Re-engineering the public hospital system: saving the safety net.

Cities across America are grappling with the problem of how to provide care for the indigent and those on Medicaid. All levels of government are reducing their public funding for health care of indigent persons, and the rapid growth of managed care is making traditional cost-shifting more difficult as it transforms the practice of medicine itself. These issues are most acute in cities like Los Angeles and New York, which traditionally have relied on public hospital systems to serve as a safety net. This article focuses on the changes being wrought at the largest health-care system in the country for indigents, the New York City Health and Hospitals Corporation (HHC), on the progress it made during the first 18 months of a major re-engineering process, and on potential options for its future reform.