Safety Net Hospitals: Key Elements of a Successful Advocacy Strategy

Safety net hospitals play a critical role in their communities, providing quality, patient centered and affordable care to all patients regardless of their ability to pay. Considering the limited resources and funding challenges faced by safety net hospitals¹, advocacy with state and federal stakeholders is essential to ensure their survival and ability to provide access to care.

To succeed, an advocacy strategy must be informed by the current federal and state policy landscape, use effective data driven messaging and foster collaborations with like-minded partners. Key elements of a successful advocacy strategy are described below.

1. Understanding State Policy Landscape and Related Advocacy Opportunities

An effective advocacy strategy begins with a deep understanding of the state’s health policy priorities and related funding opportunities, allowing safety net providers to align their efforts with state goals and maximize their impact. Advocacy strategies may differ significantly depending on the state due to varying policies, funding mechanisms, and healthcare priorities.

New York State (NYS) Health Policy Priorities and Provider Funding Opportunities: In recent years, New York State’s Governor has focused the NYS health care agenda on improving mental health, reducing maternal and infant mortality, and strengthening the healthcare workforce in New York. Those policy priorities are being supported by significant state-led investments in patient access and delivery of care. For example, the funding includes a $1 billion multi-year commitment to improving mental health, a portion of which is available to NY safety net hospitals for the development and operations of their mental health programs². Similarly, meaningful funding has been allocated to the healthcare workforce policy priority, aimed at recruiting and training healthcare professionals and social care workers.³ For other examples of NYS grant funding opportunities, including $950M in transformation grants see Manatt Brief 2. More recently, NYS has sought to promote innovative partnerships with safety net hospitals to improve access and quality through a Safety Net Hospital Transformation Program (SNHTP) included in SFY25 budget. The Governor announced seven SNHTP awards in January 2025.⁴

NYS safety net providers have leaned into these opportunities to enhance access and quality of care through strategic projects, including operating and capital funding to redesign and modernize emergency departments, establishing comprehensive psychiatric emergency programs, improving regional rural health access, building new hospitals, and enhancing access and quality for nursing homes.⁵

Illinois Health Policies Supporting Safety Net Hospitals: With the support from the Illinois Health and Hospital Association and legislative members, Illinois safety net hospitals have successfully partnered with the State to address their transformation needs. Over the years, they have built strong relationships with the legislature and Illinois Department of Public Health to promote much needed reform, ranging from defining safety net hospitals in statute to supporting their operating, capital and workforce needs.⁶

By understanding their state priority agendas, safety net providers can strategically align with statewide policy goals. In addition to advocating individually, providers collaborate to form partnerships that offer regional solutions to community needs. For example, states often encourage collaborations between community hospitals and larger systems to create economies of scale, which allows providers to address medical shortage areas and leverage shared resources for a particular population or service line. Such approaches often strengthen alignment with state objectives and enhance providers’ ability to advocate for issues and solutions, including securing funding opportunities.

2.  Navigating Federal Funding Opportunities through Effective Advocacy

On the federal level, safety net hospitals have successfully engaged in advocacy related to federal earmarks, officially known as "Community Project Funding" in the House and "Congressionally Directed Spending" in the Senate⁷. These programs enable Representatives and Senators to allocate federal funds to specific projects within their districts or states. Success factors include being able to develop lasting relationships with congressional representatives and keeping them informed of funding priorities on a regular basis.

In the healthcare sector, eligible projects include those under the Labor-HHS Appropriations bill, such as Health Resources and Services Administration (HRSA) Health Facilities and Substance Abuse and Mental Health Services (SAMHSA) grants. Safety net hospitals often secure these funds to cover costs related to construction, renovation, or capital equipment, training of healthcare professionals, and resources for substance use or mental health services, enabling much needed access to care in their communities.

3. Using Impactful Data-Driven Narrative

To advocate effectively for state or federal dollars, providers must develop a compelling business case that highlights how the programs and services being advocated for are aligned with patient needs, as gleaned from community health needs assessments and review of data from local health departments. The business case should also demonstrate provider’s strategic alignment with state and/or federal healthcare policy goals, and articulate how the advocacy ask will further that alignment (e.g., improve access and healthcare delivery in the region in certain services or for certain populations).⁸

4. Building Alliances to Advocate Together

In addition to a strong, data-driven approach, an effective advocacy strategy requires a unified voice supported by strength in numbers.

State Examples: In some states, safety net providers have developed organizing structures through state hospital associations, forming strong partnerships with state Medicaid agencies. This approach allows for collaboration on policy, program, and funding opportunities. 

• New Jersey:  The Hospital Alliance of New Jersey (HANJ) represents safety net and teaching hospitals across New Jersey, advocating for increased Medicaid funding and access to quality care. To ensure the needs of its members are met, HANJ has an organizational structure that facilitates a strong relationship with the New Jersey Medicaid office.⁹
• Illinois: The Illinois Health and Hospital Association (IHA) has strategically aligned its policy agenda to shape both state and federal policies that benefit Medicaid beneficiaries and providers. IHA has supported successful Medicaid funding reform¹⁰ with a well-organized and effective advocacy approach.

Federal examples: On the federal level, America’s Essential Hospitals (AEH) represents ~300 members and has been advocating for policy changes on behalf of safety net hospitals since 1981.¹¹ Similarly, American Hospital Association (AHA) that includes 5,000 member hospitals, actively advocates for safety net hospital needs, including safety net providers serving rural communities.

• AEH: During the pandemic, AEH played a crucial role in building bipartisan congressional support for the $178 billion Provider Relief Fund and, through highly effective regulatory advocacy, targeted $15 billion of the fund toward safety net hospitals.¹²
• AHA: AHA’s 2024 Rural Advocacy Agenda calls for improved patient access to emergency care, additional funding for maternal and obstetrics care, and workforce support in rural communities among other priorities.¹³  

Depending on the nature of required support, safety net providers may aim to secure the support of legislators, other elected officials, regulators, staff members or other stakeholders who are in the best position to drive change related to the advocacy ask.   

The Path Forward:

With the change in Administration and shifting federal priorities, many safety net hospital policy decisions are likely to shift to the state level. This will create an environment where strengthening state advocacy capabilities will become increasingly important.

As a starting point in developing or strengthening their advocacy strategies, safety net hospitals can consider the following questions:

1. What are the healthcare policy objectives at the state and federal levels, and how do they align with your organization’s strategic goals and advocacy needs?  
2. Which stakeholders have the ability to establish and direct operating or funding programs for safety net providers?
3. How can safety net providers leverage federal and local elected officials to support state-level advocacy agendas?
4. Are there partnership opportunities to better position safety net providers for funding and support?

Answering these questions will help safety net hospitals secure the necessary resources and achieve improved quality, access, and equitable care for the populations they serve.