Uncompensated hospital care. Will it be there if we need it?

The debates over health care system reform continue, but they rarely mention the enduring need for free or reduced-cost hospital care as a safety net for uninsured and underinsured individuals. Policy changes on numerous fronts threaten the ability or willingness of hospitals to provide uncompensated care. These changes include the decline of Hill-Burton funds, the closings or mergers of not-for-profit and public hospitals, the dominance of competitive forces, and the redirection of funds intended for disproportionate share hospitals or uncompensated pools. Federal and state governments lack coordinated approaches toward uncompensated care, and health system reforms may not have the expected effects on reducing hospitals' burden of paying for services to indigents. Furthermore, measurement of uncompensated care is inconsistent. In light of the persistent growth in the number of persons with inadequate health insurance coverage and the central role that uncompensated care will continue to play in ensuring access to care for the poor and uninsured, these policies need to be reexamined. Guidelines for policy based on past experience are presented herein.