Kate Bennett
CEO, Cincinnati Health Network (Retired)
Learning objectives
- Discuss the origins and role of Federally-Qualified Health Centers (FQHC)
- Discuss the different types of FQHC and populations served
- Describe how funding of FQHC is different from private medical offices or free clinics
- Describe the outcomes of FQHC’s – services provided, diseases treated
- Review the 501c3 status requirements of hospitals and community non-profits
Both FQHC’s and human service non-profits are part of the safety-net for vulnerable populations. Please respond to one of the prompts:
· Has there been an experience with a safety-net setting these last four years that stood out, positively or negatively, for you and why?
· There is some debate about using the term “safety-net”? Do we stigmatize, discriminate or let responsible parties off with our current terminology and models?
Although never explicitly introduced to me as a “safety net hospital,” I always operated under the assumption that UC was the safety net hospital for Cincinnati. I had a pre-existing hierarchy of sorts in my mind of the health systems in Cincinnati. Of the health systems, UC Health automatically held the “safety net” position in my mind, subconsciously, immediately after starting medical school. I imagined many of the facilities being dated and technology not quite up-to-date. I pictured vulnerable populations receiving their medical care here not because they necessarily wanted to but because this is their primary option. I imagined residents seeing socially complex patient after socially complex patient in their continuity clinics, and these patients getting new PCPs every year or two after the residents graduated. I recall speaking to Dr. Warm, the residency director of the internal medicine program at UC, early in my medical training. He told students about his “wild” dream that the patients facing the most barriers in the city of Cincinnati had better health outcomes than the rest of Cincinnati. This of course would be done through the Hoxworth internal medicine residency resident clinics. My classmates and I then spent a significant amount of time in the Hoxworth IM clinics, and it certainly felt like a “safety net” setting to me. There, I learned that I needed to explain basic nutrition information that I had previously taken for granted. I saw patients with the fewest resources who required the most resources, and I met many patients who had nowhere else to go. It was a positive experience for me to see this setting, but it also seemed rather cumbersome to concentrate patients with the highest resource requirements in a clinic with so many learners. It was easy to see a quick road to burnout, especially when social work and behavioral health services were difficult to connect with at times. In these somewhat short visits, resident physicians were expected to be doctors, social workers, case managers, psychologists, pharmacists, teachers, and interpreters all at the same time. Now, applying to residency in a primary care field, I have witnessed other similar clinics across the country. Similar clinics to Hoxworth, “safety net” clinics that accept most everyone and have financial assistance, have just as vulnerable and complex patient panels with greater access to interdisciplinary providers. Many of these clinics that I’ve seen feel less “safety net” with new technology, updated spaces, fortified social services, and sufficient support staff even though they are “safety net” clinics in many ways. I hope to work in an environment where the “safety net” settings have non-safety net attributes: little to no wait times, ample support staff, multidisciplinary teams such as social work, case management, pharmacy, psychology, behavioral health, interpreters, etc, and in-clinic lab and radiology services.
I think it’s funny how we shared a similar experience at Hoxworth. Overwhelming for a medical student yet routine for the residents and attendings. It’s no wonder that these physicians often face the most stress because you feel like a social worker, nutritionist, therapist, physician, family member, friend all in one visit! However when I’m typing this, I feel excited to become a resident, using my skills and training to tackle these tough scenarios and work to serve others.
I do think UC is more of the “safety-net” hospital in the area and I don’t think it’s a bad stigma. Rather, people I think feel confident and trust UC in caring for “everything.”
I also had a similar experience at Hoxworth! Obviously caring for that high-risk population is great for learning not only the medicine but the art of delivering care. I also felt like residents had to fill multiple roles from social worker to nutritionist during the visit. I remember one patient who hadn’t seen a physician in close to 10 years because they had been dismissed from multiple clinics for reasons that could be attributed under social determinants of health. I think that the solution is to renovate these clinics with more access to social services to properly take care of these patients in the short-time allotted.
I am embarrassed to say that I have never questioned the phrase “safety-net” when referring to hospitals or clinics. I even had a residency interview this week with a program that is housed in what is considered the “safety-net” hospital of their city, and I believe they called it so themselves when introducing their program. I had to google some of the discourse around this issue, and it was interesting. The term originated in the late 1970s / early 1980s with Ronald Reagan and other legislators/policymakers while they were making cuts to New Deal and Great Society, basically saying that, even though cuts are happening, “those who, through no fault of their own, must depend on the rest of us—the poverty stricken, the disabled, the elderly, all those with true need—can rest assured that the social safety net of programs they depend on are exempt from any cuts.”
After this introduction, two of the main points that I pulled out against this metaphor are the following: first that the label “safety-net” may lead others to think other programs that don’t fall under this label are unnecessary, even if they are crucial to the livelihood of others. Second, that the “net” metaphor implies that a “fall” must happen before the services can be utilized, which then means that prevention is not a priority of “safety-net” programs. The article references that this metaphor also implies that the patient is alone because falls normally happen individually, and this disagrees with public health research on the importance of human interconnectedness .
The first point did not really land with me. But I thought the second point was interesting! And not aligned with my experience or perception of healthcare “safety-net” programs, like county hospitals, FQHCs or lookalikes. I’ve recently been spending time with my community partner, Equitas, which is a community health center look-alike at this time, and SO many of the programs emphasize community support, preventative care, and assistance navigating other programs to help with housing, food and financial services. They have a ton of teammates helping with their mission of whole-person healthcare, and many services offered onsite so patients don’t have to worry about getting transportation all over the city for their needs. I also got the sense that the residency program I just interviewed for in the county hospital has wonderful community and primary care programs for their patients.
In my experience, “safety-net” programs do their best to break down so many barriers for patients and are incredibly equipped with staff and resources to do so (totally agree with Katie’s response above that they sometimes even seem higher quality care than other clinics I’ve been in), but I did not consider what the label could imply to someone outside of healthcare or even of a different healthcare mindset than my own. So, in a way, maybe labeling these hospitals or clinics like this does imply that the patients here are “other” in some way, which I do not want to do because stigma is dangerous for patients. Even though I think very fondly of the wonderful work that safety-net programs provide, that may not be the stereotype that many have. I am glad to be challenged thinking about this, so I can work on ways to speak about and advocate for the importance of these programs for my future patients in a world where there is no stigma surrounding them!
Here is the article I read if anyone else is interested:
https://pmc.ncbi.nlm.nih.gov/articles/PMC8361565/#:~:text=In%20this%20metaphor%2C%20a%20safety,not%20fall%20in%20the%20first
Caroline you always have such thoughtful responses to these prompts and I love reading what you are thinking!
To add to the discourse between you and Katie, I do think that these facilities are often even higher quality care because they will look into the determinants of health that lead to people ending up at a safety net facility in the first place, which many other providers are not looking at when they see a patient in these circumstances.
But to get back to the bulk of your point, I agree that there is something a little off-putting about this label and the implication that there was a fall in order to get to this point is something we have to challenge. A fall almost implies that it is the responsibility of the patient, for they are the ones who lost their balance in order to land in these circumstances. I feel that so often it is really a “push” from the other factors at play here which leads a person to these circumstances. But that leads to more upstream thinking, how can we stop pushing people into economic need?
I have been thinking more critically about the term “safety net” as I have spent time working at the Hopple Street Clinic, a Federally Qualified Health Center, and learning how these clinics function within their communities. Before this year, I used the term casually and uncritically. It felt like neutral shorthand for places that care for patients with fewer resources as compared to institutions that highlight their newest facilities and fanciest renovations. However, the more time I have spent inside an FQHC, listening to caregivers share their stories, understanding the structural barriers they face, and observing the immense invisible work that goes into keeping these clinics running, the less comfortable I am with the metaphor and the more desire I have to correctly bestow that honor on those that do that work and ensure that this care is being done.
The idea of a “net” implies catching someone after they fall, but that framing ignores the amount of prevention, empowerment, and community building that FQHCs do every single day. At Hopple, much of what makes the clinic effective happens before a medical crisis. Transportation coordination, behavioral health access, language services, caregiver support, early learning referrals, and social determinant screening all occur upstream. These are not reactive measures. They are proactive forms of care that acknowledge a person’s whole context. Calling these systems a net makes that work sound passive, as though clinics simply wait at the bottom while society’s most vulnerable people tumble downward, which does not reflect what I have watched these teams do.
I also worry that the language can unintentionally “other” the very patients we are trying to support. In the narrative medicine interviews we conducted, caregivers were incredibly resilient, resourceful, and deeply invested in their children’s health. Yet the term “safety net” can subtly position them as outsiders to the mainstream system or as people whose needs are exceptional rather than expected. When the label is used by those who have never set foot in an FQHC, it can reinforce the assumption that these clinics exist on the margins rather than as central pillars of community health.
What has stood out most to me is that places like Hopple are not nets at all. They are infrastructure. They are built intentionally, staffed by people with deep community ties, and designed to remove barriers that the rest of the healthcare system often fails to acknowledge. The more I have learned, the more I believe our terminology should reflect that reality. Instead of describing these clinics as last resort catchment systems, we should talk about them as essential community institutions that expand what equitable, relationship-centered care looks like. A shift in language may seem small, but it can help reduce stigma and give these organizations the recognition they deserve.
One of the most formative experiences of my clinical years was working at Hoxworth Primary Care Clinic during my third year. Hoxworth plays a crucial role in caring for patients who often fall through the cracks of traditional healthcare—many facing limited resources, unstable housing, or inconsistent insurance coverage. As a safety-net clinic, it serves as an essential home for individuals who struggle to access care elsewhere in Cincinnati. Because it was my first rotation, the experience felt raw and unfiltered. I initially struggled with the medicine, which, in hindsight, was only a small part of what we were actually addressing. Most clinic days were spent “quarterbacking” patients through those cracks in the system—trying to roll years of overdue healthcare into a single 15-minute visit. It often felt impossible, but we did what we could with the time and tools we had. Not surprisingly, I noticed patients often craved the unspoken medicine such as therapeutic listening and presence.
What stood out most was how deeply longitudinal relationships mattered. I remember following several patients across multiple visits, witnessing how trust slowly built over time. Even small interventions such as clarifying a medication schedule, coordinating social services, or transportation to and from the building often seemed to be the best medicine! At the same time, the challenges were real and exposed. I saw how structural barriers like underemployment, lack of education and fragmented access could undo even the most carefully crafted plans. As a medical student, I often turned inwards to figure out the basics for these patients and built a repertoire of tools I knew were easy to navigate and feasible. Simply put, if patients were sent back to unstable home environments or the street, you couldn’t idly sit by and hope your sophisticated plan would work. It was both inspiring and humbling: inspiring to see what dedicated primary care teams could accomplish with limited resources, and humbling to realize how insufficient our systems can be in meeting people where they are. That tension and yet working solution made Hoxworth stand out so strongly in my training.
Working in a safety-net environment like Hoxworth made me more aware of how language shapes expectations. The term “safety-net” captures an important truth: that certain clinics and clinicians step up to care for people who would otherwise be excluded. In my mind, I know these are absolutely essential. But it also subtly implies that this care is ornamentory or optional—something that exists only to catch those who fall intermittently, rather than a core institution in our neighborhood. I do think the terminology can unintentionally reinforce stigma, because it separates patients into categories of “regular” and “safety-net” recipients. It can be easy to treat these patients differently, especially when you know they may have a history of missed follow-ups or medication misuse. But we’re called to treat every patient as if they were our first—approaching each encounter with fresh judgment, clear eyes, and genuine compassion.
I’m blessed looking back on third year that I had these experiences early on that shaped how I perceive healthcare; how can we move from serving those who fall to preventing the fall in the first place?
I love what you highlighted regarding how language shapes expectation. This is such an important aspect to consider, and the power of words cannot be underestimated, especially when the health of communities is at stake. The word “safety-net” definitely has a negative effect of creating an “us” vs. “them” and a “normal” vs. “abnormal” mentality. Terminology not only makes it difficult to shift perspectives, but it can also make it easier to shift responsibility and blame. If it’s the perceived job of only safety-net settings to care for those who are being excluded by the system, then other clinics and hospitals may further increase the burden on them to care for the underserved. Like you said, if it’s assumed that safety-net settings account for the ornamentory care, then why bother partaking in sharing the load?
The question you asked at the end gets to the heart of public health, the need for systemic change in our healthcare system, to see improved patient outcomes!
The term safety-net implies a different level of care than the other methods of care that patients should be able to access. Because you have to designate a care center as a safety-net, it suggests that there are other facilities that are not safety nets. This creates an inherent difference in the perception of care, which may also lead to a real difference in the quality of care, or even patient hesitancy to go to a place that is described as a “safety-net.”
Kate Bennett clearly describes the quality of care that is offered at these “safety-net” programs, which is often high-quality and highly specified to the needs of their patient populations. She clearly outlines that these facilities are capable of the same level of care. Yet there should not be a need to go to a separate medical facility in order to receive the care that a person needs. Separate but equal is inherently unequal, we have learned that enough throughout our countries history. So, while these facilities are meeting a clearly defined need, meeting it in a way that reaches people where they are, and even generates positive economic impact in their communities, we should challenge their existence as separate. Maybe the push shouldn’t be to move this type of care into the non-safety net facilities and make them take ownership, but to push those facilities to send their providers and their resources to these centers. I don’t know how the economics of that would work but it’s an idea!
As a few others have already pointed out, for UC medical students, the Hoxworth Primary Care Clinic is one of our primary exposures to a safety-net setting. I want to share an experience that shifted the way I approach patient care.
One morning, after a handful of patients had no-showed, I was asked to see a patient my preceptor jokingly referred to as a Hoxworth special. It was a term many of the attendings and residents used to describe patients with a complex medical and social background, and looking back, I better understand it as an acknowledgment of the extra support they didn’t always feel they could provide. Already a bit apprehensive about the visit, I decided to start by better understanding what barriers the patient might be facing. I had been told that she’d missed several follow-up visits and was not taking her medications. As the visit started, I gradually realized that much of the patient’s behavior was simply the manifestation of a deeper systemic issue.
She was experiencing a vicious cycle of not having the social support she needed, which led to decreased capacity to keep up with the health care she was connected to, which allowed her conditions to worsen and her needs to increase, which was exacerbated by her lack of social support, and so forth. On the other hand, the clinic providers who also didn’t have all the support they needed experienced a similar cycle of not having the capacity to parse through and address the patient’s increasing needs, which also allowed her conditions to worsen, etc, etc.
After almost 50 minutes, we had done talk therapy, patient education, medication education, and adherence strategies, all in addition to getting a thorough picture of where her medical conditions stood. By the end of the visit, the patient expressed looking forward to her next visit and a better understanding of what she needed to do. Even after the rotation ended, my preceptor shared that after that visit, she had continued keeping her appointments and been consistently taking her medications. This was great news, and I was happy for the patient, but it also saddened me at the same time.
I hadn’t done anything particularly special, but I did have an advantage that my attendings and residents did not– time. As a learner, I could afford to spend nearly an hour with a patient, without negatively impacting the clinic flow or impeding the care of other patients. Not having lists of patients with similar issues to the one I saw also made it easier to have the emotional bandwidth that the encounter required.
It was this experience that made me reflect on how safety-net settings often demand more of providers, while offering proportionally less time and space for them to serve the patients who need the greatest support. Often leaving them burnt out, stretched thin, and jaded. Despite this reality, the Hoxworth Clinic also showed me that even in the face of difficult conditions, it is still possible to provide high-quality, compassionate care, and I believe that it’s this apparent heart for service that makes all the difference.
I agree on this perspective of Hopple clinic, Micha. I was very overwhelmed when I rotated there for the first time and 20 patients would pop up on the appointment screen at once with each resident immediately designating themselves to each one almost haphazardly, then spend 10 minutes in the room before staffing and then seeing the next. Likewise, all the patients had very complex social, financial, and medical needs that I was thankful to spend more time understanding. But it does bewilder me how these residents can or cannot address all of these needs at once. For example, an asthma case in which we had a negligent landlord refusing to address the black mold/mildew in their apartment, low income and lack of transportation as a barrier to her asthma medications, and low literacy in understanding what each different inhaler was for. I do think one aspect that was helpful was the coordination of multiple professions – Hopple had transportation coordination, a social worker, education centers, and so on.
I am so glad that this patient got to see you, Micha. I think you did do something particularly special, though. I think it’s the highest honor when a patient who experiences more barriers to care than average comes back to see you – and you are already building relationships that do that so early in training. You created trust that kept this patient coming back and probably rippled off of you to what (sounds) like a burnt out primary provider. I bet the primary provider also felt a sense of trust in what is possible with time and commitment to the broader picture of a patient. I hope that helped them invest more time with patients who they may see as ‘Hoxworth specials’. I hate that this patient was introduced to you like that – and I wonder how the bias inherent in that term had itself impacted the type of care this patient had received from this provider in the past.
I want to work in a safety net setting in the future and, while I don’t know what attendinghood is like yet, I do think that the use of such a term as hoxworth special is in and of itself contrary to the spirit of a safety net setting. As you noted prior to entering that room for the first time, patients with poor adherence to medication regimens and high no show rates often have barriers that have yet to be addressed by the medical team. I imagine it’s hard as a physician to live in that murky water of not being able to fix every problem while still trying to decrease barriers at each visit. I remember when I was at Hoxworth I was encouraged to focus on only one problem at a time. But patients with many social and structural barriers to care frequently need more attention than that. I’m still optimistic that doing so is possible with a can-do attitude and efficiency – especially when patients trust you and want to keep seeing you 🙂
Like others in this module, I did not realize that there is controversy over the label of “safety-net” hospitals. And likewise, this term was used multiple times during my time at Hopple clinic, in my residency interviews (by myself and the admission leadership team), and with my family members (many of whom are uninsured). I have done some research into the current discourse.
This Emory Law article begins by discussing how the term “safety-net” is ambiguous. Do we select those programs based on how much they “deserve” help (e.g. how much they invest into their community) or how much they “need” help (e.g. % of medicaid/medicare population)? And is safety-net for only dire care in hospitals, all programs that provide some contribution to the “human ecosystem”, or any preventative programs?
Accordingly, this ambiguity in the label and how different officials perceive which organization is considered a safety-net is important because it has affected qualification for funding for these organizations. For example, a report by this PBS article found that “America’s Essential Hospitals…counts 300 members” while “Other definitions put the number much higher.” The same article states that while federal funding has a single standard, most funding is dependent on the state’s discretion. As a result “there’s no clear relationship between the hospitals that get DSH payments and the hospitals with the highest proportions of low-income or uninsured patients”.
The Emory Law article also discusses how “safety-net” assumes an individual has “fallen”. As a result, law creation and funding has prioritized programs that support the individual with “last resort” resources (healthcare funding, food stamps, etc.) rather than to preventative programs that act upstream in systems-based inequalities (housing, employment, education, etc.). In addition, safety-net implies that the programs are “temporary” and only to be during a “dramatic fall” which de-prioritizes the need for services to be sustainable.
So what term is currently being discussed to replace “safety-net”? This Becker’s HR article discusses the benefits of shifting to use of “essential” hospitals. They argue that there should be a single federal designation that states should follow in funding that deems hospitals as “essential” based on not just proportion of the population that is lowly-insured but also on their mission, services, training, public health roles, and coordinated care networks committed to low income, underserved populations. As a result, essential hospitals are less likely to deal with unstable funding with changing definitions over time and there is emphasis based on infrastructure roles of these hospitals rather than temporary assistance. This surely puts an extra emphasis on what these hospitals/programs do for the community rather than who they serve/what they need.
Based on my own interpretation of these articles as well as my own personal experiences, I do think in theory, the change to “essential” terminology has a lot of good faith. I do think there should be priority in preventative programs and systems-based services rather than temporary assistance. However, I think there should also be care to study what de-emphasizing number of medicare/medicaid individuals the hospitals serve as a qualification for funding can negatively affect. In catching more of the population by funding all hospitals that provide “essential services”, are we giving less funding to those hospitals who need more help?
I think my main experience with safety-net hospitals has been working at UC during my fourth year, which I also understood to be the safety-net hospital for Cincinnati. During my IM AI, I was on the renal team. Our patient population was one with significant chronic comorbidities and social determinants of health would frequently impact care. Within that group of patients on dialysis were “community dialysis” patients who either could not get care through traditional dialysis centers or had been dismissed from multiple centers. I think that the experience of caring for this group of patients was a mixed-bag. On one hand, there was a significant portion that truly cared about their health and it was hard to watch them not be able to receive the level of care they need. On the other hand, there was a portion that had missed it because it seemed they didn’t care as much about getting better. Obviously, with the latter group there was often times more going on behind-the-scenes with SDOH/misaligned goals of care. Regardless, I think that these patients were often lumped into one mental hierarchy for residents and attendings of the “difficult to treat” patients, and I do believe that this mental hierarchy impacted patient care whether consciously or subconsciously.
I think that the term “safety net” should be changed in our medical vocabulary because it separates hospitals immediately and almost gives them an excuse to not care for a higher-risk population. I think that all systems should give the best care to every patient despite income, zip code, and prior healthcare experiences. It also stigmatizes people who receive care at “safety net” hospitals and can lead to bias among healthcare professionals which will definitely lead to an altered level of care at these hospitals.
During my fourth year, I completed a lactation medicine elective at UC that deeply shaped how I think about safety-net care. We worked with a diverse population of new parents trying to initiate breastfeeding within the first day of life. I quickly realized how little formal education physicians receive about lactation, despite its major impact on postpartum and infant health.
What struck me most was how structural and cultural factors influenced feeding decisions. UC has the lowest breastfeeding rates in the greater Cincinnati region. Many working mothers lack protected space or time to pump. Formula marketing has created distrust in natural milk supply. In some communities, particularly among Latina families, there are generational influences shaped by prior food insecurity that normalize formula supplementation.
Evidence shows that Black and Latina mothers receive less lactation education in hospital settings, and breastfeeding rates are significantly lower in these groups. During the rotation, I conducted a QI project surveying parents who had planned to breastfeed but initiated formula within the first day of life. The vast majority supplemented out of fear that they were not producing enough milk. I had not appreciated how small — and how sufficient — early colostrum volumes are. Without reassurance, it’s easy to interpret normal physiology as failure.
I also observed that Black mothers were more likely to plan exclusive breastfeeding prenatally but were disproportionately represented among those who initiated formula in the hospital. I didn’t directly observe differential counseling, but it was clear that in a high-volume safety-net setting, lactation consultants had limited time and Black patients often had fewer social supports and less flexibility to stay home.
What stayed with me most was watching lactation consultants restore confidence. They helped new parents trust their bodies. They created space for questions in a moment of exhaustion and vulnerability. It reminded me that equity work in medicine is often about small, practical interventions — clear education, reassurance, follow-up — layered within larger structural barriers like paid leave policy and economic instability.
That experience reinforced for me that safety-net care requires both clinical skill and systems awareness. It also made me want to train in a setting where I learn how to navigate social determinants thoughtfully rather than simply reacting to them.