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“Safety-net” health care organizations are a critical backbone of the US healthcare system, providing care to millions regardless of their ability to pay. Despite significant variability in how the safety-net is characterized, a growing number of definitions identify safety-net providers based on the populations they serve: traditionally disadvantaged individuals, including historically marginalized racial and ethnic minorities, low-income, and rural communities — many of whom are often insured through Medicaid or lack insurance. Examples of safety-net institutions include (but are not limited to) community health centers, public and critical access hospitals, local health departments, community mental health centers, certified community behavioral health clinics, and special service providers such as family planning clinics and school-based health programs. Care in the safety-net can be high-quality and cost-effective, but fragmentation and inadequate funding has led to gaps in coordination and insufficient resources to deliver comprehensive care. Without sustainable payment systems, many safety-net providers have been forced to shut down altogether.
“Value-based” care – with person-level payments linked to accountability for whole-person care – can equip providers with tools for driving care coordination, quality, and financial resiliency. Yet, safety-net representation in value-based payment (VBP) models remains relatively limitedcompared to growth for other types of providers. This disparity is due in part to misaligned funding streams, lack of capital investments, and unsustainable payment design features. However, recent reforms including those from ACO REACH and the expansion of Medicaid flexibilities through Section 1115 waivers have increased opportunities for safety-net providers to participate in VBP arrangements, especially as ongoing equity efforts in the VBP policy landscape continue to target safety-net providers.
This Forefront article demonstrates how safety-net providers can and do succeed in VBP models with the support of multi-stakeholder alignment and conducive policy environments. Our goal is to illustrate how VBP can help strengthen care delivery and how additional reforms can encourage broader participation. We draw from a focused literature review and interviews with safety-net organizations, payers, funders, and federal and state policymakers.