2019 Edition — California’s Health Care Safety Net

A patchwork of programs and providers

Matthew Newman, Blue Sky Consulting Group
Eunice Roh, Blue Sky Consulting Group


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The health care safety net is a patchwork of programs and providers that serves low-income Californians. The implementation of the Patient Protection and Affordable Care Act (ACA) in 2014 has transformed the safety net landscape, largely through expansion of the Medi-Cal program. Most legal residents of the state earning less than 138% of the federal poverty level are now eligible for health care coverage through Medi-Cal. Many Californians earning more than this threshold have gained subsidized insurance through Covered California, California’s health insurance exchange.

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This coverage expansion has affected programs and providers as well as patients. For example, far fewer patients rely on county programs for the medically indigent relative to the pre-ACA period as more people now have access to health insurance. Meanwhile, many providers have experienced increases in demand for their services.

California’s Health Care Safety Net: A Patchwork of Programs and Providers presents data on the providers and programs that comprise California’s system for providing health care to people with low incomes.

  • Both the number of Federally Qualified Health Center (FQHC) organizations and the number of patients seen by them increased by 37% between 2013 and 2017. FQHCs saw 4.7 million patients in 2017, with Medi-Cal providing the majority of the funding for these patients.
  • Many FQHCs are relatively small: the median clinic had about $14 million in revenue in 2017 and saw about 14,000 patients.
  • Nonprofit hospitals remained the cornerstone of the state’s hospital network in the study period, providing 62% of all hospital inpatient days and 72% of outpatient visits. Meanwhile, city/county hospitals provided a disproportionate share of services to Medi-Cal patients and those served by county indigent programs.
  • Since 2013, the median operating margin improved for most hospital types. However, the median operating margin for city/county and district hospitals remained negative.

The full report, and all the charts found in the report, are available for download below. These materials are part of CHCF’s California Health Care Almanac, an online clearinghouse for key data and analyses describing the state’s health care landscape. See our entire collection of current and past editions of California’s Health Care Safety Net.