ACCESS, QUALITY, AND SATISFACTION

Access and quality of care in the traditional Medicaid program have never been optimal. The literature shows that Medicaid beneficiaries have historically faced financial and other barriers to care from private practitioners and have had to rely on emergency departments and publicly funded institutions for their health care services (The Kaiser Commission on the Future of Medicaid, 1995; The Medicaid Access Study Group, 1994). Many of managed care's principal features—its potential to strengthen preventive services and care coordination, better case management, and a clearly identifiable health care provider with overall patient management responsibilities—are generally viewed as holding promise for improving access to care for a historically underserved population. In addition, the savings that may be achieved through the use of managed care could be reinvested to improve and enhance delivery of primary care services.

Yet the very characteristics that give managed care its power also give the system a potent reason to discriminate against patients who are considered costly, difficult, or in some way “undesirable” (Rosenbaum et al., 1997). Like other managed care plans paid on a risk or capitated basis, Medicaid managed care provides financial incentives to limit beneficiary use of covered services deemed to be unneeded or inappropriate. Furthermore, because Medicaid beneficiaries may have little or no ability to choose among managed care organizations, they may be less able to express dissatisfaction by disenrolling from plans that arbitrarily deny access to needed covered services (Frederick Schneiders Research, 1996).

Incentives to economize on care could pose special problems for Medicaid beneficiaries, an economically disadvantaged group without the financial resources to purchase care directly. Many Medicaid beneficiaries reside in medically underserved areas and often have more complex health needs than higher-income Americans (Darnell et al., 1995). In addition, many Medicaid beneficiaries present with a range of other challenges, including illiteracy, inadequate social support, poor nutrition, and problems with transportation and communication, that many health plans are unprepared to address (Landon et al., 1998).

A 1995 review of the literature concluded that Medicaid managed care enrollees receive care that is at least comparable in quality to that received by their fee-for-service counterparts (The Kaiser Commission on the Future of Medicaid, 1995). More recent studies on how managed care affects access and satisfaction show mixed results. Surveys on quality and satisfaction in Medicaid managed care conducted by researchers and state Medicaid offices in a number of states (e.g., Wisconsin, Oregon, Maryland, and New York) demonstrate evidence that beneficiaries in those states are more satisfied with their health plans than fee-for-service enrollees are (CareData Reports, 1997; Oregon Department of Human Resources, 1997; Piper and Bartels, 1995; Sisk et al., 1996; United Hospital Fund, 1998). A survey of New York City Medicaid beneficiaries found that those in Medicaid managed care were more likely than their fee-for-service Medicaid counterparts to rate their medical care as excellent (13 versus 7 percent) or very good (23 versus 18 percent) (Sisk et al., 1996). A Rhode Island Department of Human Services assessment of RIte Care, presented at a May 1998 committee workshop, showed that the program had improved prenatal care and infant health outcomes (Christine Ferguson, workshop testimony, May 1998). Another study from Wisconsin indicates that the Medicaid health maintenance organizations in that state provide superior preventive care for children and have better immunization rates (Piper and Bartels, 1995).

However, findings from a Henry J. Kaiser Family Foundation survey of low-income adults in five states (Florida, Minnesota, Oregon, Tennessee, and Texas) found that Medicaid managed care enrollees were more likely than low-income, privately insured managed care enrollees to be poorer, have health problems, and experience access problems (Lillie-Blanton and Lyons, 1998). The study demonstrated that compared with the low-income, privately insured populations and Medicaid fee-for-service populations, Medicaid managed care enrollees show some improved access to a regular provider but are more likely to be dissatisfied with their health plans or experience more difficulty obtaining care.

A report on 21 focus groups that included low-income Medicaid beneficiaries in five states found that Medicaid beneficiaries' reactions to managed care depend in great part on their prior experience with seeking health care (i.e., whether they were satisfied with their previous Medicaid services) (Frederick Schneiders Research, 1996). The experiences of Medicaid beneficiaries in managed care varied widely from state to state, by economic status, by region within a state, and by other factors. Even in states where beneficiaries had positive experiences, there were problems if the switch to managed care was abrupt and poorly understood by the beneficiaries.

The most frequently cited advantage that Medicaid beneficiaries experience in managed care is improved availability of primary care, but the consistency of this trend across geographic areas and the sustainability of this trend are open to question (Felt-Lisk et al., 1997a). Improved access to primary care is closely associated with local market dynamics, rate adequacy, contractual requirements, and adequate tracking and oversight mechanisms.

Better access to primary care providers does not remove all access problems. Problems related to making an appointment, obtaining specialty care, and receiving care after hours have been cited as potential impediments to improved access. The issue of availability of care versus actual accessibility and acceptability of care needs to be clarified and better understood for the more complex and traditionally underserved Medicaid population (Billings et al., 1998; Darnell et al., 1995).

Several efforts have been initiated nationally to provide tools and performance indicators for Medicaid. These include

• the Health Care Financing Administration's Quality Assurance Reform Initiative;
• a Medicaid version of the Health Plan Employer Data and Information Set, currently the tool most commonly used to assess health plan performance;
• the Quality Improvement System for Managed Care, designed for managed care plans that participate in Medicaid; and
• the Consumer Assessment of Health Plans (CAHP), a performance measurement instrument based on consumer reports; although the core CAHP model was designed for a general population, optional supplementary modules were also designed for Medicaid enrollees.

All of these quality assurance mechanisms are evolving, and as yet, little is known about the degree to which they will be effectively implemented or standardized across health plans or how they will affect the quality of care provided by each plan (Landon et al., 1998). John Holahan and colleagues looked at the status of Medicaid managed care quality monitoring requirements as they are being developed and implemented in the 13 states that are part of the Assessing the New Federalism project (Holahan et al., 1998). The survey found that to date there is no clear evidence of the extent to which these standards are being enforced. An early review of the impact of Section 1115 waiver programs in five states reported that none of the states had sufficient data to routinely monitor either baseline care patterns or changes in access (Gold et al., 1996).

The transitional nature of Medicaid eligibility makes quality measurement techniques more problematic. One of the major issues still to be resolved in this area is determination of the appropriate balance between federal quality assurance requirements and the flexibility of the states in designing and implementing their own programs and standards in this area.

As with other aspects of health care oversight and management, the quality oversight and management capacities of the states vary enormously. The Medicaid programs of some states are inadequately staffed to assume many of the new contracting and management functions required as Medicaid is transformed to a value-based purchaser. In implementing mandated Medicaid managed care, some states failed to recognize the importance of adequate preparation and resources for effective transition (Gold and Aizer, 2000; Gold et al., 1996). In part to compensate for uncertainties and gaps in knowledge, the federal government and states are imposing what many believe is an excessive and perhaps unproductive layer of oversight and regulatory requirements (Maura Bluestone, Bronx Health Plan, interview, December 1998; Hurley and McCue, 1998). Nevertheless, given past and more recent Medicaid marketing scandals and quality abuses, there is considerable merit in developing stringent regulations to safeguard Medicaid beneficiaries. With experience, states may be able to find a more streamlined, effective infrastructure for monitoring and oversight.

NONFINANCIAL BARRIERS TO ACCESS TO HEALTH CARE

Whereas most Americans do not require outside assistance to access and negotiate the medical system, vulnerable populations are likely to experience nonfinancial barriers that may be impediments in their search for care. These include lack of transportation and a shortage of providers in rural and inner-city areas, language and culture, and prior experiences with the medical system. Research shows that ensuring access for vulnerable populations requires consideration of both financial and nonfinancial barriers (Darnell et al., 1995; MDS Associates, Inc., 1994).

Overcoming these impediments has often been accomplished through the use of enabling services such as translation, transportation, outreach, and case management services. There is preliminary evidence that the move to capitated managed care, with its budget constraints, may affect the continued availability of outreach and other important enabling services (Felt-Lisk et al., 1997b; Hoag et al., 1999). In a more price-competitive environment, these kinds of services are more difficult to justify in the absence of hard evidence of their effectiveness and cost-effectiveness (Felt-Lisk et al., 1997b; MDS Associates, 1994). Comprehensive information on enabling services is limited, and almost no information exists on how and to what degree these services are being provided within managed care organizations (MDS Associates, 1994; R. Kotelchuck, New York regional meeting testimony, January 1999). An effort is under way to develop a mechanism for collecting and monitoring data on the utilization and costs of enabling and supportive services delivered by community-based health care providers (American Express Tax and Business Services, 1999). By developing a standardized system for the tracking of enabling services, community-based health care providers may be better able to establish their value and negotiate reimbursement for these services from payers including managed care organizations.

IMPROVING THE SCOPE AND CONTENT OF BENEFICIARY CHOICE

The issue of plan and provider choice continues to be one of the major lightning rods in the ongoing national debate over the perceived virtues and vices of managed care. The concept of choice appears to be particularly important to Americans not only in the selection of their health plan and provider but as a larger societal value. Studies and surveys on the issue of provider choice consistently indicate that people without a choice at enrollment are substantially less satisfied with their plans and managed care in general than people with choices (Fraser et al., 1998; Frederick Schneiders Research, 1996; Gawande et al., 1998). People without choice have disproportionately lower incomes and work for small employers (Fraser et al., 1998).

The Balanced Budget Act (BBA) of 1997 allows states to limit most Medicaid beneficiaries to a choice between two managed care organizations in urban areas and to a single plan in rural areas (Rosenbaum and Darnell, 1997). In neither cases does it require managed care organizations to give beneficiaries a choice among primary care physicians. Nor does the BBA of 1997 require that managed care organizations contract with physicians, hospitals, or clinics that have traditionally served low-income families and with whom Medicaid beneficiaries may have established a relationship. Nevertheless, a number of states have developed incentives for plans to include traditional safety net providers.

For the majority of Medicaid beneficiaries, who are accustomed to the fee-for-service system, learning how to navigate the managed care system and choosing a plan can be a perplexing process (Molnar et al., 1996; U.S. General Accounting Office, 1996). Investing in resources that can be used to educate beneficiaries and to counsel beneficiaries while they are choosing a plan is essential. A number of studies have looked at state education and enrollment policies and have concluded that no single consistent strategy that outlines the optimal way to inform and protect Medicaid beneficiaries as states transition to managed care can be defined (Horvath and Kaye, 1996; Mollica et al., 1996; U.S. General Accounting Office, 1996). Nevertheless, current studies and surveys help to inform beneficiaries about many of the critical issues related to education and enrollment. The key lessons that have been learned from these assessments are summarized in Box 5.2.

BOX 5.2

Lessons Learned from Managed Care Enrollment. Although most states use the enrollment process as an opportunity to promote beneficiary understanding of the program and selection of a managed care organization, states vary significantly in their respective (more...)

Many safety net providers believe that current marketing restrictions negatively affect their enrollments and detract from patients' ability to make informed choices (Kalkines, Arky, Zall and Bernstein, LLP, 1998). A study of New York City Medicaid managed care enrollees found that individuals enrolled at provider sites were far more likely than other plan members to understand plan procedures and to express satisfaction with their care (Molnar et al., 1996).

Even states with more comprehensive and sophisticated enrollment systems find that some beneficiaries are hard to reach or do not make a choice and are therefore automatically enrolled in a plan or assigned a primary care provider. Conventional wisdom has held that the voluntary versus the automatic enrollment rate is the best available indicator for measuring the effectiveness of a state's education and enrollment strategies (Maloy et al., 1998).

The U.S. General Accounting Office studied four states (Minnesota, Missouri, Ohio, and Washington) viewed as having effective enrollment programs (U.S. General Accounting Office, 1996). Although these “best-practice” states attempted to reach voluntary selection rates of 80 percent or higher, in their actual experiences the rates have ranged from 59 to 88 percent (U.S. General Accounting Office, 1996). Some states have automatic enrollment rates of greater than 50 percent.

Recent research indicates that understanding the dynamics of automatic enrollment and their implications for Medicaid beneficiaries is much more complex than was originally perceived. There appears to be little knowledge about whether, from a beneficiary's standpoint, automatic enrollment is associated with less satisfaction, lower rates of access and utilization, and less understanding of the managed care system (Maloy et al., 1998). Ongoing research in this area is beginning to show that automatic enrollment rates may ultimately be less important than what Medicaid beneficiaries actually experience once they enroll in a plan. For example, automatic enrollment may be less meaningful if a beneficiary's provider participates in both plans being offered or beneficiaries know that they can easily move out of a plan if they are not satisfied.

State enrollment policies often play two critical and potentially conflicting roles in Medicaid managed care, and both roles have major implications for beneficiaries. First, enrollment policies can play a vital role in the goals of educating beneficiaries about their managed care options and the selection of a plan of their choice. A high rate of voluntary enrollment is viewed by states as an indicator that the goals are being achieved. Second, automatic enrollment has been used by states as a vehicle to create a market for new start-up plans or for special classes of providers deemed important to the program. For example, such states as New York and California use automatic enrollment as a way to steer patients to safety net providers. As the Medicaid managed care market matures and states improve their enrollment practices, the rate of automatic enrollment will likely decline. In light of the recent exit of commercial plans from the Medicaid market, some states may continue to rely on automatic enrollment as a lever to attract certain plans to the program.

HOW EFFECTIVE ARE CURRENT ENROLLMENT AND CHOICE POLICIES?

The ultimate test of any education and enrollment strategy is how well it works in helping beneficiaries make informed and meaningful choices. Unfortunately, there has been a dearth of evaluations, and strong performance measures of effective education and enrollment efforts are not available (U.S. General Accounting Office, 1996). Voluntary disenrollment rates tend to be low (3 percent or less) and too small for meaningful aggregate analysis (information about individual disenrollment decisions may be more useful) (Horvath and Kaye, 1996). Until now, most state Medicaid programs have focused primarily on threshold dimensions of managed care (e.g., how managed care differs from the fee-for-service system, the difference between mandatory and voluntary enrollment, enrollment guidelines, and the scope of beneficiary protections). Although this information is useful and relevant for beneficiaries, numerous studies have shown that Medicaid patients care less about what plan they can join than about whether they will have access to a specific provider or group of providers (Ku and Hoag, 1998). However, timely and accurate participating provider lists are not routinely available to enrollees. A recent United Hospital Fund survey of New York City Medicaid beneficiaries showed that 46 percent of managed care enrollees reported that they had not received a provider list (Cantor et al., 1997). Beneficiaries are also interested in information on their covered benefits, but about 25 percent of those surveyed thought that their benefits would expire if they did not sign up for a plan (Cantor et al., 1997). A study on state enrollment systems being conducted by the Center for Health Services Research and Policy at The George Washington University found that a lack of information about providers and plan networks consistently precluded meaningful Medicaid beneficiary choice during enrollment (Maloy et al., 1998).

Medicaid beneficiaries report that their most valued and trusted sources of information about their choice of plans were their providers or community-based organizations (Maloy et al., 1998; U.S. General Accounting Office, 1996). However, although the Medicaid and uninsured populations often have an array of special needs, most states do not provide much comparative information about providers' capacities to meet those needs (Fraser et al., 1998).

MAINSTREAMING

Mainstreaming is often cited as a goal in extending managed care to vulnerable populations. The Medicaid program originally sought to bring low-income Americans into the mainstream of medical care, moving them away from their almost exclusive reliance on safety net providers. In reality, Medicaid has fallen far short of that goal. Because of its low payment rates and socially unpopular clientele, the program has for the most part failed to attract the participation of a broad range of providers, particularly for primary care (The Medicaid Access Study Group, 1994). A more price-competitive health care landscape has made Medicaid a more attractive payer to the commercial sector. To compensate for shrinking revenues, commercial plans and providers have focused on enlarging market share and the number of covered lives.

Many HMOs were initially attracted to the Medicaid market as an opportunity to quickly increase revenues, but other reasons also prevailed. Several states, including Minnesota, require HMOs to serve the Medicaid population as a condition for offering a commercial product to state employees. Plans also use the Medicaid market to expand and leverage their provider networks or as a beachhead from which they can increase their market share of other payers. Finally, certain plans participate in Medicaid to be viewed as good corporate citizens in their communities (Hurley and McCue, 1998).

In the early 1990s commercial plans had yet other incentives for commercial plans to participate in Medicaid managed care. Before 1994, enrollment in managed care had mainly remained voluntary and reimbursement rates were relatively generous (Bovbjerg and Marsteller, 1998; Hurley and McCue, 1998). Some states actively sought commercial plans' involvement in the Medicaid market as a way to mainstream low-income beneficiaries and to move away from a perceived two-tier health care system.

In a number of states the entry of commercial plans may have contributed to the broadening of access to primary care. According to focus groups, some Medicaid beneficiaries “felt the advantage of high-quality doctors” or appreciated the chance to “see mainstream providers in mainstream delivery settings” (Frederick Schneiders Research, 1996). These observations are tempered by evidence and testimony heard by the committee that some beneficiaries return to seek care from their traditional providers with whom they feel more comfortable and accepted (Kalkines, Arky, Zall and Bernstein, 1998; West, 1999; Florida site visit testimony, April 1998). There appear to be no reliable data, however, on the number of Medicaid patients who leave their traditional providers to join other managed care organizations or on the number who return to traditional providers after having been enrolled in a commercial plan.

Experience is beginning to show that mainstreaming is not easily accomplished and, to the degree that it exists, that it must occur on two levels: both the plan and the provider levels (Hurley and McCue, 1998). Medicaid beneficiaries' enrollment in a commercial plan is no guarantee that they will have access to the same network of providers as their counterparts whose premiums are paid by private payers, particularly for referral and specialty care services (Marsteller, 1998). Even when states have attempted to regulate equity of access, enforcement of such provisions has proved problematic for state officials, given the technical complexity of assessing even the basic adequacy of a network (Fagan and Riley, 1998). More research is needed on how participation by commercial plans influences access to mainstream care and how it affects quality (Kaye et al., 1999).

Regardless of the intrinsic merits of mainstreaming Medicaid beneficiaries as a policy objective, efforts to move in this direction may be losing some momentum. In the past 2 years, several large commercial plans have exited from all or major segments of the Medicaid market, citing rate inadequacy, rate volatility, and administrative burdens associated with government requirements, as indicated in two studies (Hurley and McCue, 1998; McCue et al., 1999). Those studies examined the financial performances of health plans and interviewed a number of Medicaid managed care plan executives. Many of the managed care plan executives admitted that their predominantly commercial plans probably would not be able to surpass the growing Medicaid-only plans in customizing their services for Medicaid beneficiaries. These executives expressed concern, however, over the long-term ability of Medicaid-only plans to provide high-quality care for their beneficiaries given these providers' dependence on Medicaid revenues and their having to accept whatever rates would be meted out.

Traditional safety net providers have claimed that they see more patients with greater health risks than do their counterparts in commercial plans. There is some evidence that when marketing to Medicaid beneficiaries commercial plans focus their efforts on the healthier segments of this population, particularly pregnant women (Gaskin et al., 1998). A recent study examining the services and status of Oregon's health care safety net conducted by Milliman and Roberston for the Office for Oregon Health Plan Policy and Research sheds some additional light on this question (Oregon Department of Administrative Services, 1999). The study's findings confirm that, in general, both safety net and mainstream clinics find Medicaid patients to be more difficult to serve. The study found, however, that the state's safety net plan, CareOregon, and its clinics saw a sicker population than mainstream plans in three categories and that the reimbursements that these providers received were low relative to the costs of providing such care. In addition, although enabling services were offered in both mainstream plans and CareOregon, the study suggests that safety net clinics are more effective than mainstream clinics at delivering enabling services to Medicaid patients who have special needs.

Another study comparing the quality management practices of health plans participating in Medicaid managed care found that Medicaid plans are more likely than commercial plans to target programs directed to the specific needs of the Medicaid population (Landon and Epstein, 1999). The study concludes, however, that neither commercial nor Medicaid plans showed notable strong records in actual quality improvement.

The results of the analysis of the Oregon health care safety net as well as other research highlight the importance of adequate risk adjustment methodologies not only to promote fairer competition among health plans but also to help ensure that consumers have an adequate choice of providers in their markets (Bovbjerg and Marsteller, 1998). Currently, premiums are usually adjusted for age, gender, and geographic regions, but there is growing interest in adjusting payments for the health status of enrollees. More refined risk adjustment will better compensate plans that enroll higher-risk or sicker patient populations and reduce incentives for selecting only healthier enrollees. At this time only two states, Colorado and Maryland, incorporate health-based risk-adjustment systems into their capitation rates (Holahan et al., 1999). In the absence of adequate risk adjustment, states have opted to carve out certain services from health plans' benefits packages or to include stop-loss provisions in their contracts with managed care organizations.

THE UNINSURED POPULATION

By any measure, the growing number of uninsured people, 18.4 percent of the country's total nonelderly population and more than 30 percent of the nation's low-income individuals in 1998, is the most serious and troublesome by-product of the new health care paradigm. In a market-driven environment the uninsured, who do not represent a market force, are excluded.

A range of research has shown that relative to insured people, uninsured people are much more likely to have unmet health care needs, are less likely to have a usual source of care, have lower rates of health care use, and experience worse health outcomes, including increased rates of mortality. Individuals without health care coverage have long been a public policy concern for a nation whose coverage system is largely built on employment status or eligibility for publicly financed programs. The combination of eroding employment-based coverage, changing demographics, welfare reform, the shrinking ability on the part of health care providers to cross-subsidize the costs of health care, and the move to Medicaid managed care has raised the problem of this nation's uninsured to what many perceive to be a critical juncture. State programs directed at improving access for the uninsured have been developed in such states as Oregon, Washington, and Minnesota. Although these efforts have been shown to improve the levels of access, each of these programs is facing funding problems and has had to limit some of the original objectives (Lipson and Naierman, 1996).

Although most of the published literature indicates that safety net providers have been able to maintain their commitment to the uninsured population, recent anecdotal evidence indicates that a weakened safety net is beginning to reduce the standby protection for those who remain uninsured. Safety net providers are treating a growing number of uninsured patients whereas the number of paying patients is declining and the payments for them are being reduced. In some communities, uninsured patients are having to wait longer or must be sicker to get an appointment, and some services offered previously are no longer available (Baxter and Feldman, 1999). In their review of safety net hospitals and community health centers in 12 communities, Baxter and Feldman found evidence that some of these providers were being forced to limit access to health care services because of the growing demand for services for the uninsured population. Reductions in Medicaid disproportionate share hospital payments, restructuring of state charity pools in Newark, New Jersey, and Boston, Massachusetts, and the changing insurance status of immigrant populations in Miami, Florida; Orange County, California; and Phoenix, Arizona, are forcing providers in these communities to reduce the level of access for the uninsured population (Baxter and Feldman, 1999).

INNOVATIVE NEW APPROACHES TO CARE FOR THE UNINSURED POPULATION

A positive sign on the current horizon is experimentation with managed care approaches to providing care for the indigent uninsured population. The first and best-known model for using managed care to provide access to health care to the uninsured population was established in Tampa, Florida, in 1991 (Lipson et al., 1997; Norton and Lipson, 1998). Faced with a rising number of poor workers and high-risk individuals without insurance, Hillsborough county petitioned the Florida Legislature for authority to levy a half-cent sales tax to help finance access within a coordinated system of care. Contracting on a competitive basis with networks of community health centers, hospitals, and other providers, Hillsborough HealthCare now serves an estimated 25,000 people. According to testimony heard during the committee's site visit, Hillsborough HealthCare has contributed to a marked lowering of hospitalizations for diabetes and asthma complications through improved access to primary care and reduced emergency department expenditures (Patricia Bean, Hillsborough County Health Plan, Florida regional meeting testimony, April 1998; Commissioner Thomas Scott, Hillsborough County Board of Commissioners, Florida regional meeting testimony, April 1998). For its success, the program has received the “Models that Work” award from the Health Resources and Services Administration for innovative health improvement programs. Similar programs that link uninsured people to a primary care provider or medical home to coordinate their care have been started by public hospitals in Indianapolis, Boston, and Bextar County, Texas.

The success of Hillsborough as a model that could be replicated in other parts of the country was an important catalyst behind the launching of a major new $16.8 million initiative, Communities in Charge: Financing and Delivering Health Care to the Uninsured, sponsored by the Robert Wood Johnson Foundation. The program is designed to help a broad-based consortia of organizations in the community develop and implement managed care delivery systems for low-income, uninsured individuals, emphasizing prevention and early intervention.

Similarly, the W.K. Kellogg Foundation's Community Voices program is another major philanthropic-sponsored effort targeted to sustaining, improving, and expanding health care for the uninsured populations. Begun in 1998, Community Voices seeks to ensure the survival of safety net providers and strengthen community support services, “given the unlikely prospect of achieving universal health coverage in the next 5 years” (Community Voices, 2000). Thirteen diverse communities— selected to serve some of the hardest-to-reach underserved populations— have received grants to serve as laboratories of change to sort out what works from what does not in meeting the needs of those who receive inadequate or no health care.

OTHER CHALLENGES

As previous studies have shown, although health insurance coverage is an important component of ensuring access to care, it is not the only factor. A new study that looked at changes in access to care from 1977 to 1996 indicates that during this time access to a usual source of care has declined sharply for Hispanics and young adults aged 18 to 24 (Zuvekas and Weinick, 1999). However, no more than 20 percent of the change in access could be explained by declines in rates of health insurance coverage. Demographic changes, large decreases in rates of access among the uninsured population, and, for young adults, decreased rates of access among those with insurance were shown to be important contributing factors.

Other dynamics associated with a more competitive, price-based environment, such as conversion, consolidation, and privatization, in the future may add new pressures to an already tenuous national capacity to serve the vulnerable and uninsured populations. Although recent reports on conversions and privatization indicate that access for low-income patients is not yet seriously degraded, those studies and surveys attest to a changing and unstable environment that requires more active attention and monitoring (Needleman et al., 1997).

As part of the new managed care requirements and as a means of survival in a more competitive environment, traditional providers are being compelled to place greater emphasis on performance, development of a more customer-responsive environment, and more efficient operations. To the degree that improvements in this area continue, the move to managed care will benefit the care of the nation's most vulnerable citizens. Inadequate capitation rates and declining subsidies, however, may quickly erode this potential, particularly given the rising number of uninsured people and the tenuous hold that these providers have in balancing their missions and margins.

Medicaid managed care in many ways can be likened to a halfway technology: a concept that has significant potential but one that is as yet hamstrung by programs and policies that blight the promise. Instead of pursuing mainstreaming as an objective per se, giving beneficiaries access to quality providers under conditions of informed choice may be a more relevant and meaningful goal for certain vulnerable populations. In a competitive, cost-driven marketplace and in the absence of a national policy on the uninsured population, a quality provider for vulnerable populations must be a provider or plan that will ensure some continuity of care as individuals cycle on-and-off coverage.

Only a stronger national commitment directed to the problem of the nation's growing number of uninsured people will help fulfill the true promise of managed care for America's low-income populations. Nevertheless, there will always be some Americans whose vulnerabilities and special needs will exceed the capabilities of the services that can be purchased with a health insurance card alone.

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Footnotes

1

The committee developed the information contained in Box 5.1 through a deliberative process using the literature, expert hearings, and regional testimony. In each case, a list of common factors was developed and field tested to establish content validity in consultation with key informants from across the nation representing safety net providers, managed care organizations, and state and local authorities.

2

See The Urban Institute publications Assessing the New Federalism (Urban Institute, Washington, D.C.), which describes a multiyear project designed to analyze the devolution of responsibility for social programs from the federal government to the states. Also see Center for Studying Health System Change publications (Center for Studying Health System Change, Washington, D.C.) on how the health system is evolving in 60 communities across the United States and the effects of those changes on people. See also the Henry J. Kaiser Family Foundation and The Commonwealth Fund series Managed Care in Low-Income Populations: Lessons from Medicaid Managed Care in Five States.