As care costs have gone up, the number of uninsured has increased, at the same time that Medicaid reimbursements and subsidies cover a decreasing share of costs for “safety-net” providers – health care providers servicing Medicaid and uninsured patients. Concurrently, efforts at comprehensive reform of the US health care system have failed. A systems dynamics analysis of the mutual influence of the factors underlying the relationship of the safety net to systemic health care reform, starting with the factors influencing an urban public hospital, shows that any adequate predictions on the viability of health reforms in the US must consider political feasibility, including longstanding principles of American political culture. In the shorter term shoring up the safety net may well forestall efforts at more systemic reform. In the longer term, however, incentives for more cooperation among providers, more reliable sources of reimbursement for preventive services, and increased political support for more universal coverage as more working people become uninsured, could provide leverage that would reverse the cycle of increasing burden on the “safety net.”