In the King County Health Action Plan's January 2000 report, Finding the Balance Points, we wrote the following about threats to the Health Care Safety Net:

It cannot be assumed that today's safety net delivery system will necessarily be tomorrow's. The way the health care safety net has been developed with a policy decision here, grant funding there, a funding allocation requiring annual renewal, etc., the safety net is vulnerable to losing funding sources and creating gaps in services. In addition, a political climate which favors downsizing government, limiting government spending, and balancing government budgets raises questions regarding the funding streams traditionally relied upon by safety net providers.

If possible, these words resonate even more truly today than when they were written over a year ago. According to the Institute of Medicine, the health care safety net is "intact but endangered." However, many state and local policymakers responsible for assuring access to health care services for the poor and vulnerable, and providers on the frontline of delivering these services are concerned that the safety net is far more endangered than it is intact. In the context of rising numbers of both uninsured and underinsured, impacts of mandated Medicaid managed care, and erosion of subsidy dollars, the already fragile network of safety net providers, special programs, and financing mechanisms that constitute the health care safety net, are increasingly stretched to meet the challenge.

At a recent meeting of the Action Plan's Steering Committee, Scott Barnhart, Medical Director for Harborview Medical Center, discussed his organization's concerns about the disintegration of the health care safety net in King County and asked the Action Plan Steering Committee to convene a regional dialog regarding this problem. Some of the concerns brought to the table were:

• Public hospitals are seeing increasing numbers of individuals with Medicaid or no health insurance (Harborview has been running at 97% capacity) with razor thin margins
• Medically indigent funding not in the Governor's Budget
• Reduction of mental health funding for King County and overall
• A growing gap in Medicaid reimbursement and cost of services
• Community Health Clinics seeing increasing numbers of uninsured
• UW and Swedish/Providence and other hospitals all running close to the financial edge
• Public Health dealing with cuts from Initiatives
• ER's are busier and feeling increases due to shortages in public care

The Action Plan sub-committee on the health care safety net will use the following list of "to dos" as a point of departure for their initial discussions and work:

• Map the fraying of the safety net and document effects that are being felt by consumers and providers
• Identify core system changes that need to occur to strengthen the safety net
• Explore ways in which social marketing can be employed to raise public and policymakers' awareness of the effects of a disintegrating safety net
• Explore issues around FQHC funding streams, lack of access to specialty care, and develop solutions to pilot locally
• Engage the provider community in the exploration of alternative short term mitigating approaches to the provision of safety net services
• Develop a contingency plan for worsening trends that appear to be on the horizon

It is expected the sub-committee will meet four to five times over the next six months.

According to the Institute of Medicine, the national health care safety net is "intact but endangered." Our local problems are compounded by Washington State's current fiscal challenges. As health costs increase along with the demand for coverage, state funding sources are unable to keep pace. Low reimbursement rates are causing King County safety net providers to stop serving the uninsured and Medicaid population. PacMed, one of the region's largest safety net providers has had to reduce services in order to respond to fiscal losses. The anticipated lay-offs at Boeing threaten to increase the number of uninsured in the area, applying additional pressure to King County's safety net system.

Members of the King County Health Action Plan Steering Committee formed a subcommittee to address these concerns and develop recommendations to strengthen the safety net system. Key providers from community clinics and hospitals were invited to participate in subcommittee discussions. Through this community dialogue specialty care referral data has been analyzed to identify system gaps and three pilot projects have emerged as having the potential to reinforce the safety net services in King County. These three pilot projects are:

• Pac Med has enthusiastically committed to participate in a GI Specialty Referral Pilot Project utilizing CHAP. This pilot is in the process of being implemented and will focus on specialty referrals for GI from four Puget Sound Neighborhood Health Center clinics and one Public Health clinic to participating specialty group practices and provide support for patients, clinics and providers by working to decrease no show rates and to provide wrap around services such as pre-visit preparation and interpretation.
  
  
• Pursue ways to "systematize" referrals for Primary Care within the Safety Net network of provider clinics. Openings for Primary Care referrals among the clinic members of the Community Health Council would be maintained and updated by CHAP, as a source of current information, so that referrals to needed health care homes within the community would be readily updated and available at a central source. A baseline of how far out clinics are currently booked will be established as a point of reference for an anticipated increase in demand as cuts from Olympia are felt in the community and Emergency Room Departments are flooded.
  
  
• Organize the specialties within and among the member Community Health Council clinics to create a shared "internal specialty/expertise capacity." This would allow those physicians who are known to be keen in certain areas to become available to train and "grow" the expertise of others within the Community Health Care system. This idea could also develop into a "rotation" system in some specialties e.g. Ortho., Derm., and GI. This pilot will be of great assistance in helping to decompress the flooding of patients at Harborview Medical Center.

• Develop a new community-based specialty care clinic with public and private Foundation assistance to respond to the increasing referral needs of community health centers, Public Health and community clinics. This could initially be staffed by rotating volunteer specialty doctors but to assure continuity of care would need to evolve into providing a more stable contingent of practitioners.
  
  
• By targetting one specialty area such as dermatology, (which would require a minimal number of visits and equipment), create and pilot loaned physician planned visits to community health centers and clinics. With this "circuit rider" approach, specialty physicians could establish a contract with community clinics for a given number of hours that they would regularly be on-site to see patients. This on site approach could decrease the no show rate and allow for services such as interpretation to be arranged for locally.