The declining public hospital sector

Jack Needleman, Michelle J Ko

Research output: Chapter in Book/Report/Conference proceedingChapter

7 Scopus citations


Public hospitals have long served as the backbone of the health care safety net, caring for the poor, uninsured, and racial and ethnic minorities, as well as providing critical regional services. In major metropolitan areas, public hospitals provide more than 20 percent of emergency and 33 percent of outpatient visits, as well as 60 percent of burn and 36 percent of trauma care. Medicaid and uninsured patients account for more than 50 percent of all public hospital visits (NAPH 2009). In rural areas, they are major components of local health systems, representing nearly 40 percent of hospitals. Public hospitals have also traditionally provided extensive outpatient services, community public health programs, and culturally and linguistically appropriate care. Under health reform, there will continue to be a need for safety-net hospital services. It has been estimated that, following the implementation of health reform, 23 million Americans will still be uninsured and 16 million will be covered by Medicaid or the State Children's Health Insurance Program, populations historically reliant on public hospitals (CBO 2010). In the wake of the 2008 recession, state and local governments have been under financial pressure, which has in turn threatened the financial stability of public hospitals. State and local budget crises have prompted large cutbacks in funding for many institutions while the number of uninsured and those covered by Medicaid have grown at record rates (Hartocollis 2010; KFF 2010; Skipp 2010; Sun and Mummolo 2010). Prior to the economic downturn, public hospitals were already battling financial and political pressures to survive in an increasingly cost-driven health care market, and many were closed or converted to private ownership (Lewin and Altman 2000). When considering future changes in health care and implications for access to care, particularly for the most vulnerable Americans, it is important to understand the trends in the decline of the public hospitals that are major providers of safety-net care. In this chapter, we examine the shifts in US public hospital supply from 1983 to 2003. We focus on hospital closures and conversions to private ownership, and regional and rural-versusurban differences. We also examine the countertrend of development of new public hospitals. We describe the role of these institutions in their respective communities and augment the analysis of the trends with the discussion of individual cases.

Original languageEnglish (US)
Title of host publicationThe Health Care "Safety Net" in a Post-Reform World
PublisherRutgers University Press
Number of pages14
ISBN (Electronic)9780813553177
ISBN (Print)9780813553061
StatePublished - 2012
Externally publishedYes

ASJC Scopus subject areas

  • Social Sciences(all)


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