Emperor of the Empire

Abstract

T he Covid-19 pandemic has been a crucible for the U.S. health care system, particularly for the safety-net hospitals, community health centers, and independent clinicians who provide a lifeline for underinsured and un-insured people. Despite facing immeasurable strain in the past year, the safety net has played an essential and often innovative role at the intersection of health care, public health, and emergency response. As we enter a new stage of pandemic response and recovery in which we must address issues of racial health inequities, frontline health care infrastructure , and community preparedness the country faces questions about what constitutes adequate support for the safety net, both immediately and over the longer term. The challenges encountered by all health systems during the pandemic were compounded in safety-net systems, given their central role in serving the low-income communities hit hardest by Covid-19. Although many emergency and inpatient settings were overwhelmed by Covid-19 cases, in several regions, safety-net hospitals serving predominantly Medicaid-insured and uninsured populations cared for the preponderance of patients with Covid-19. In a system already stretched thin by prepandemic payment cuts, hospital closures, and bare-bones staffing infrastructure, this added strain has had chilling implications for patient outcomes and has resulted in higher mortality in safety-net hospitals than in other facilities. 1 In addition, safety-net systems faced greater financial, workforce, and technological pressures than other systems. The suspension of profitable services, the transition to telehealth, and inadequate access to federal emergency funding were felt especially acutely by safety-net providers that had historically slim margins and minimal cash reserves. 2 The trauma experienced by the health care workforce was compounded in safety-net institutions, whose staff members often come from the communities they serve, which were disproportionately affected by the pandemic; this resulted in increased rates of burnout and staff turnover. Though most safety-net hospitals have weathered the pandemic, these strains have led to closures of many community-based independent practices that had served as key access points for immigrant and Black and Latinx communities. Even as the pandemic exposed