• M Susan Marquis, Jeannette A Rogowski, and José J Escarce.
• RAND, Arlington, Virginia, USA. susanm@rand.org
• Med Care. 2004 May 1; 42 (5): 408-15.

BackgroundPolicymakers and researchers are concerned that changes in the healthcare market have stressed and weakened the safety net nationwide.ObjectivesThe objectives of this study were to investigate variations in the safety net across communities and over time and to explore the effect of market changes on the safety net.Materials And MethodsWe examined the safety net in all large urban communities from 1993 to 1998. Data from a variety of sources measure uncompensated hospital care, local government spending for health, admissions to safety net hospitals, visits to outpatient departments of safety net hospitals, visits to community health centers, and demographic and market characteristics of the communities. Descriptive analyses examine trends and community variations. Multivariate methods are used to estimate the effect of market structure and of economic factors on the safety net.ResultsThe safety net did not erode in urban areas over the study period. There was substantial variation across communities, but the disparity did not increase over time. HMO penetration and hospital competition are not significantly related to variations in the safety net, although demographic and economic factors are.ConclusionsLocal financing capacity is a factor in variations across communities in the safety net. The economic downturn and pressures on state budgets could lead to future problems.

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