Understanding Safety-Net Medical Centers
Safety-net medical centers serve a crucial role in the US healthcare system, providing care for low-income, uninsured, and vulnerable patient populations. However, for safety-net centers to maintain the funding and staff needed to deliver optimal stroke care, the very definition of a safety net must first be made clearer, according to an expert panel at the 2026 International Stroke Conference.
As the crowd continued to trickle into the early-morning session, Paula Chatterjee, MD, MPH, assistant professor of medicine at the University of Pennsylvania, general internist, and policy researcher, couldn’t help but point out the impressive attendance for a 7:30 AM start. Disparities in care have garnered increased attention across disease states in recent years, and stroke is no exception.
The Growing Focus on Healthcare Disparities
The significant turnout at this early session demonstrates the medical community’s increasing recognition that addressing healthcare disparities requires urgent attention. Stroke care, in particular, has emerged as a critical area where inequities between safety-net and well-resourced hospitals create substantial gaps in patient outcomes.
Defining Safety Net in the US Healthcare System
Chatterjee emphasized that a wide range of medical centers could be defined as safety net, meaning the challenge is defining true safety-net hospitals across geographic regions to then allocate resources appropriately. While many think of urban hospitals in the context of safety-net care, rural centers can just as well be safety-net providers—the challenge is creating a definition that encompasses both.
Why Definition Matters for Policy
Defining safety-net care, Chatterjee said, is crucial from a policy standpoint because safety-net hospitals require financial support, and they cannot receive that support if they are not well-defined. In this area, policy intent and reality have yet to align.
“We’re seeing a mismatch between where financial support is supposed to be going to support the safety net and what the reality of safety net hospitals actually is, and that’s why I think definition matters,” Chatterjee explained. “If you can’t get money to where you think it needs to go, you’re not going to achieve your policy goal.”
Common Challenges Across Settings
While different in many ways, rural and urban safety-net hospitals share some common traits, according to Chatterjee:
- They disproportionately serve patients who bear structural determinants of health
- Facilities face financial challenges providing care that is not compensated
- There are limited resources to improve outcomes and contain costs
Distinct Policy Solutions Required
Despite these common issues, rural and urban safety-net hospitals require distinct policy solutions, Chatterjee said. In the rural setting, safety net facilities are often smaller than urban safety-net centers, and they tend to be geographically isolated. Rural facilities may also treat fewer Medicaid-insured patients in states that did not expand Medicaid, leading to more uncompensated care than at urban centers, which are often in cities in Medicaid expansion states, Chatterjee explained.
Potential Rural Solutions
While potential solutions to support rural safety-net centers include bolstering transfer networks for timely stroke care, building the workforce by recruiting and training people from rural areas to work in rural health centers, or even upfront investments to drive updates to rural safety-net medical centers, these solutions cannot be implemented if the targets are not clear.
“I’ll end where I started and say that the US healthcare safety net is broad and diffuse,” Chatterjee said. “It is something that we need to define with a big tent definition but not be so imprecise that we don’t actually achieve the policy goals that we’re seeking out to achieve.”
Barriers to Evidence-Based Stroke Care in Safety-Net Hospitals
With the challenges around defining safety-net care and barriers to care improvement laid out, Nicole Gonzales, MD, FAHA, professor in the Department of Neurology at University of Colorado Anschutz, highlighted the overwhelming nature of even conceptualizing the issues affecting safety-net facilities in the US. In the context of delivering high-quality, evidence-based stroke care, there are obstacles to overcome at the patient, institutional, and policy levels.
The Knowledge Gap
“What is true at all levels is, despite all the information that we have telling us about all of the different ways that inequity shows up in stroke care, there’s a striking lack of knowledge about how we impact that,” Gonzales said.
Institution-Level Barriers
Institution-level barriers include staffing challenges and burnout, emergency department inefficiencies, imaging and diagnostic barriers, and stroke center certification and post-acute care, among others, Gonzales said. Some issues, especially workforce shortages, worsened during and after the COVID-19 pandemic, she added.
The Role of Policy
“People are creative and resourceful, and we surprise ourselves all the time, and some of these strategies can become feasible within safety-net hospitals when they’re paired with the right policy,” Gonzales said. Policy can significantly shape stroke care, amplifying or attenuating certain struggles. For example, value-based penalties can disproportionately affect safety-net hospitals, increasing strain on systems if social risk is not fully adjusted.
Community-Tailored Interventions
As far as what can work to make progress on the many issues impacting stroke care at safety-net systems, many solutions come down to appropriate tailoring for the target system and community. Even something as seemingly straightforward as increasing stroke symptom recognition education in the community—including emergency medical service providers, physicians, and neurologists—is important and effective, but this education must be community-based, multi-modal, and culturally tailored to have the greatest impact, Gonzales said.
Mobile Stroke Units
Mobile stroke units are another intervention with potential to address disparities in stroke treatment, with research showing potential to reduce time to treatment in underserved and marginalized communities. Government legislation could also be more wide-spanning, like a Lithuanian national policy that improved access to reperfusion therapy and increased treatment at stroke centers.
“The goal is not to do everything that we know works, the goal is to pick one thing and start there,” Gonzales concluded. “Find it, adapt it, tailor it, iterate it, and learn from it.”
Telestroke as a Bridge for Access Gaps
Bart M. Demaerschalk, MD, FAHA, professor emeritus of neurology at Mayo Clinic College of Medicine and chief digital officer and director of vascular brain health at Atria Research and Global Health Institute, discussed the evolution of telemedicine as a bridge to underserved areas.
Telestroke Network Evolution
Reflecting on his work with the Mayo Clinic’s telestroke network, he noted that while telestroke can equalize emergency metrics—such as diagnosis accuracy and thrombolysis eligibility—outcomes can still suffer post-emergency if the partnership isn’t integrated into the hospital’s broader culture.
Reimbursement Challenges
“We’re also not well-served in terms of our diagnostic coding and reimbursement. In particular, with individuals with large-vessel occlusion ischemic stroke, costs are higher than for small-vessel ischemic stroke, but the reimbursement may not be on par,” Demaerschalk explained.
Technology’s Potential
Demaerschalk reiterated the potential of technology to facilitate stroke care in the community, including equipped mobile stroke units and telerobotic stroke interventions, which have potential to address gaps in stroke treatment availability outside of major centers.
Financial Threats to Rural Hospitals
Tim Putnam, DHA, LFACHE, faculty member at the Medical University of South Carolina and former president of the National Rural Health Association, drew on decades as a hospital CEO and EMT to illustrate how fragmented systems continue to delay stroke care.
System Fragmentation
“It’s not about a lack of good people, it’s not about a lack of resources,” Putnam said. “Many times, it’s not about a lot of research. It’s about doing the right things and coordinating it together.”
Policy Impact
Putnam noted that recent legislation created more issues for rural hospitals by trimming back the provider tax and changing the 340B program. The changes to Medicaid work requirements can also lead to losses, with overall reimbursements dropping an estimated 4% for hospitals.
Rural Health Care Transformation Fund
The new $50 billion Rural Health Care Transformation Fund, while intended to quell some of these impacts, may allow work on infrastructure, workforce, technology, and building systems, Putnam said. States are using these funds differently—Alabama intends to build a stroke trauma network, North Dakota aims to reduce stroke occurrence, and Minnesota seeks to close the distance between residents and stroke centers.
Building Better Healthcare Systems
“I don’t know whether that’s going to work or not,” Putnam said. “We’ll see what happens. Everybody’s doing something slightly different, but the deal is we need to build a better healthcare system.”
The collective challenge facing healthcare providers, policymakers, and communities is clear: addressing barriers, implementing proven solutions, and coordinating efforts to ensure all patients receive timely, evidence-based stroke care regardless of their geographic location or socioeconomic status.
