{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T14:06:32Z","timestamp":1789740392070,"version":"4.0.1"},"reference-count":21,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":2,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100014848","name":"Arnold Ventures","doi-asserted-by":"publisher","award":["24-12119"],"award-info":[{"award-number":["24-12119"]}],"id":[{"id":"10.13039\/100014848","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,9,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Safety net hospitals (SNHs) disproportionately serve uninsured, Medicaid, and low-income Medicare patients, yet no universally accepted SNH definition exists. Existing binary measures frequently identify divergent hospital sets, creating research inconsistency and risking misaligned policy protections, concerns heightened by recent federal Medicaid cuts and site-neutral payment reforms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using Medicare cost report data for community hospitals, we introduce and validate a continuous, multidimensional SNH Index constructed as a composite of Medicaid revenue share, uncompensated care burden, and low-income Medicare share.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Hospitals in the highest SNH Index quartile had substantially lower operating margins (\u22122.0% vs 3.1% in the lowest quartile), fewer days cash on hand (91 vs 158 days), and higher rates of financial distress (36% vs 21%). The SNH Index showed stronger correlations with financial performance than 5 binary SNH definitions and a proxy for MACPAC\u2019s Medicare SNH Index. Within each quartile, system-affiliated hospitals significantly outperformed independent hospitals financially.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>These findings suggest that policies protecting SNHs should incorporate composite, burden-based measures, and account for system-level financial resources rather than relying on binary classifications alone.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/haschl\/qxag240","type":"journal-article","created":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T07:20:05Z","timestamp":1788420005000},"source":"Crossref","is-referenced-by-count":0,"title":["Beyond binary measures: introducing a safety net hospital index"],"prefix":"10.1093","volume":"4","author":[{"given":"Fredric","family":"Blavin","sequence":"first","affiliation":[{"name":"Policy Development and Research, Blue Cross Blue Shield Association , Washington, DC 20001 ,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-9022-3756","authenticated-orcid":false,"given":"Avani","family":"Pugazhendhi","sequence":"additional","affiliation":[{"name":"Health Policy Division, Urban Institute , Washington, DC 20024, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen","family":"Zuckerman","sequence":"additional","affiliation":[{"name":"Health Policy Division, Urban Institute , Washington, DC 20024, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Holahan","sequence":"additional","affiliation":[{"name":"Health Policy Division, Urban Institute , Washington, DC 20024, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,3]]},"reference":[{"issue":"1","key":"2026091809353122200_qxag240-B1","doi-asserted-by":"publisher","first-page":"278","DOI":"10.1186\/s12913-021-06292-9","article-title":"Defining safety net hospitals in the health services research literature: a systematic review and critical appraisal","volume":"21","author":"Hefner","year":"2021","journal-title":"BMC Health Serv Res"},{"issue":"27","key":"2026091809353122200_qxag240-B2","doi-asserted-by":"publisher","first-page":"2593","DOI":"10.1056\/NEJMp2030228","article-title":"Essential but undefined\u2014reimagining how policymakers identify safety-net hospitals","volume":"383","author":"Chatterjee","year":"2020","journal-title":"N Engl J Med"},{"issue":"1","key":"2026091809353122200_qxag240-B3","doi-asserted-by":"publisher","first-page":"298","DOI":"10.1089\/heq.2021.0076","article-title":"Evaluating how safety-net hospitals are identified: systematic review and recommendations","volume":"6","author":"Powell","year":"2022","journal-title":"Health Equity"},{"key":"2026091809353122200_qxag240-B4","volume-title":"Bill S705: An act to amend the public health law, in relation to regulating commercial reimbursement rates for certain health care services","author":"New York State Senate"},{"key":"2026091809353122200_qxag240-B5","author":"Centers for Medicare & Medicaid Services"},{"issue":"7","key":"2026091809353122200_qxag240-B6","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2025.23923","article-title":"Variation, overlap, and stability in defining safety net hospitals","volume":"8","author":"Chatterjee","year":"2025","journal-title":"JAMA Netw Open"},{"issue":"5","key":"2026091809353122200_qxag240-B7","doi-asserted-by":"publisher","first-page":"590","DOI":"10.1177\/1077558709334895","article-title":"Understanding the safety net: inpatient quality of care varies based on how one defines safety-net hospitals","volume":"66","author":"McHugh","year":"2009","journal-title":"Med Care Res Rev"},{"issue":"8","key":"2026091809353122200_qxag240-B8","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.8577","article-title":"Comparison of 3 safety-net hospital definitions and association with hospital characteristics","volume":"2","author":"Popescu","year":"2019","journal-title":"JAMA Netw Open"},{"issue":"9","key":"2026091809353122200_qxag240-B9","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2023.32392","article-title":"Variance of US hospital characteristics by safety-net definition","volume":"6","author":"McNeill","year":"2023","journal-title":"JAMA Netw Open"},{"key":"2026091809353122200_qxag240-B10","author":"Medicare Payment Advisory Commission"},{"key":"2026091809353122200_qxag240-B11","author":"Congressional Budget Office"},{"key":"2026091809353122200_qxag240-B12","author":"Kaiser Family 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