The Importance of Community Safety-Net Hospitals

Safety-net hospitals come in all sizes and shapes:  they’re large and small, urban and rural, public and private.  Some are freestanding and independent, some are part of health systems, and others belong to academic medical centers.  They can be found in all 50 states.

What safety-net hospitals have in common, regardless of how big they are or where they are located, is that they serve areas where especially high proportions of the residents are socially, economically, and medically vulnerable.  Many of these residents are insured by Medicaid, if they’re insured at all, and most are challenged by one or more social determinant of health.

Policy-makers increasingly are concluding that the obstacles created by these social determinants of health require public policies designed to tackle those social determinants while ensuring that those who face them have fair and equitable access to health care.  These conclusions have been brought into new, bold relief by the battle against COVID-19, which has starkly illuminated the challenges the medically vulnerable face – and the challenges safety-net hospitals face when striving to meet their health care needs.

That last part is important:  any attempt to address the social determinants of health and better serve the medically vulnerable needs to begin by identifying as safety-net hospitals those facilities that actually serve meaningful numbers and proportions of the medically vulnerable.  For many years these hospitals have been hamstrung by underinvestment, a paucity of commercially insured patients, inadequate Medicaid payments, and large numbers of uninsured patients, and as a result they have struggled to meet the challenges they face every day.

As the leading voice for community safety-net hospitals, the National Alliance of Safety-Net Hospitals has long championed the needs of community safety-net hospitals and has plunged headfirst into the current discussion about how to define such hospitals because these hospitals are vital community partners in efforts to address the social determinants of health and pursue health equity.  When the new congressional Social Determinants of Health Caucus issued a request for information, NASH submitted a detailed, substantive response that drove to the heart of the challenges community safety-net hospitals face.  When MedPAC began its discussion on the question of what makes a provider a safety-net hospital, NASH wrote to the commissioners with our own proposed data-driven methodology for identifying such hospitals.

At the heart of the NASH methodology for identifying community safety-net hospitals is to look not at individual hospitals and consider what kinds of patients they serve but to identify vulnerable communities and then zero in on the hospitals that are caring for meaningful proportions of their residents.  We believe this approach will offer a new, better way of determining where to direct the federal resources needed to address health equity and the social determinants of health.

In the future we’ll share more about community safety-net hospitals:  what they are, what they do, and what they need.  For now, though, we maintain that any effort to better serve the medically vulnerable and mount a successful fight against the effects of social determinants of health must better arm safety-net hospitals for that fight and that doing so must begin with identifying which of the more than 5000 hospitals in the U.S. are truly safety-net hospitals.

We’ll share more about these issues again soon.  Happy new year!

Ellen Kugler, Esq.

Executive Director

MedPAC Meets

The government agency that advises Congress on Medicare payment matters met publicly in Washington, D.C. last week.

During the virtual meeting, members of the Medicare Payment Advisory Commission discussed and debated future Medicare payments for:

  • hospital inpatient services
  • hospital outpatient services
  • physician services
  • ambulatory surgical center services
  • outpatient dialysis
  • hospice care
  • skilled nursing facilities
  • home health
  • inpatient rehabilitation facilities
  • long-term-care hospitals

MedPAC is an independent congressional agency that advises Congress on issues involving Medicare.  While its recommendations are not binding on either Congress or the administration, MedPAC is highly influential in governing circles and its recommendations often find their way into legislation, regulations, and new public policy.  Because so many patients of community safety-net hospitals are insured by Medicare, MedPAC’s deliberations are especially important to those hospitals.

For a look at the agenda for the two-day meeting and to find the presentations for each of these subjects, go here.

NASH Asks Congress to Block Medicare Sequestration Cuts

Stop the looming Medicare sequestration cuts, NASH asked in a message it sent to members of Congress on Tuesday, December 7.

The cuts – a resumption of the long-time two percent Medicare sequestration and an additional four percent sequestration cut necessitated by federal PAYGO rules – would pose a problem for community safety-net hospitals that still find themselves caring for significant numbers of COVID-19 patients amid rising costs, supply chain challenges, and rising personnel costs and labor shortages.

Go here to see NASH’s message to Congress.

Federal Health Policy Update for Tuesday, September 21

The following is the latest health policy news from the federal government as of 2:45 p.m. on Tuesday, September 21.  Some of the language used below is taken directly from government documents.

NASH Advocacy

  • NASH has submitted formal comments to CMS on the agency’s proposed outpatient prospective payment system regulation for calendar year 2022.  Writing from the perspective of private community safety-net hospitals, NASH addresses proposals and request for information about health equity, the section 340B prescription drug discount program, hospital price transparency requirements, proposed changes in Medicare’s inpatient-only procedures list, and the extension of provider flexibilities introduced in response to the COVID-19 public health emergency.  See NASH’s comment letter here.
  • In July the newly formed Congressional Social Determinants of Health Caucus invited stakeholders to respond to a series of questions designed to help the caucus learn more about social determinants of health and what Congress might do to address them more effectively.  Go here to read NASH’s response to the caucus’s questionnaire.

Provider Relief Fund

  • HHS has updated its Provider Relief Fund reporting portal’s frequently asked questions.  Find the updated FAQ here.
  • HHS has published a Provider Relief Fund reporting portal user guide.  Find the guide here.

The White House

Department of Health and Human Services


  • The federal government has responded to recent increases in COVID-19 cases by assuming control of the distribution of monoclonal antibodies used to treat the virus.  Learn more from the announcement of this new approach.  Federal officials also explain the new policy, why they are pursuing it, and how it will work in this video of a web event.

Health Policy News

  • HHS has extended the open enrollment period for people seeking health insurance on the federally facilitated marketplace and has extended the scope of services provided by navigators for that marketplace.  The department also has authorized state marketplaces to set their own open enrollment dates.  Learn more from this HHS news release.
  • HHS and its Health Resources and Services Administration (HRSA) have awarded $48 million to 271 HRSA-supported health centers in 26 states, Puerto Rico, and the District of Columbia to expand HIV prevention and treatment, outreach, and care coordination services.  To learn more about the awards, how the money will be used, and the award recipients, see this HHS announcement.
  • HHS and HRSA have awarded $350 million in grants to every state to support safe pregnancies and healthy babies.  Funding will be used expand home visiting services to families most in need, increase access to doulas, address health disparities in infant deaths, and improve data reporting on maternal mortality.  The money is being awarded through the Maternal, Infant, Early Childhood Home Visiting Program, the Healthy Start Initiative, and the State Systems Developmental Initiative.  To learn more about how HHS intends for the money to be spent, how much money is being allocated through these programs, and how much money individual recipients will receive, see this HHS announcement.
  • HRSA has announced the availability of funding to support continued access to comprehensive, culturally competent, high-quality primary health care services for communities and populations currently served by its Health Center Program.  Eligible organizations include domestic public or non-profit private entities that propose to serve an announced service area and its associated population(s) to ensure continued access to affordable, quality primary health care services.  Learn more from this HRSA announcement.

Centers for Medicare & Medicaid Services


Health Policy News

  • The latest edition of the CMS online publication MLN Connects includes Medicare’s quarterly provider quality compliance newsletter and information about annual HPSA updates, flu vaccine payment allowances, updated clinical lab fees, and more.  Find the September 16 edition of MLN Connects here.
  • CMS has posted a pre-publication version of a final rule that sets forth revised 2022 user fee rates for issuers offering qualified health plans (QHPs) through Federally-facilitated Exchanges and State-based Exchanges on the federal platform; repeals separate billing requirements related to the collection of separate payments for the portion of QHP premiums attributable to coverage for certain abortion services; expands the annual open enrollment period and Navigator duties; implements a new monthly special enrollment period for qualified individuals or enrollees, or the dependents of a qualified individual or enrollee, who are eligible for advance payments of the premium tax credit (APTC) and whose household income does not exceed 150 percent of the federal poverty level, available during periods of time during which APTC benefits are available such that certain applicable taxpayers’ applicable percentage is set at zero, such as during tax years 2021 and 2022 under the section 9661 of the American Rescue Plan Act of 2021; repeals the recent establishment of a Direct Enrollment option for Exchanges; and modifies regulations and policies related to section 1332 waivers.  Find the document here.
  • CMS has published three FAQs that explain that the agency will not take enforcement action against certain payers for the payer-to-payer data exchange provision of the May 2020 Interoperability and Patient Access final rule until future rulemaking is finalized.  CMS’s decision to exercise enforcement discretion for the payer-to-payer policy until future rulemaking occurs does not affect any other existing regulatory requirements and implementation timelines outlined in the final rule.  Go here to see the announcement and find links to the FAQs.
  • CMS has proposed repealing the Medicare Coverage of Innovative Technology and Definition of ‘”Reasonable and Necessary” final rule, which was published on January 14, 2021 and is scheduled to take effect on December 15.  The repealed rule was a response to concerns that breakthrough technologies were not being made available to the Medicare population in a timely manner but CMS now believes more care must be taken before authorizing the use of such technologies for Medicare patients.  Find the proposed rule here.
  • CMS has published its Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Quarterly Q&As December 2020 document so inpatient rehabilitation facility (IRF) providers have the benefit of clarifications to existing guidance.
  • CMS has published the Long-Term-Care Hospital (LTCH) CARE Data Set Quarterly Q&As, September 2021, Consolidated September 2020 to September 2021 document so LTCH providers have the benefit of the clarifications to existing guidance.
  • CMS has awarded $15 million in planning grants to 20 states to support expanding community-based mobile crisis intervention services for Medicaid beneficiaries.  Learn more about the services the grants will underwrite and find a list of grant recipients in this CMS announcement.

Centers for Disease Control and Prevention

Food and Drug Administration

  • The FDA has revised its emergency use authorization (EUA) for the monoclonal antibodies bamlanivimab and etesevimab, administered together, to include emergency use as post-exposure prophylaxis (prevention) for COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) who are at high risk for progression to severe COVID-19, including hospitalization or death.  In this revision of the EUA, bamlanivimab and etesevimab, administered together, are authorized for use after exposure to the virus and are not authorized for pre-exposure prophylaxis to prevent COVID-19 before being exposed to the COVID-10 virus.  Learn more from the FDA announcement, the revised EUA, and this fact sheet for providers.
  • The FDA has updated its enforcement policy for masks, barrier face coverings, face shields, surgical masks, and respirators during the COVID-19 public health emergency.  Find the updated policy here.

National Institutes of Health

  • The NIH has awarded $470 million to build a national study population of diverse research volunteers and support large-scale studies on the long-term effects of COVID-19.  Learn more from this NIH news release.

Stakeholder Events

MACPAC – September meetings – September 23 and 24

The Medicaid and CHIP Payment and Access Commission (MACPAC) will hold its scheduled September meeting of commissioners on Thursday, September 23 and Friday, 24 to discuss federal Medicaid and CHIP policies.  The meetings will be held virtually.  Find the meeting agenda here and go here to register to view the sessions.

CDC – Evaluating and Supporting Patients Presenting With Fatigue Following COVID-19 – September 30

The CDC will hold a webinar on evaluating and supporting patients who present with fatigue following treatment for COVID-19.  The webinar will be held on Thursday, September 30 at 2:00 p.m. (eastern).  For further information on the subjects the webinar will cover, those who will be participating in the event, and how to join the webinar, go here.

FDA – Workshop Addressing Response to the Opioid Crisis – October 13

The FDA will hold a workshop titled “Reconsidering Mandatory Opioid Prescriber Education Through a Risk Evaluation and Mitigation Strategy (REMS)” to give stakeholders an opportunity to provide input on aspects of the current opioid crisis that could be mitigated in a measurable way by requiring mandatory prescriber education as part of a REMS effort.  The public workshop will be held on October 13 from 1 p.m. to 5 p.m. (eastern) and October 14 from 1 p.m. to 4:00 p.m.  For information about participating in the workshop or submitting comments or materials, see this Federal Register notice.


Federal Health Policy Update for Thursday, August 26

The following is the latest health policy news from the federal government as of 2:30 p.m. on Thursday, August 26.  Some of the language used below is taken directly from government documents.

NASH Advocacy

  • NASH has written to the chairs and ranking members of the congressional committees of jurisdiction over health care to ask them to prevent the anticipated January 1, 2022 tripling of the current Medicare sequester from two percent to six percent of all provider Medicare payments and to consider the challenges that community safety-net hospitals have long faced, and that they now continue to face to an unprecedented degree, when looking for budget savings to offset new federal spending during upcoming federal budget deliberations.  See NASH’s letter here.

Provider Relief Fund

The White House

Centers for Medicare & Medicaid Services


  • Health care providers can now receive additional payments from Medicare for administering vaccines to multiple residents in one home setting or a communal home setting.  Previously, CMS increased Medicare payments for vaccines administered in the home, and now, under this new policy, vaccine providers can receive the increased payment up to five times when fewer than ten Medicare beneficiaries receive the vaccine on the same day in the same home or communal setting.  Learn more from this CMS announcement.
  • CMS has written to Medicare Advantage organizations and Medicare-Medicaid health plans to inform them that in light of the recent surge of the COVID-19 delta variant and increased hospitalizations across the country, it strongly encourages those organizations to waive or relax plan prior authorization requirements and utilization management processes to facilitate the movement of patients from general acute-care hospitals to post-acute care and other clinically-appropriate settings, including skilled nursing facilities, long-term-care hospitals, inpatient rehabilitation facilities, and home health agencies.  The ability of hospitals to transfer patients to appropriate levels of care without unnecessary delays or administrative burdens, CMS writes, is critical to ensuring that hospitals have open acute-care beds to treat patients requiring emergency care.  See the CMS message here.
  • CMS has updated its Medicare provider enrollment relief FAQ.  Find it here.

Department of Health and Human Services

Health Policy News

  • Along with the Department of the Treasury and Department of Labor, HHS is vested with responsibility for implementing the 2020 law that requires health care payers to make available to the public machine-readable files for in-network rates and out-of-network allowed amounts and billed charges for plan years.  That information was to be available publicly by January 1, 2022, but now, the departments have delayed implementation of this requirement for six months.  Learn more from this HHS FAQ.
  • HHS’s Office of the Assistant Secretary for Preparedness and Response will award a single grant of $3 million to establish a new Regional Disaster Health Response System site.  It would be part of a tiered system that builds upon and unifies existing assets within states and across regions to support a more coherent, comprehensive, and capable health care disaster response system able to respond health security threats.  Entities eligible for grants include hospitals, local health care facilities, political subdivisions, states, emergency medical services organizations, and emergency management organizations.  Learn more about the funding opportunity here and here and about the Regional Disaster Health Response System here.  Applications are due September 20.
  • HHS’s Agency for Healthcare Research and Quality has published a statistical brief on diabetes-related inpatient stays in 2018.

Food and Drug Administration


  • The FDA has granted its first full (non-emergency use authorization only) approval of a COVID-19 vaccine.  The vaccine that has been known as the Pfizer-BioNTech COVID-19 Vaccine and will now be marketed as Comirnaty (koe-mir’-na-tee), for the prevention of COVID-19 disease in individuals 16 years of age and older.  The vaccine also continues to be available under emergency use authorization for individuals 12 through 15 years of age and for the administration of a third dose in certain immunocompromised individuals.  Learn more from this FDA news release.
  • The FDA has posted updated information about COVID-19 booster shots, including when they will be available, who should get them, and when people should get them.  Find that information here.

Centers for Disease Control and Prevention


U.S. Citizenship and Immigration Services

  • Under provisions of the Immigration and Nationality Act, the Department of Homeland Security’s U.S. Citizenship and Immigration Services administers the public charge ground of inadmissibility as it pertains to applicants for admission to the U.S. and adjustment of status.  The agency has published an advance notice of proposed rulemaking to seek broad public feedback on the public charge ground of inadmissibility to the U.S. that will inform its development of a future regulatory proposal.  Find the Federal Register notice here.  Comments are due by October 22.

National Institutes of Health

  • A study funded by the NIH has found that drinking alcohol and smoking tobacco cigarettes throughout the first trimester of pregnancy is associated with nearly three times the risk of late stillbirth compared to women who neither drink nor smoke during pregnancy or quit both before the end of the first trimester.  Learn more from this NIH news release.

Medicare Payment Advisory Commission (MedPAC)

  • MedPAC has submitted formal comments to CMS in response to CMS’s proposed home health prospective payment system regulation for 2022.  See MedPAC’s comment letter here.

Congressional Research Service

  • The Congressional Research Service has updated its report Finding Medicare Fee-For-Service (FFS) Payment System Rules:  Schedules and Resources.  Find it here.


Vaccination Rates Low Among Medicaid Recipients

Individuals enrolled in Medicaid are less likely to have received COVID-19 vaccines than the population as a whole, according to a recently published report.

Among the possible reasons for this low rate, observers speculate, is greater vaccine hesitancy among low-income individuals (as identified in a nation-wide survey), less flexible work schedules, and economic barriers such as lack of transportation or child care.

This can pose a special challenge for safety-net hospitals because the communities they serve have more Medicaid beneficiaries than the typical community.

Learn more about the extent of the problem around the country and what state Medicaid programs are doing to encourage more Medicaid beneficiaries to roll up their sleeves and get vaccinated in the Roll Call article “Medicaid beneficiaries less likely to get COVID-19 shots.”