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Posted to Web: April 01, 2001

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National policy makers focus on insurance coverage from a national perspective—expanding it (or not) or re-engineering it (or not), noted this article on gaps in insurance and emerging options in safety-net systems. Interest in promoting insurance for all has for the moment waned, though the number of uninsured Americans has generally increased for over a decade. The ultimate backstop for uninsured access is the local safety net, dominated by hospitals and clinics with a mission to serve the underserved. Federal policy mandates limited hospital access to emergency hospital care, but only indirectly influences general provision of care. General safety net access is left for local provision of care and, usually, local funding. Insurance policy, public and private, is pressuring the hospital-based safety net through payment cuts and managed care shifts in patterns of delivery. Some localities are experimenting with new organizational arrangements. Their experience suggests some policy options for the twenty-first century. The safety net ought to get more policy attention at higher levels of government. (Journal of Legal Medicine 2001 April; 22(2): 247-262).

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