describes hospitals that provide large amounts of uncompensated care and hospitals with sizable teaching programs, using data from the American Hospital Association. Despite current public financial support mechanisms, safety-net hospitals have a lower average total margin and a greater percentage with negative total margins than other groups of hospitals. For graduate medical education, however, the current public financial supports have assisted teaching hospitals with the largest training programs in maintaining their financial viability, although teaching hospitals' average total margins remain below those of nonteaching hospitals.

Preserving the mission.

Teaching hospitals and medical schools are changing with the times, but the authors argue that other players in the delivery system--government, insurers, hospitals, and health systems--must share in the effort to preserve the nation's medical education and research infrastructure.