Unprecedented Resilience: Analysis of U.S Safety-Net Hospitals Response to COVID-19



The longstanding disparities between safety-net and non-safety-net hospitals have been underscored by the advent of the COVID-19 pandemic, as the overwhelming burden placed on safety-net hospitals has become increasingly evident. This literature review aims to examine the healthcare structures of safety-net hospitals, explore novel perspectives on pre-existing research, and propose possible solutions to address healthcare challenges in the future. Through analyzing qualitative and quantitative articles that focused on COVID-19-related primary and secondary patient outcomes, healthcare accessibility, and financial impacts, among other key dimensions, this paper attempts to elucidate the immense pressures and challenges faced by safety-net hospitals during the COVID-19 pandemic and their capacity to overcome these barriers. The findings highlight how pre-existing healthcare disparities have contributed to patients at safety-net hospitals exhibiting higher rates of untreated chronic diseases, lack of access to preventative services, and ultimately poorer COVID-19 outcomes. Notwithstanding the challenges encountered by safety-net hospitals amid the pandemic, these institutions have demonstrated remarkable resilience and capacity for innovation. Additionally, in an effort to shed light on the critical role of safety-net hospitals, this paper accentuates the indispensable contributions and sacrifices in overcoming resource constraints and innovating during a health crisis.


The COVID-19 pandemic has exacerbated pre-existing healthcare disparities and imposed a strain on safety-net and non-safety-net healthcare facilities around the country. The pandemic has compounded the already precarious position of safety-net hospitals (SNH), which work within a double bind of resource scarcity and a patient population with a higher risk of adverse COVID-19 outcomes1. Subsequently, many of these hospitals were propelled to divert resources away from other services including elective surgeries, preventative care programs, and mental health services, hindering their ability to deliver all-encompassing care2. While pre-pandemic resources at SNHs were already constrained, the influx of newly uninsured and underinsured patients due to COVID-19-related economic job loss pushed these institutions toward the brink of collapse.

Whilst every hospital in the country faced tremendous pressure, the COVID-19 pandemic further escalated the disparities between SN and non-SNHs. Non-SNHs generally serve a more financially stable patient population with fewer uninsured individuals, where the health demographics of non-SNH users see fewer patients with underlying health conditions, in turn decreasing the rate of adverse COVID-19 outcomes3,4. The relative financial security of non-SNHs due to paying patients and private sector funding also meant greater access to healthcare resources and fewer staffing shortages3. Consequently, all of these factors played into inequity in healthcare accessibility, quality, and outcomes between SNH and non-SNH patients during the COVID-19 pandemic.

As a result, the pandemic has served as a formidable demonstration of the role a robust healthcare system plays in confronting public health emergencies. This unforeseen event has shed light on various shortcomings within the current healthcare framework, including the severe disparities present in the U.S. healthcare system along socioeconomic lines. With a particular emphasis on healthcare quality, accessibility, disparities, as well as healthcare financing, this study compares the literature on SNHs and non-SNHs. The experiences of SNHs and non-SNHs during the pandemic can be analysed to uncover effective models of care and identify how to better prepare for future health crises; where such research endeavors can further acknowledge the indispensable contributions and sacrifices hospitals and hospital staff have made to overcome resource constraints and innovate during a health crisis. Thereby, this study also hopes to provide a set of recommendations at the governmental, state, and local levels aimed at mitigating the problems identified.

Brief History

The bulk of healthcare services in the United States is provided through private means, with the majority of individuals obtaining medical insurance through employer-sponsored benefits5. Nevertheless, there exist public options such as Medicare and Medicaid which are geared towards senior citizens aged 65 and above as well as a certain threshold of low-income individuals respectively6. In spite of the existence of public healthcare programs, tens of millions of Americans still remain uninsured due to eligibility barriers imposed by state policies7. With the aim of assisting the sizable number of low-income individuals who were unable to afford medical insurance and also did not qualify for Medicaid, the Affordable Care Act (ACA) was introduced in 20108. Specifically, one of the key components of the ACA expansion was the requirement that mandated all states to raise the threshold for Medicaid eligibility to 138% of the federal poverty line8. However, the ACA provisions were challenged in the Supreme Court, where it was ruled that states could either opt to expand Medicaid or not, which resulted in the minimum income requirement for Medicaid eligibility varying among states9. Therefore, while the ACA’s implementation in some states has culminated in more than 10 million Americans gaining health insurance, 30 million individuals remain without coverage at the onset of the COVID-19 pandemic10


Patient Outcomes

Individuals who are underinsured and reliant on SNHs typically experience a higher rate of untreated chronic diseases, lack access to preventative services, and display higher distrust in the medical system1112. The collision of these facets led to a disproportionately elevated rate of COVID-19 infection, poor COVID-19 outcomes, and COVID-19-related mortality at SNHs compared to non-SNHs13.
An interdependent relationship can be displayed between consistent patterns of disparities apparent prior to the pandemic and the poor COVID-19 outcomes exhibited amidst the pandemic. As the pre-existing racial disparities resulted in Black and Hispanic patients constituting the majority of SNH users4. Therefore, the effect was paralleled in SNHs, where Black and Hispanic patients experienced higher rates of hospitalization and severe COVID-19 outcomes compared to their white counterparts14. Furthermore, there was a positive correlation between income decline and hospitalization, where the first decile experienced an impatient death of 30% while the proportion was 10% in the tenth decile15.

While the standard of inpatient and outpatient treatment for non-COVID patients declined in both SNHs and non-SNHs, SNHs encountered a greater rate of unfavorable patient outcomes16. For instance, this was exemplified by patients who presented with acute diseases such as heart attack and stroke, who were often sicker upon arrival due to treatment delays17. In addition, a multi-center retrospective study revealed lower rates of timely follow-up for non-COVID-19 conditions18.

Finally, both patient outcomes and patient care accessibility were impacted by COVID-19 in SNHs. Studies have found that SNHs experienced longer wait times and delays for care during the pandemic, marking a 23% increase in wait times19. The operating volume could not be increased to clear the extra patient backlog since the hospital’s operative capacity would already be at its maximum capacity due to many individuals who were infected with the virus but unable to quarantine or isolate elsewhere1920. Additionally, SNHs faced an influx of patients who had lost their employer-sponsored medical insurance coverage, in addition to those who were previously uninsured or underinsured21. Therefore, SNHs had higher rates of mortality and readmissions for COVID-19 patients in comparison to non-SNHs18.

While the presented information provides an overview of the disparities between SNHs and non-SNHs, it is important to note that there may be a lack of generalizability in the findings due to various factors. The demographics of SNH and non-SNH users can vary significantly across different regions and populations. The specific racial and ethnic composition, socioeconomic status, and healthcare needs of SNH users may differ in different locations. The extent of COVID-19 cases and the response to the pandemic can vary between regions, with some areas experiencing higher infection rates than others20. When considering the methodological limitations of studies patient records and private health data (under HIPAA) pose challenges in obtaining comprehensive and standardized datasets15,16. It is difficult to determine if a patient sought care from multiple hospitals, leading to incomplete data. Additionally, data collection is often retrospective, relying on existing records not specifically designed for the study15,16. Despite these limitations, the presented information effectively portrays the interconnected relationship between pre-existing healthcare disparities, underinsurance, and poor COVID-19 outcomes in SNHs.

Reimagining Non-Essential Care

Both SNHs and non-SNHs experienced COVID-19-related scarcities, including a backlog of testing, a lack of critical care units, and a shortage of PPE, ventilators, and other necessary equipment22. Transforming and stretching hospital resources to accommodate COVID-19 patients and protocols led to a decrease in the availability of non-essential care23. For example, hospitals with high COVID-19 case rates encountered a greater reduction in non-essential care and non-COVID-19-related hospitalization when compared to hospitals with lower case rates2324. Even though virtually all major hospitals converted hospital rooms into makeshift critical care units, the conversion rate was far greater in SNHs which in turn coincided with a significant reduction in non-essential care17.

While all hospitals had to deal with a degree of resource constraints and shortages, the rise in adverse secondary outcomes due to COVID-19 was particularly salient for SNHs. Decisions made by SNHs during the pandemic had to be ones of constant checks and balances due to the dual burden of operating as both health care and social service providers. For instance, physicians at SNHs would prolong the length of hospitalization for COVID-19 patients, not because they required hospital care but because of their inability to self-isolate outside of the hospital20. As a result of the complex dynamics, SNHs constantly had to decide how and when to provide social services such as a house for unhoused patients with COVID-19, how best to protect the community they serve, how to deliver service for non-COVID-19 cases, and how to stretch a very limited set of resources to accommodate everyone.

Financial Implications

A study by Bailey et. al discovered that SNHs have been more negatively impacted financially by the pandemic than non-SNHs, with larger declines in patient volume and revenue25. This gap in revenue loss has been ascribed to the greater dependence of SNHs on outpatient services, which were severely diminished during the pandemic owing to stay-at-home orders and cancelled elective remedies. As a result, the federal government has contributed funding through multiple assistance packages to address the financial issues experienced by SNHs during the pandemic. The Coronavirus Aid, Relief, and Economic Security Act (CARES) offered $100 billion in support for healthcare26. Notwithstanding these attempts to give financial assistance to SNHs, discrepancies in funding allocation between SN and non-SNHs remain to persist. Academic hospitals and hospitals with more pre-COVID-19 assets got higher levels of funding, whereas critical access hospitals received less; thereby, the CARES Act grants may have gone to hospitals that were in a better financial position prior to the pandemic than those that were not27.

Advantages of Adversity

Facing immense resource constraints, SNHs were compelled to adapt and alter healthcare delivery to protect medical staff and patients alike. SNHs were particularly successful in accelerating the adoption of telemedicine and enhancing recovery protocols across the country as a means of providing healthcare while reducing the risk of exposure to the virus.

Prior to the COVID-19 outbreak, the usage of telemedicine across the U.S. was around 8%, since then the number of beneficiaries obtaining telemedicine services has expanded by 683% owing to the extensive flexibility telemedicine offered28. By enabling patients to receive care from the comfort of their own homes and removing obstacles to care like transportation, mobility, and distance, telemedicine has revolutionised access to healthcare29. This aspect was crucial during the pandemic when many people avoided healthcare facilities given the risk of contracting COVID-19. By reducing wait times, enabling clinicians to see more patients, and minimizing the need for in-person visits for routine care, telemedicine has led to better health outcomes in the management of chronic illnesses, despite the rise in virtual encounters3031. For instance, telemedicine has shown that it is possible to better control blood pressure, blood sugar, and other health indicators31. Telemedicine has therefore been regarded as a potential application in the future that could serve as a practical means of delivering cost-effective healthcare services, particularly for routine treatment and follow-up visits32.

Likewise, during the pandemic, there was a widespread tendency to shorten hospital stays. A structured DMAIC (Define, Measure, Analyze, Improve, Control) methodology was enforced to reduce hospital stays following unilateral DIEP surgery and spare resources for additional reconstructive patients33. Qualitatively, 77% of patients reported feeling ready to be discharged, and as a result, no profound complications were seen following an earlier discharge33. Moreover, arthroplasty procedures were successfully resumed through the use of a multidisciplinary enhanced recovery protocol, resulting in shorter hospital stays, an increase in same-day discharges, and no increase in complication or readmission rates when compared to arthroplasty procedures carried out prior to the pandemic34. Due to the growth that arose from these modifications, the prohibition on elective arthroplasty could thus have the potential to thrive in a post-pandemic era and in any future global crises.

Even though the incredible work of research hospitals and institutions is often acknowledged, it is equally important to recognize how SNHs contributed to innovation during the pandemic. Intentionally or unintentionally, the resource-constrained landscape surrounding SNHs created new ways of delivering healthcare that minimize the risk of COVID-19 infection. With that said, no technological development can occur without limitations. Telemedicine, in particular, presents challenges in accessibility and technical literacy35. In localities with poor connectivity, such as more rural areas, communication disruptions can hinder remote healthcare delivery. Accessibility may also prove to be a barrier. While telehealth removes barriers such as transportation for lower-income people and people experiencing housing insecurity, other barriers may be erected in their place such as access to the necessary technology, private spaces and a good Wifi connection. While technology has become more user-friendly over time, there are still individuals who may struggle with navigating the necessary platforms and applications required for telemedicine consultations35. Older adults, for example, or those with limited exposure to digital devices may find it particularly challenging to adapt to telemedicine technology. Although misdiagnosis rates may experience a slight increase due to limited physical exams, healthcare providers are actively developing remote diagnostic tools to improve accuracy in assessments36.


Often the last resort and only option for low-income, uninsured, and medically marginalized populations, SNHs undertook not only medical accountability but also social responsibility for the aforementioned patient population. At the forefront of the pandemic, emerged the key driving force of social determinants of health, where SNHs bore the disproportionate load of navigating the social fallout that arose from the clash between COVID-19 and the economic, social, and racial inequality that shapes healthcare in the U.S.

While acknowledging the significant role SNHs play in providing healthcare services to underserved communities, it is also critical to recognise the significance of maintaining their primary function as healthcare providers. The overwhelming duties SNHs exhibited when acting as social service and healthcare providers during the pandemic have demonstrated the demand for sufficient financing. By addressing the social determinants of health that contribute to subpar health outcomes, SNHs can continue to provide quality healthcare services to vulnerable populations during the pandemic and beyond. Therefore, funding for staff, medical equipment, and essential medical supplies in SNHs and a sounder budget for affordable housing, education, and job training for external social services is pivotal.

Despite the forenamed challenges confronted by SNHs, SNHs promptly embraced telehealth technology and multidisciplinary enhanced recovery protocol procedures to elevate patient care and outcomes. Even with a lack of funding and resources, SNHs were able to pull their weight and continue developing innovative practices in order to stand by their mission of bettering healthcare for underprivileged communities. Therefore looking forward, greater investment into the abilities of SNHs is essential to ensure their continued success in serving their communities.

The lack of funding for SNHs has been a recurring theme throughout the pandemic. To surmount the monetary challenges encountered by SNHs and guarantee access to care for low-income and uninsured patients, several policy recommendations could be implemented. Firstly, if Medicaid coverage was expanded to lower the threshold for qualification, more low-income individuals would be able to access essential medical care. Extending Medicaid comes with a significant financial commitment, which raises expenses for both the federal and state governments. Correspondingly, the political environment surrounding Medicaid expansion will likely be contentious, as demonstrated by past attempts to increase Medicaid coverage. Nevertheless, a large number of states have effectively expanded Medicaid, which has improved healthcare access, relieved financial burdens on those with low incomes, and boosted stability for healthcare providers.

Secondly, funding community health care services and preventive services in lower-income and at-risk communities could help to reduce the burden on SNHs by preventing and treating illnesses prematurely. Examples of successful services have included mobile cancer screening, free community health care centres, and community vegetable garden development.  In spite of that, there are several challenges associated with implementing these services for hard-to-reach populations, and there is no guarantee the provision of services will lead to uptake. Any implementation of service for at-risk populations will need to involve community input and engagement, education, the inclusion of social determinants of health, comprehensive outreach and broadly an approach that goes beyond the sole provision of healthcare.

Thirdly, funding SNHs both on the medical and social services front could help provide comprehensive care to their patients. By improving the link between SNHs and social services, patients could gain access to additional resources, such as housing and food assistance to support their overall health and well-being. The intertwined nature of medical and social factors makes it challenging to separate them, reinforcing the need for better linkage between the two to effectively address the burden on healthcare providers and improve patient outcomes. However, creating a better linkage requires significant financial resources, which can be difficult to obtain due to limited budgets, competing priorities, fragmented funding streams, and the need for political support.

Finally, addressing physician burnout by reducing the caseloads of physicians could lead to improved patient outcomes and reduce staff turnover in SNHs. Given the shortage of physicians in the U.S., the demand for healthcare services often surpasses the supply of physicians available, which means reducing caseloads without increasing the number of medical staff could strain an already limited workforce. It may be difficult to find additional physicians to distribute the workload evenly without compromising access to care for patients.

Enhancing pandemic preparedness requires a coordinated effort to establish seamless communication and collaboration among healthcare systems, public agencies, providers, and patients. Such a collaborative endeavour is needed in order to facilitate the effective dissemination of information regarding future pandemics and other public health emergencies. Likewise, empowering patients to participate in the process of disease surveillance programs, diligently monitoring their symptoms, and seeking timely medical care when required can enhance patient outcomes and aid the prevention of widespread impacts.

The COVID-19 pandemic has exerted unparalleled pressure on healthcare systems worldwide, and SNHs in the U.S. have been no exception. While confronting resource constraints, these hospitals have innovated novel procedures and technologies to safeguard the well-being of their personnel and patients. Often faced with numerous adversities, SNHs have remained resolute in offering vital healthcare services to their local communities, displaying an unwavering commitment to their mission of serving the most vulnerable populations.

To achieve equitable healthcare access and outcomes, it is fundamental to recognize that infectious diseases do not discriminate based on income or social status. The COVID-19 pandemic has highlighted the significance of providing equitable care to all individuals, regardless of their financial situation and health insurance status. It has become evident that individuals who lack access to healthcare not only endure the consequences themselves but also place others in jeopardy. SNHs hold a critical position in providing care to vulnerable populations, and adequate funding for these hospitals is therefore vital. By investing in community healthcare services and preventative measures, an effort towards reducing the risk of infectious diseases and improving overall health outcomes for all individuals can unfold.


This literature review may be subjected to potential sources of biases, including a limited scope of research databases and the possibility of missed articles. As such, it is important to acknowledge that the data used in this literature review may not be generalizable to the entire population but rather provides an overview. It is difficult to determine if a patient sought care from multiple hospitals therefore crossover was not accounted for. The studies included in this review may have focused more on urban populations within the United States, and thus may not be applicable in other contexts as a one-to-one comparison cannot be assessed. Within the specific studies, a portion of the data involving patients was not collected for the study explicitly, due to HIPAA concerns, which can introduce complexities and affect the interdependence of the findings. As a whole, the review was restricted to English-language publications, which might have excluded pertinent works written in other languages. Therefore, despite the efforts to include a range of scholarly databases, it is plausible that some relevant studies were overlooked owing to the exclusion of particular databases or search terminologies. These restrictions may have influenced the comprehensiveness of the study, as this literature review alone may not have captured all the nuances amongst the different healthcare structures that exist within the U.S.


The conducted research will be done in the form of a literature review. Through this method, the demographics of various healthcare structures will be examined, alongside finding innovative ways to interpret pre-existing research and suggesting potential solutions applicable in a post-pandemic era. The 34 articles that will be used for this literature review will be confined to the U.S. in order to concentrate on a single political and judicial system, written in the English language, published between 2020-2023 in order to regard the analysis through a COVID-19 lens, and the works cited will be retrieved from scholarly sources (Google Scholar, PubMed, Medline, etc). Moreover, the research will be based on keywords such as “COVID-19,” “USA,” “safety net,” “telemedicine,”  and “resource constraints.”

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  2. Meredith, J. W., High, K. P., & Freischlag, J. A. (2020). Preserving elective surgeries in the COVID-19 pandemic and the future. Jama, 324(17), 1725-1726. []
  3. Popescu, I., Fingar, K. R., Cutler, E., Guo, J., & Jiang, H. J. (2019). Comparison of 3 safety-net hospital definitions and association with hospital characteristics. JAMA network open, 2(8), e198577-e198577. [] []
  4. Hsu, H. E., Ashe, E. M., Silverstein, M., Hofman, M., Lange, S. J., Razzaghi, H., … & Goodman, A. B. (2020). Race/ethnicity, underlying medical conditions, homelessness, and hospitalization status of adult patients with COVID-19 at an urban safety-net medical center—Boston, Massachusetts, 2020. Morbidity and Mortality Weekly Report, 69(27), 864. [] []
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  19. Yoon, D. H., Koller, S., Duldulao, P. M. N., Ault, G. T., Lee, S. W., & Cologne, K. G. (2021). COVID-19 Impact on Colorectal Daily Practice—How Long Will It Take to Catch Up?. Journal of Gastrointestinal Surgery, 25, 260-268. [] []
  20. Komaromy, M., Harris, M., Koenig, R. M., Tomanovich, M., Ruiz-Mercado, G., & Barocas, J. A. (2021). Caring for COVID’s most vulnerable victims: a safety-net hospital responds. Journal of General Internal Medicine, 36, 1006-1010. [] [] []
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  33. Stern, C. S., Plotsker, E. L., Nelson, J. A., Matros, E., Kalandranis, E., Fatterusso, D., … & Mehrara, B. J. (2022). P91. OPTIMIZING UNILATERAL DIEP FLAP BREAST RECONSTRUCTION LEADS TO DECREASED HOSPITALIZATION TIME: A QUALITY IMPROVEMENT STUDY. Plastic and Reconstructive Surgery–Global Open, 10(4S), 92-93. [] []
  34. Taylor, A. J., Kay, R. D., Tye, E. Y., Bryman, J. A., Longjohn, D., Najibi, S., & Runner, R. P. (2021). Implementation of an enhanced recovery protocol at a safety net hospital: a silver lining to COVID-19?. Bone & Joint Open, 2(10), 871-878. []
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